Every finding on record at Eastchester Rehabilitation and Health Care Center

Based on observation and interviews, the facility did not ensure that food was stored in accordance with professional standards for food service safety. Specifically, prepared and frozen foods were not labeled and dated appropriately. This was evident during the kitchen observation. The findings are: The facility policy and procedure titled, Dating and Labeling, last revised 01/20/2026, documented kitchen will assume food safety by maintaining proper dates and labels on all food items including ready to eat food products. Additionally, products in storage should be labeled with the date the package was opened and expiration date. The facility is to allow for 48 hours for leftovers and ready to use food items after opening and discard all foods that expire immediately. During a kitchen observation tour with the Food Service Director on 02/24/2026 from 09:28 AM to 09:47 AM, opened and leftover frozen foods were observed in the reach-in freezer. Items found included: A blue plastic bag containing an unidentifiable item labeled received date 2/12/26 and opened date 2/17/26 A clear zipper bag containing leftover cooked bacon labeled Bacon 1/22/26 An opened plastic bag of unidentifiable items, not wrapped tightly and dated 2/23/26 and 2/26/26 An opened package of frozen items loosely wrapped by the plastic packaging and covered with foil without any label An unidentifiable frozen item in a clear bag dated 2/16/26. A clear bag containing unidentifiable items without a label. Aluminum foiled items loosely wrapped with cling wrap labeled turkey burger 2/3/26 Two clear zipper bags containing unidentifiable items dated 10/24/25 and 10/24/25 An unidentifiable frozen food item in a loosely tied storage bag without any label A clear bag containing frozen crinkle fries dated 1/17/26 A clear bag of frozen pasta shells dated 1/7/26 On 03/02/2026 at 11:59AM, Food Service Director stated stored food items found in the reach-in freezer should have been labeled with expired date and that they will need to reinforce and in-service the staff again on how to properly store and label open packaged foods. On 03/02/2026 at 12:45PM, Dietary [NAME] #1 was interviewed and stated that any opened packaged meats are properly wrapped and labeled with date of opening and expired/used by date. Any leftover prepared foods are rarely stored; however, if stored, it should be labeled and used within 48 hours. Dietary [NAME] #1 acknowledged that meat stored in the reach-in freezer should have been wrapped and labeled with used by date. They admitted that they missed labeling these items and it was an error on their part. On 03/02/2026 at 12:50PM, Dietary [NAME] #2 was interviewed who stated they are aware the process of proper packaging and labeling of opened food items includes labeling the used by date. Dietary [NAME] #2 further stated that they always follow this procedure, so they don't know why the listed items were found without the proper labeling. 10 NYCRR: 415.14(h)

Based on record review and interviews conducted during the Recertification survey from 1/03/2024 to 1/10/2024, the facility did not ensure the Infection Preventionist completed specialized training. This was evident during infection control review. Specifically, the Infection Preventionist did not complete specialized training in infection prevention prior to being hired as the facility's Infection Preventionist. The findings are: The facility policy titled Infection Preventionist dated 11/2023 documented the Infection Preventionist completed specialized training in infection prevention and control. There was no documented evidence the Infection Preventionist received specialized training on facility infection prevention and control. During an interview on 1/09/2024 at 9:50 AM, the Infection Preventionist stated they became the Infection Preventionist on 12/6/2023 and did not complete specialized training with regards to he Infection Preventionist role prior to their employment with the facility. The Infection Preventionist stated they completed a standard infection control course that awarded them 4 hours of continuing education credit. During an interview on 1/09/2024 at 3:32 PM, the Director of Nursing stated the facility's Assistant Director of Nursing and Minimum Data Set Coordinator received training in infection control and worked with the Infection Preventionist who will now complete the specialized training required to become an Infection Preventionist. 10 NYCRR 415.19

Based on record review and staff interviews conducted during the Recertification survey, the facility did not ensure that a surety bond or similar protection with the amount equal to at least the current total amount of resident's funds was maintained. Specifically, the surety bond held by the facility did not cover the total amount of resident personal funds deposited with the facility. This was evident for 72 of 151 residents who maintained personal funds accounts at the facility. The findings are: On 10/08/2021 at 1:17 PM, the Administrator presented a surety bond with an effective date of 01/31/2021 and termination date of midnight 01/31/2022 in the amount of $100,000. The facility document titled List Resident Funds dated 10/08/2021 documented the current total amount of resident's funds was $262,729.22. The facility did not ensure that the value of the surety bond covered funds currently held in all residents' accounts. On 10/08/2021 at 01:13 PM, the Finance Coordinator (FC) was interviewed. The FC stated that the Surety Bond was not the responsibility of the FC and was kept in a safety deposit box. On 10/08/2021 at 01:17 PM, an interview was conducted with the Facility Administrator (FA). The FA stated that the corporate office sends the Surety Bond annually and it is filed in the records. The FA also stated that the facility is not a stand-alone facility and is covered by a corporate office which addresses matters pertaining to the Surety Bond. The FA further stated that the current Surety Bond does not match the amount of money in the facility. 415.26(h)(5)(v)

Based on observations, record reviews and staff interviews conducted during the recertification survey, the facility did not ensure that a resident receives care consistent with professional standards of practice to prevent pressure ulcers. Specifically, a resident with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . This was evident for 1 of 4 residents reviewed for Position/ Mobility out of a sample of 33 residents. (Resident # 92) The findings are: The facility policy and procedure titled Splint/Orthotics Policy and Procedure dated 1/2021, documented Treatment/ Evaluating therapist need to stay on top of the device status( delivery, wear time). The responsibilty falls on everyone, without exception, everyone who is assigned a patient has a goal for a device must review the goal frequently and follow up with the device. Constant communication between the Director of Rehab and treatment therapist working with the resident requiring the device is a must. This will include folowing up with the device. Resident # 92 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set assessment dated [DATE] documented: Resident with severely impaired cognitive skills, at risk of developing pressure ulcers/ injuries and had 1 Stage 4 Pressure Ulcer which was present upon admission. The MDS also documented the resident was receiving pressure reducing devices for chair and bed and pressure ulcer care. On 10/04/21 at 11:21AM and 3:25PM, Resident #92 was observed wearing cushion boots on the left heel. There were no cushion boots observed on the right heel On 10/05/21 at 10:06AM and 3:27PM, Resident #92 was observed wearing cushion boots on the left heel. There were no cushion boots observed on the right heel. On 10/06/21 at 9:21 AM and 3:02PM, Resident #92 was observed wearing cushion boots on the left heel. There were no cushion boots observed on the right heel. The Comprehensive Care Plan (CCP) for Pressure Ulcer, revised 6/8/2021 documented interventions which included B/L(bi-lateral) heel off-loading cushion boot to be worn at all times. Remove for skin care and during care. The (CCP) for Skin Integrity, revised on 10/19/2020 documented bilateral heel pads provided. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/05/21 at 2:54PM, Certified Nursing Assistant (CNA) #1 was interviewed. CNA # 1 stated that the resident has only one boot for the left heel, and no boot for right heel. CNA #1 also stated that sometimes I apply the left boots on the left heel and sometimes the therapy staff apply the left boot on the left heel. CNA#1 further stated the CNA had not seen a heel boot for the right heel. CNA#1 further stated the LPN#1 was made aware there in no boot for the right heel. On 10/05/21 at 2:57PM, The Licensed Practical Nurse (LPN) # 1 was asked if CNA#1 told there is no boot for the right heel. The LPN#1 stated I did not know if the resident's right heel needed to have a heel boot also. LPN#1 stated I will check the doctor's order. The LPN#1 came back and stated there is an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The LPN#1 further stated that I should have provided a boot for right heel so that CNA can apply boot to both heels. On 10/05/21 at 3:00PM, Registered Nurse Unit Manager (RNUM) #1 was interviewed. RNUM # 1 stated that the resident has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The RNUM #1 also stated the resident should have cushion boots on both heels and did not know why only the left heel had a cushion boot applied. RNUM #1 further stated my responsibility is to make sure all protective devices, example booties are applied as ordered by the Physician. On 10/07/21 at 2:23PM, the Director of Nursing (DON) was interviewed. The DON stated that the expectation is that when there is an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The CNA then documents in the Sigma electronic medical record (EMR). The DON also stated that the assigned nurse is notified by the CNA if there is a problem with device application and brings it to the attention of rehab team. The DON further stated that the Unit Manager is responsible to ensure that devices ordered by the physician are applied correctly.The DON also stated that an in-service education will be done going forward to ensure that devices are applied as ordered by the physician. 415.12 (c)(1)

Based on record review and interviews conducted during Recertification and Abbreviated survey (NY 800), the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice. Specifically, a resident with a low blood pressure after a fall was not monitored, and the doctor was not made aware. This was evident for 1 out of 3 residents reviewed for Quality of Care out of a sample of 33 residents. (Resident # 308) The findings are: The facility's policy and procedure titled Change in Condition and Hospital Transfer dated ,d+[DATE] documented that the facility will ensure that each resident obtains optimal improvement and does not deteriorate. Any deterioration in health, mental, or psychosocial status causing life-threatening conditions, such as cardiovascular emergencies and the resident's baseline medical condition that constitutes an abnormal condition, will be reported to the nursing supervisor, RN manager, and the physician. Resident # 308 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) dated [DATE] identified Resident # 308 cognition as moderately impaired and required extensive assistance of one staff for bed mobility, toilet use, and personal hygiene The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #308 received Losartan-[MEDICATION(S)] and [MEDICATION(S)] at 9:00 AM as ordered. A review of the progress notes and the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse's Progress Note dated [DATE] at 11:54 AM documented that Resident # 308 had a fall at 11:40 AM. The resident was observed lying on the floor in the room next to the bed. The resident was unable to give an account, and upon assessment, no injury was noted-blood pressure ,d+[DATE], heart rate 68. The doctor made aware of the fall. Review of the Nurse's progress Note revealed no documented evidence that Resident #308 was placed on monitoring post fall. The physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] #308 was observed lying on the floor next to his bed. The resident was not able to tell what had happened. Upon assessment, no injury was noted. The plan documented included physical and occupational therapy for functional decline and gait decrease. A review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The Clinical Monitoring Detail Report dated [DATE] to [DATE] at 3:19 AM documented that Resident #308's blood pressure ranged between ,d+[DATE] to ,d+[DATE]. The Nurse's Progress Note dated [DATE] at 1:18 AM documented that on [DATE] at 11:40 PM, Resident # 308 was observed with a change in mental status, unresponsive to verbal stimuli, eyes open, skin cool to touch, blood pressure ,d+[DATE], heart rate 60. The Supervisor and respiratory called and attended. Venti mask applied, and 911 activated. The Nurse's Progress Note dated [DATE] at 1:24 AM documented that Resident #308, was unresponsive to verbal and tactile stimuli. Oxygen saturation 57% on 2 liters nasal cannula, Venti mask applied at 10 liters with saturation to 66%. 911 was activated at around 12:05 AM and responded around 12:15 AM and took over. Resident # 308 was intubated by the 911 team and taken to the hospital for further management. The resident left the facility around 12:40 AM. The Nurse's Progress Note dated [DATE] at 4:20 AM documented that the hospital called and reported that Resident #308 was pronounced dead at 2:40 AM. On [DATE] at 10:46 AM, Licensed Practical Nurse (LPN) #1 was interviewed. LPN #1 stated said that Resident #308 was observed lying on the floor in the room on [DATE]. Vital signs were taken, and the blood pressure was ,d+[DATE]. LPN #1 also stated the supervisor was made aware of the fall and assessed the resident. LPN #1 further stated that there were no orders for monitoring, and no neurological assessment was done, and it is the facility's protocol for neurological assessments to be done when residents fall and strike their heads on the floor. On [DATE] at 2:26 PM, LPN #2 was interviewed. LPN #2 stated that the Certified Nursing Assistant (CNA) informed them at around 11:40 PM on [DATE] that Resident #308 was not looking well. LPN also stated that Resident #308 was observed with labored breathing and was not responding so they placed oxygen on the resident, took the vital signs, and called the supervisor immediately. LPN #2 further stated that residents with falls are monitored frequently, and neurological checks are done usually every 15 minutes or every 30 minutes, after a resident fall depending on the situation. On [DATE] at 11:41 AM, the Registered Nurse Supervisor (RNS) was interviewed. The RNS stated that the LPN called at the beginning of the night shift on [DATE] to report that Resident #308 was unresponsive. 911 came and intubated the resident, the resident was sent to the hospital and died later. The RNS also stated that the facility protocol is that residents are monitored after falls and staff are required to check the vital signs and check for any delayed injury. On [DATE] at 2:23 PM, the Medical Doctor (MD) was interviewed. The MD stated that the resident fell and was assessed, and there was no injury, so no recommendation was given. The MD also said they were not aware that Resident #308's blood pressure was ,d+[DATE]. The MD further stated that neurological checks would have been recommended if there was an apparent injury. The MD stated that the nursing staff should have informed them of the low blood pressure and repeated it. The MD stated they were aware that the resident had fallen but they were not informed of the low blood pressure. On [DATE] at 9:04 AM, the Director of Nursing (DON) was interviewed. The DON stated the resident fell , the Registered Nurse Supervisor performed a head to toe assessment, and the resident had no injury. The DON also stated the resident should have had vital signs and range of motion monitored to see if there was any change from the baseline. The DON further stated the frequency of vital signs assessment will depend on the initial vital signs and on the overall status of the resident. The DON stated that the neurological check is done depending on the circumstances under which the resident was found and the staff should have done the neuro check since the resident was found lying on the floor. 415.12

Based on record review and interviews conducted during the Recertification survey the facility did not ensure that baseline care plans were developed within 48 hours and a written summary provided to the resident or the resident's representative. This was evident for 3 out of 33 residents reviewed. (Residents # 158, #83, & #131) The findings included but were not limited to: The facility policy titled Care Planning dated 01/2021 documented that the facility develops a Baseline Care Plan within 48 hours based on initial admission/readmission assessments. 1. Resident # 158 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severely impaired cognition. The Baseline Care Plan created 7/29/21 was documented as completed on 7/30/21. Review of the progress notes dated 07/29/2021 to 08/18/2021 revealed no documented evidence that a written summary of the baseline care plan was given to the resident or resident's representative. 2. Resident # 83 was admitted into the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS assessment dated [DATE] documented the resident had intact cognition. The Baseline Care Plan created 5/13/21 was documented as completed on 5/20/21. The baseline care plan was not completed within 48 hours of admission. Review of the progress notes dated 10/08/2021 to 10/08/2021 revealed no documented evidence that a written summary of the baseline care plan was given to the resident or resident's representative. 3. Resident #131 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) assessment dated [DATE] documented resident with moderate cognitive impairment. Baseline Care Plan created 6/12/21 was documented as completed on 6/15/21. Social Services note dated 6/17/21 documented that a baseline team meeting was held with resident's family members on that date. There was no documented evidence that the baseline care plan had been developed within 48 hours and a written summary of the baseline care plan provided to resident or representative. On 10/08/21 at 10:16 AM, Registered Nurse (RN) #3 was interviewed. RN #3 stated that the Baseline Care Plan (BCP) was done upon the availability of the MD and can be done by video calls at times. RN #3 also stated that the Dietician, Nurse, Manager, Rehab, MD, and Social Work usually participated. RN #3 further stated that the BCP is completed within 72 hours of any resident admission. RN #3 stated that on weekends, it can be an interrupted process but normally the facility tries to get it done within the 48 hours. Once the BCP is completed, a meeting is held with the resident and their involvement in the meeting is reflected in the documentation in the Social Services section of the electronic record. On 10/08/21 at 11:44 AM, the Social Worker (SW) was interviewed. The SW stated that the BCP is done within 72 hours of admission to the facility. The SW also stated that the BCP meeting is held and discussed with the resident or family and documented on the computer with an electronic signature. On 10/08/21 at 01:52 PM, the Director of Nursing (DON) was interviewed. The DON stated that all newly admitted residents receive a BCP. The DON also stated that the family is contacted to determine their availability for the meeting, and they can attend either in-person or via phone. The DON stated that the timeline for BCPs is within 48 hours of admission and they are aware that it is not being done within the regulatory timeline all the time as it can be a challenge on the weekends. The DON also stated that the BCP completion is documented on the Electronic Medical Record and if some disciplines are absent, it can be done via a phone call. The DON further stated that the resident always gets a printed copy of the BCP, it is printed and filed in the medical chart, and Social Services and the MDS Coordinator will write a note that a baseline care plan meeting was done. On 10/08/21 at 02:04 PM, the Facility Administrator (FA) was interviewed. The FA stated that the Baseline Care Plan is done upon admission and that they would communicate with each department to get them done. The FA also stated that they make the notification of all new admissions so that the departments are aware of the admission. The FA further stated that they were aware of the 48 hours timeline. 415.11(c)(2)-(i-iii)

Based on record review and staff interviews conducted during the Recertification survey, the facility did not ensure that individual financial records were available to the resident through quarterly statements. Specifically, a resident did not consistently receive quarterly statements from 01/01/2021 to 10/07/2021. This was evident for 1 out of 1 resident reviewed for Personal Funds out of a sample of 33 residents. (Resident #20). The finding is: The facility policy Resident Funds with an effective date of 10/01/2018 and revised 09/2021 contained no reference to the provision of quarterly statements. Resident #20 was admitted to the facility with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented that resident's had intact cognition. On 10/04/2021 at 02:34 PM, the resident was interviewed. The resident stated that Social Security funds had been issued and they had not been receiving quarterly statement of their finances being held by the facility. The Resident Fund Ledger dated 01/01/2021 - 03/31/2021, 04/01/2021 - 06/30/2021, and 07/01/2021 - 09/30/2021were not signed by the resident. There was no documented evidence that the resident was provided with the quarterly statements for the period of 10/01/2020 - 09/30/2021. On 10/08/2021 at 10:07 AM, the Social Worker (SW) was interviewed. The SW stated that they were not involved in providing financial statements to the resident and that was handled by the Medicaid Representative. On 10/08/2021 at 11:26 AM, the Finance Coordinator (FC) was interviewed. The FC stated that their duties included the oversight of the resident's funds once they are admitted to the facility. The FC also stated that residents are provided with statements every three months. A copy is printed, and the Recreation Department will distribute to all residents. The FC further stated the residents sign the log and a copy of the log is kept in the finance and recreation offices. On 10/08/2021 at 01:13 PM, the FC was re-interviewed. The FC provided quarterly statements for the period 10/01/2020 - 09/30/2021 that were all unsigned. The FC stated that they were unable to locate log sheets for the statement periods above. On 10/08/2021 at 01:17 PM, the Administrator (ADM) was interviewed. The ADM stated that given out by recreation and recreation and nursing both keep copies of the resident funds. The ADM stated that all residents get a quarterly statement, the alert residents receive their own and finance and recreation will mail to the families if residents are not alert. The ADM stated that the alert residents will sign indicating receipt of the document. 415.26(h)(5)

Based on observation, record review and staff interviews, the facility did not ensure that a comprehensive person-centered care plan to meet resident's medical needs was developed and implemented. Specifically, a care plan was not developed for a resident with a neurological condition and the presence of a ventricular-peritoneal (VP) shunt and status [REDACTED]. (Resident # 125) The facility policy: Care Plans-Comprehensive revised (MONTH) 2019 documented the following: an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident . # 3. Each resident's comprehensive care plans is designed to: (a) incorporate identified problem areas; (b) incorporate risk factors associated with identified problems; (e) reflect treatment, goals, timetables and objectives in measurable outcomes; (f) identify the professional services that are responsible for each element of care; (i) reflect currently recognized standards of practice for problem areas and conditions. The finding is: Resident # 125 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. (A VP shunt is a tube placed in the brain to drain excess fluid) The Minimum Data Set (MDS ) 3.0 assessment dated [DATE] documented the resident's cognition as severely impaired and the resident is totally dependent on staff for Activities of Daily Living (ADL's). The MDS also documented that the resident had a feeding tube and was maintained on a ventilator. On 03/20/2019 at 12:34 PM, and on multiple occasions during the recertification survey, the resident was observed lying in bed with a tracheal tube connected to a ventilator. In addition, a peg tube was observed with feeding infusing well. Review of the physician's orders [REDACTED]. Neurology consult completed on 03/13/2019 documented enlarged ventricles on Computer tomography (CT ) of the VP shunt with the following recommendations; follow up in two weeks and it is important that the resident sits up more upright to help the shunt drain. Review of the Comprehensive Care Plans (CCP ) dated 12/06/2018 revealed there was no care plan implemented to address the neurological condition of a resident who has a VP shunt and is status [REDACTED]. On 03/22/2019 at 12:30 PM, the Registered Nurse Manager RNM #1 was interviewed. RNM #1 stated that she had developed a neurological care plan for the resident's [MEDICAL CONDITION] but did not make one for the VP shunt. RNM#1 also stated that she did not know she needed to create one for that concern. On 03/22/2019 at 12:35 PM, RN#3 who is the facility educator was interviewed. RN #3 stated that there was a care plan in place for increased intracranial pressure which was not continued after the resident was hospitalized and readmitted to the facility. 415.11 (c) (1)

Based on record reviews and interviews conducted during an abbreviated survey (NY 018), the facility did not ensure the development and implementation of comprehensive person-centered care plan for a resident. This was evident in 1 out of 4 residents sampled (Resident #1). Specifically, the facility did not ensure a comprehensive care plan was developed, with measurable goals and person-centered interventions to address several blisters, some of which were ruptured, on Resident #1's left 2nd, 3rd, 4th and 5th toe. Findings: Resident #1 was initially admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) dated 12/20/2017 documented that Resident #1 had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation and ability to recall information) and scored 8/15, associated with moderate impairment of cognition (00-7 severe impairment, 08-12 moderate impairment and 13-15 cognitively intact). The facility policy and procedure titled, Comprehensive Care Plan (CCP), dated 12/2015 states that the Comprehensive Care Plan (CCP) will be individualized, defining the problems/needs identified from each discipline's assessment, attainable goals and interventions. Each resident's CCP shall be reviewed and updated by the interdisciplinary team as per MDS 3.0 schedule and if the resident's condition warrants it. A Nurse's Progress Note by the Registered Nurse Supervisor #1 (RNS #1) dated 12/27/2017 at 1:04 PM, documented that RNS #1 was called to Resident #1's room by the attending nurse and the resident was noted with opened areas to the 2nd, 3rd, and 4th left toes. All 5 left tarsal digits noted with multiple fluid blisters and a blood- filled blister to the great toe. A Nurse's Progress Note by RN#2 (Wound Nurse) dated 12/27/2017 at 5:01 PM, documented that she assessed Resident #1's left foot. The left first toe had multiple blood-filled blisters, left 2nd toe with ruptured blister; left 3rd toe with ruptured blister, left 4th toe with ruptured blister; and left 5th toe with fluid filled blister. The treatment included xeroform dressing and dry pressure dressing daily and as needed. A Physician's Progress Note dated 12/27/2017 at 5:22 PM, documented that Resident #1 was seen for abrasion (skin tear) to left 2nd, 3rd and 5th toes. A Physician's Progress Note dated 12/28/2018 at 1:10 PM, documented that Resident #1 was receiving wound care for multiple opened blisters on the left toes. Record review revealed that a skin impairment CCP was not initiated with interventions in place to address Resident #1's skin condition. RN #2 was interviewed on 06/08/2018 at 11:42 AM and stated that RNS #1 called her to assess Resident#1's left foot on 12/27/2017, and she observed the blisters on the resident's toes and that a CCP was not created to address the blisters on the resident's left foot. The Director of Nursing Service (DNS) was interviewed on 12/21/2018 at 4:40 PM and stated that a Care Plan (CP) on Skin Alteration should have been created whether the resident received treatment or not and that any RN could have created the CP. 415.11 (c)(1)

Based on interviews and record review conducted during an abbreviated survey (NY 018), the facility did not ensure that an accident was investigated. This was evident for 1 out of 4 residents sampled (Resident #1). Specifically, Resident #1 was noted to have open areas and blisters to the left foot toes after a Certified Nursing Assistant (CNA) reported bumping the resident's foot with a Geri-Chair. The facility did not investigate the accident to rule out abuse, neglect or mistreatment. Findings: Resident #1 was initially admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) dated 12/20/2017 documented that Resident #1 had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation and ability to recall information) and scored 8/15, associated with moderate impairment of cognition (00-7 severe impairment, 08-12 moderate impairment and 13-15 cognitively intact). The facility policy and procedure titled, Accident-Investigation Data Collection, dated 11/2003 states that all accidents will be investigated, documented and reported to the New York State Department of Health as appropriate. A review of the facility's Accident/Incident Reports for 12/01/2017 through 12/31/2017 revealed no incident report regarding an accident involving Resident #1 on 12/27/2017, when a CNA hit the resident's left foot with a Geri-Chair. A Nurse's Progress Note by the Registered Nurse Supervisor #1 (RNS #1) dated 12/27/2017 at 1:04 PM, documented that the attending nurse called RNS #1 to Resident #1's room. The resident was noted with opened areas to the 2nd, 3rd, and 4th left toes. All 5 left tarsal digits noted with multiple fluid blisters and a blood- filled blister to the great toe. The CNA stated that while the resident was lying in bed, the padded section of the Geri-Chair bumped the resident left great toe. The resident verified that the chair bumped her left great toe. A Nurse's Progress Note by RN #2 (Wound Nurse) dated 12/27/2017 at 5:01 PM, documented she assessed Resident #1's left foot. The left first toe with multiple blood-filled blister, left 2nd toe with ruptured blister; left 3rd toe with ruptured blister, left 4th toe with ruptured blister; and left 5th toe with fluid filled blister. The treatment included xeroform dressing and dry pressure dressing daily and as needed. RNS #1 was interviewed on 06/08/2018 at 03:04 PM and stated that she received a report from Resident #1's nurse stating that the resident's toes were open. She stated that the CNA (not the assigned CNA to the resident) reported that the same great toe was bumped by the Geri-chair of another resident. She stated that the CNA reported that the resident's foot was hanging off the bed while the resident was lying in bed and that the chair bumped into the resident's left foot while she was transporting the resident's roommate in the Geri chair. RN #1 stated she asked the CNA to write a statement. The CNA admitted she bumped the resident's left foot with the Geri-chair and she reported it to the Charge Nurse. RN#1 also stated that she made an occurrence report and gave the statements to the Director of Nursing (DNS). Licensed Practical Nurse #1 (LPN #1) was interviewed on 06/22/2018 at 11:15 AM and stated that she no longer works at the facility. According to LPN #1, a CNA (cannot recall the name) notified her that the resident had opened areas to the left toes. The resident was in bed and had her left foot extended out of the bed and that the CNA bumped the resident's left foot with the resident's roommate's Geri-chair. LPN #1 stated she cleaned the area and notified RN#1. She further stated that RN #1 did not make an incident report and that RN #1 told her that it was an existing blister that popped, and an incident report was not needed. The resident confirmed that a wheelchair hit her foot. CNA # 1 was interviewed on 06/23/2018 at 11:41 AM and stated that she was pushing one of Resident #1's roommate in a recliner chair (Geri-chair) and did not see Resident #1's left foot hanging out of the bed. She bumped the resident's left foot with the Geri-chair and observed skin tear and bleeding on the 4th toe. She realized that she hit Resident #1's foot with the Geri-Chair when she heard the resident cried out. She does not recall if Resident #1 had blisters on her toes prior to the incident. She wrote a statement of the incident and gave it RN #1. The Director of Nursing (DNS) was interviewed on 06/08/2018 at 3:04 PM and stated that she cannot find the facility investigation of the incident for the incident on 12/27/2017 involving the CNA bumping Resident#1's foot with the Geri-chair. She stated that she was not the DNS at the time of the incident. During a follow-up interview with the DNS on 12/21/2018 at 4:30 PM, she stated that RN#1 assessed the resident's toes after the CNA reported bumping the resident left foot with the Geri-chair. 415.4 (b)

Based on interviews and record review conducted during an abbreviated survey (NY 718), the facility did not provide in-service and training to existing nurse aides that include how nurse aides would understand behavioral symptoms of residents that may increase the risk of abuse, and how nurse aides had to respond. This was evidenced in 1 out of 4 residents sampled (Resident #1). Specifically, Certified Nursing Assistant #1 (CNA #1) was assigned to perform one to one supervision for Resident #1 on 04/04/2018. CNA #1 attempted to redirect Resident #1 and the resident became physically aggressive with the CNA. CNA #1 pushed Resident #1 away from him and the resident fell on his back; sustained a 3cm laceration to the back of his head. Record review revealed that CNA #1 did not receive training on how to understand behavioral symptoms and how to respond to the physically aggressive resident. CNA #1's personnel file revealed that the CNA was last in-serviced on abuse prevention 08/25/2014. The Findings are: The Facility's Policy and Procedure on Abuse Prevention and Reporting dated 03/2018 documented that the resident will be free of abuse. Residents must not be subjected to abuse by anyone, including but not limited to facility staff, consultants or volunteer staff of other agencies. The facility will maintain a system in place to protect the residents from abuse and to protect the health and safety of the resident. It is documented that regularly scheduled in-service training programs are designed to teach staff how to better understand the resident's abusive actions. It is also documented that upon hire, annually, and as needed, all facility employees will receive in-service education on Abuse, Reporting, Behavior Management and care of the Resident with Dementia. Resident #1 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool), dated 03/12/2018 documented that the resident had severely impaired cognition (never/rarely made decisions). An Admission's Assessment note dated 03/05/2018 documented that Resident #1 was at risk for abuse secondary to Dementia and Alzheimer's. Resident #1 was unable to tolerate frustration and acted out impulsively. A Comprehensive Care Plan (CCP) dated 03/12/2018 documented that Resident #1 was care planned for the potential for exhibiting inappropriate behavior as evidenced by [MEDICAL CONDITION]. The interventions documented that the staff should identify patterns in the resident's behavior, document in the progress notes; the intensity, duration or frequency of the behavior. Encourage the resident to participate in activities of daily living (ADLS), notify the physician immediately of behavior and refer to the psychiatrist. Provide redirection or distraction to minimize frequency or duration of behavior. A Resident CNA Documentation Record dated 03/05/2018, revealed no instructions on how the CNAs are to understand and respond to Resident #1's physical aggression. The nurses' notes dated from 03/11/2018 to 03/14/2018 documented that Resident #1 was aggressive towards staff and difficult to redirect. The resident had excessive agitation and/or debilitating restlessness and showed physical aggression towards caregivers. A nurse's note dated 03/16/2018 at 8:47 AM documented that at around 7:30 AM, Resident #1 filled the toilet with diaper and toilet tissue. During redirection, the resident fought, hit and scratched the staff. A nurse's note dated 03/17/2018 documented that Resident #1 was alert and restless most of the evening. [MEDICATION NAME] given with no effects and one-on-one was unsuccessful. A nurse's note dated 03/18/2018 documented that Resident #1 continued with increased restlessness and agitation. The resident kicked, bit, and scratched at the staff. A nurse's note dated 03/20/2018 documented that Resident #1 was restless throughout the tour. He kicked and scratched the staff. Medication given with no effects. A nurse's note dated 03/21/2018 documented that the resident was restless and combative at times. He kicked and bit the staff during care; gentle approach was ineffective. A nurse's note dated 03/23/2018 documented that Resident #1 defecated in his roommate's garbage can. The resident was unable to understand instructions and redirection. A nurse's note dated 04/01/2018 documented that shortly after 6:30 AM, a CNA heard Resident #1 in another resident's room calling out get this man out of here. Resident #1 was naked from the waist down. He was escorted back to his room and was dressed. Resident #1 again wandered into another resident's room. The supervisor, Social Worker (SW) and medical doctor to follow up. A nurse's note dated 04/02/2018 documented that Resident #1 was combative towards staff when they redirected him. A nurse's note dated 04/03/2018 (night shift) documented that Resident #1 was restless and physically aggressive. Resident #1 hit both CNAs as they were attempting to escort him to his room. A nurse's note dated 04/03/2018 (evening shift) documented that the resident was physically aggressive towards staff. The resident punched a staff in the arm and cursed at them. A Social Worker's (SW) note dated 04/03/2018 documented that Resident #1 was very difficult to redirect as he does not follow directions well. Review of the facility's surveillance camera, revealed that on 04/04/2018 at 6:35 AM, CNA #1, who was assigned to provide one-on-one monitoring for Resident #1, was with the resident in the dining room. Resident #1 was pulling the wet ones from a container and was tossing them in the dining room. CNA #1 attempted to redirect him and Resident #1 became physically aggressive. Resident #1 was throwing fast, repetitive punches at the CNA. CNA #1 had his hands held up attempting to block the punches as he was backing away from the resident. Resident #1 pursued CNA #1 with continuous punches. The CNA continued to back away with his hands held up and extended (blocking the punches). However, one of the resident's punches connected with the CNA's lower left cheek. CNA #1 raised his left leg, further extended his arms touching Resident #1 on the chest, and pushed the resident away from him. Resident #1 fell on his back and the CNA went into the hallway and motioned for assistance. As the staff attempted to apply First Aid, Resident #1 became physically aggressive with the staff. The resident twisted the nurse right hand and punched her in the chest. Two other staff members were punched in the face and chest. Staff were observed running away from Resident #1. A nurse's note dated 04/04/2018 at 7:21 AM documented that at around 6:35 AM, CNA #1 approached the nursing station and reported that Resident #1 fell and was bleeding from the head. Resident #1 was assessed and had no complaints of pain. Mild bleeding noted from the laceration at the back of the resident's head. Resident #1 twisted the nurse's right hand and punched her in the chest as she was providing treatment. Two other staff members were punched in the face and chest. The resident was transferred to the hospital. A Physician's note dated 04/04/2018 documented that the resident was observed on the floor in the dining room, sustained superficial laceration 2cm, to the back of the head. The resident was sent to the Emergency Department (ED) for CT-Scan of the head. The resident returned to the facility and his condition was stable. Staff to maintain safety precaution and one to one protocol for wandering behavior. Registered Nurse Unit Manager #1 (RNUM #1) was interviewed on 06/08/2018 at 11:40 AM and stated that Resident #1 was aggressive to CNA #1. Resident #1 punched and hit the CNA while they were in the dining area. Assessment revealed that Resident #1 sustained a laceration to the back of his head with minimal amount of bleeding. During assessment, Resident #1 continued to be aggressive. The physician was informed and ordered that Resident #1 be transferred to the hospital for further evaluation. Resident #1 was on one to one supervision due to his aggressive and combative behavior. The RNUM does not know if CNA #1, who was assigned to provide one to one supervision to Resident #1 (first time assigned to the resident) had prior training on how to handle the resident during his aggressive behavior. She was not aware if any of the staff received training on how to handle aggressive residents. CNA #1 was interviewed on 06/11/2018 and on 07/16/2018 and stated that he was never assigned to provide care to the residents on the units. His duties mainly consisted of escorting residents to and from clinical appointments, monitoring residents in the dining room and at times provided one to one supervision. It was his first time providing one to one supervision to Resident #1. A nurse instructed him, don't let the resident fall, don't let the resident get up and don't hit the resident. At around 6:30 AM, he was monitoring Resident #1 in the dining room when the resident started pulling wet wipes from its container and was throwing them. He attempted to redirect Resident #1 and the resident became physically aggressive. The resident was punching at him as he was trying to move away. He was just trying to get away from the resident. He stated, I did not scream for help, I thought the resident would calm down and it happened so quickly. Resident #1 fell because he was wearing socks. After the resident fell , he was still punching, scratching and hitting at the staff as they tried to provide First Aid. He provided one to one monitoring for other residents, but they never acted like this resident (Resident #1). I didn't know he would act like this. He does not remember the last time he received in-service on abuse prevention and that he never received training on how to handle the residents when they acted like this (aggressive and combative). A Licensed Practical Nurse (LPN) was interviewed on 06/11/2018 at 2:45 PM and stated that Resident #1 was on one to one supervision because of his wandering and aggressive behavior. On 04/04/2018 at approximately 6:00 AM, the resident was awake and went to the dining room with the CNA that was providing one to one monitoring. CNA #1 came to her and reported that the resident fell in the dining area. She went to check Resident #1 and observed him on the floor bleeding. Resident #1 was hitting the staff as pressure dressing was being applied to the site. CNA #1 did not inform her that Resident #1 was being aggressive or that the resident hit him. She stated that she informed CNA #1 that Resident #1 was aggressive and that he should monitor the resident and report to the Charge Nurse (CN) or the supervisor if the resident was aggressive. She received in- service on abuse prevention but unable to recall if she had received in-service on how to deal with the aggressive resident. A Charge Nurse was interviewed on 06/11/2018 at 3:23PM and stated that Resident #1 returned to the facility status [REDACTED]. There was no bleeding noted and there were no changes in mental status. She was not familiar with the resident as she floated to the unit on 04/04/2018 post incident. Resident #1 was on one to one supervision because of his aggressive behavior. He wandered around the unit and got physically aggressive when redirected. The facility provided in-service on abuse prevention, but she does not remember receiving in-service on how to deal with the combative resident. The In-Service Coordinator was interviewed on 07/26/2018 at 11:10 AM and stated that she does not recall the staff receiving in-service or training on how to handle/approach aggressive and combative residents. She stated that she could not find a current in-service on abuse prevention for CNA #1. A follow-up interview was conducted with the In-Service Coordinator on 08/06/2018 at 9:46 AM. She stated that she is the wound care nurse for the facility and she assumed the position of In-Service Coordinator 01/2016. She is responsible for ensuring that all the staff receive in-services on abuse and how to care and manage cognitively impaired residents as well as how to manage residents with behavior problems in the long-term care unit. Facility and agency staff received in-services during orientation and mandatory in-services are provided annually to all staff. Staff received in-service on abuse prevention 01/2017. However, there were no in-services on Dementia Management and or training for staff understanding of how to handle aggressive residents to prevent abuse. The Director of Nursing Service (DNS) was interviewed on 07/16/2018 at 2:32 PM and stated that it is the nurse's discretion to provide one to one supervision when a resident is aggressive and combative. The CNA who provided one to one supervision was given verbal instructions on how to deal with the aggressive resident. CNA #1 did not have an updated in-service on abuse prevention (last in-service 08/25/2014) and the nursing staff did not receive in-service on how to manage the physically aggressive resident. A follow-up interview was conducted with the DNS on 07/17/2018 at 10:00 AM. The DNS, stated that it is the responsibility of the facility to give in-services to all agency staff and that mandatory in-services are conducted once a year. The staff working on the long-term unit must receive in-service on Dementia Care. The facility does not have a policy regarding the in-servicing and training of staff. 415.(b)(7)(b)

Based on observations, record reviews and interviews, the facility did not ensure that the facility prepared food under sanitary conditions. Specifically, Dietary and Kitchen staff were observed during multiple observations preparing food while not properly wearing hair restraints such as hair and beard nets. The findings are: 1) On 05/24/2017 at 11:26 AM during the observational tour of the facility's kitchen Dietary staff were observed not properly wearing hair restraints or beard nets while preparing food. Dietary #8 was observed preparing had hair on his chin about 1/2 inch long, without a beard net, preparing coleslaw. During that same time the Cook who was chopping vegetables for soup was observed with a beard approximately ½ inch of hair on his chin. The Cook did not have on a beard net. The Assistant Food Supervisor (AFS) was observed assisting with the tray line - handling cold items. The AFS was wearing a hairnet. However it was not properly covering her hair as hair from both sides were sticking out from the hairnet. Dietary Aide #6 was observed preparing eggs for sandwiches. She was wearing a hairnet. However, the hairnet did not properly cover her hair, as her hair was sticking out from the sides of the hairnet. 2) On 05/25/2017 at 10:19 AM during a second observational tour of the facility's kitchen the Cook was observed preparing vegetables and did not have a beard net covering his beard. On 05/26/2017 at 9:30AM an interview was conducted with the Food Service Manager (FSM). FSM stated that men should have clean-shaven moustache and the female Dietary Aides (DA) must have their hair fully covered as soon as they enter the kitchen. FSM further stated that Staff must wear the hairnet at the hairline to secure loose hair. FSM stated that a Staff In-service training regarding the use of hair restraints/hairnets is done once a month. FSM added that if any Dietary Aide is not in compliance, the Dietary Aide will be disciplined. A copy of the policy and procedure for the use of hairnet/beard net was provided. Assistant Food Supervisor (AFS) was not interviewed since AFS was off on 5/26/2017 On 05/26/2017 at 11:09 AM The Cook was interviewed and said he forgot to wear the beard net during entrance and on the second day. He worked at the facility for [AGE] years now. The facility policy documents that men must be clean shaven. A small trimmed mustache is permitted . Hair must be pulled away from face and secured. Hairnets must be worn to secure all loose hair. 415.14(h)

Based on observations, staff and resident interviews and record review the facility did not ensure that pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) were provided to meet the needs of each resident. Specifically, Resident #24 did not receive her scheduled medication for two days because the medication was not in stock. The procedure for dispensing medication to the facility was not followed, resulting in dispensed medication not being received by the facility from the pharmacy in a timely manner. As a result, the facility did not have medication available. This was evident for one (1) resident out of 6 residents reviewed for Unnecessary Medication out of a sample of 31 residents. (Resident # 24). The finding is: Resident # 24 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 05/22/17 at 9:45 AM resident # 24 informed the SA that she is still waiting to receive her medication since yesterday Sunday (05/21/17). She stated that she is been told repeated that this past weekend that pharmacy has not delivered it because they are located in New Jersey. She stated that the nurses also have told her that pharmacy will deliver it on the next delivery but it never came. The resident stated that this medication helps her with her hand spasms and pain. The physician order dated 05/50/17 documented medications including, carbamazepine (Tegretol) 200 milligrams twice a day 9:00 am and 5:00 pm for muscle spasms Review of the Medication Administration Record [REDACTED]. Reason: 05/21/17 9:00 am pharmacy called. to dispense on next run. On 05/21/17 at 5:00 pm not administered. Awaiting delivery. PMD (primary medical doctor) aware. On 05/22/17 at 9:00 am not administered. Awaiting delivery PMD aware. Review of the MAR for 05/22/17 timed at 11:45 am documented Carbamezepine 200 mg by mouth was administered. Review of Nursing Progress notes from 05/19/17 - 05/21/17 found no documented evidence that medication was unavailable. Review of the nurse progress note dated 05/22/17 documented, did not get her medication for [DIAGNOSES REDACTED] .resident in no acute distress .no complaint of pain .wants her medication before going to therapy . On 05/22/17 at 11:40 am the SA observed a ten (10) day supply of carbamazepine 200 mg by mouth given twice a day was delivered and received by the unit nurse manager who then signed the packing slip. On 05/22/17 at 11:45 am the resident received her medication. RN #1 was interviewed on 05/22/17 at 10:30 AM. RN #1 is the Nurse Manager for the 1st floor. RN #1 stated that she was just informed this morning that an issue of medication for this resident had occurred over the weekend. She stated that she spoke to the medical doctor and called the pharmacy to request a stat (immediate) delivery of this medication. She stated that she was told by the pharmacy that a delivery for this medication had been made on May 5th. RN #1 stated that she looked in on the resident who expressed that she needed her medication before going to therapy today. RN #1 stated that the resident did not tell her that she was in any pain. RN #1 further stated that the nurses are to report medication issues to the supervisor and that the doctor should be made aware. She stated that this is not a typical pain medication and therefore no pain scale is used. She stated that the resident is asked daily if she is in pain and that it is documented in the daily notes. She stated that medications are to be reordered at least three days prior to the resident running out. Nurses can call or use the computer to reorder. She stated that it is important that nurses report when medications are unavailable, and other pharmacy issues. She stated failure to do so has the potential to affect scheduled medication administration times and treatment schedules. LPN #2 (Licensed Practical Nurse) was Interviewed on 05/23/17 at 9:30 AM. LPN#2 was on duty on Friday 05/19/17 during the day shift. LPN #2 stated that she called the pharmacy during the afternoon on 05/19/17 to reorder the Carbamezepine because the resident had only three pills remaining. The Pharmacy informed her that a thirty (30) day supply was sent on May 5, 2017. The Pharmacy staff told her that they would get back to her because they would have to be reimbursed. LPN #2 stated that when issues of medication arise, or when there is a pharmacy issue she is to notify her supervisor. She stated that she did not do this. LPN #2 stated that she did not report this to the oncoming shift. She stated that the resident had enough medication for Friday 05/19/17 and Saturday 05/20/17. LPN #3 was interviewed on 05/23/17 at 11:15 AM. LPN #3 was on duty during the day shift on Saturday 05/20/17. LPN #3 stated that medications are to be reordered five to seven days before the resident is out of medication. She stated that she called the pharmacy, but not about this medication. She stated that she recalls the there were enough medications in the blister pack. LPN #4 was interviewed on 05/24/17 at 9:42 AM. LPN #4 was on duty during the evening shift on Saturday 05/20/17. LPN #4 stated that she called the pharmacy about the need for the above medication and was told that a delivery would be made in the evening. LPN #4 did not report to the supervisor that the resident had run out of the Carbamezepine. LPN #5 was Interviewed on 05/24/17 at 11:15 AM. LPN #5 was on duty during the day shift on Sunday 05/21/17. LPN #5 stated that the pharmacy did not deliver the medication Carbamezepine. LPN #5 stated that she was told to expect a delivery and none was made. She stated that she called the pharmacy in the afternoon and was told that the facility would be billed and that a delivery would be made in the evening. She stated that she informed the resident that her medication would be delivered in the afternoon. She stated that the resident was ok and did not complain of being in pain. She denied that the resident rang the call bell frequently to request her medication. She stated that she checked in frequently to reassure her that her medication would be delivered. The LPN stated that she did not report this issue to her supervisor, or the physician. She stated that she informed the nursing staff on the incoming evening shift to expect the delivery of the Carbamezepine. LPN #6 was Interviewed on 05/24/17 at 3:35 PM. LPN #6 was on duty during the evening shift on Sunday 05/21/17. LPN #6 stated that she was informed by the day shift nurse that the resident did not receive her 9:00 AM medication Carbamezepine and to expect a pharmacy delivery in the evening. She stated that she checked in with the resident often because she was worried that the resident did not receive her medication. She stated that the resident looked uncomfortable and that the resident told her that she was having tingling and spasms and might have been in pain. She stated that she called the pharmacy and was told that a midnight delivery would be made. LPN #6 stated that she did not follow up with her supervisor and that the doctor was not notified. She stated that she informed the oncoming night shift to expect a delivery of the residents medication. Interview with the medical doctor on 05/23/17 at 1:50 pm and stated that he is the treating physician since the residents admission. He stated that the resident has a disease that manifests itself with spasms which affect her entire body particular her bladder, her hands and her spinal cord. I have seen her a few times to listen to her lungs, take her pulse and ask her, how are you doing?. She has not mentioned that she has pain. I have not asked her if she is experiencing pain. I expect patients to tell me if they are having pain. I did not associate her having pain with her spasms and was not mentioned to me. I was not previously made aware that she did not get her medication all day Sunday and part of Monday. I was made aware of this today by the nurse manager. I visited her today Monday afternoon, once she received her medication and she told her hands felt tingly,. I expect that when a problem with medication come up that I am made so that I can reorder something else. Interview on 05/24/17 at 12:30 pm with the pharmacy customer service personnel stated that she refills MEDICATION ORDERS FOR [REDACTED]. The first order was requested and received on 04/07/17 with delivery made on 04/08/17 for 30 days. On 05/03/17 60 pills (30 day supply) was delivered as a request was placed by phone for the same medication. When asked for proof of delivery none was available. She stated that no receipt is available for proof of this delivery / transaction. She stated that outside vendor called wellness express is contracted out to make deliveries. She stated that a call was received on 05/05/17 by a nurse saying that the medication was not available. We re-sent a 30 day supply. When asked for proof of this delivery none was available. She stated that the driver is to scan the bar code on the packing slip. She stated that the driver carries a small device that scans the bar code and that this may have not been done by the driver. She stated that a ten day supply was sent on Monday 05/22/17. Proof of this delivery was provided. On 05/24/17 at 12:30 pm the pharmacy customer service agent was interviewed. She was stated that she refills MEDICATION ORDERS FOR [REDACTED]. The first order was requested and received on 04/07/17 with delivery made on 04/08/17 for 30 days. On 05/03/17 60 pills (30 day supply) was delivered as a request was placed by phone for the same medication. When asked for proof of delivery none was available. She stated that no receipt is available for proof of this delivery / transaction. She stated that outside vendor is contracted out to make deliveries. She stated that a call was received on 05/05/17 by a nurse saying that the medication was not available. We re-sent a 30 day supply. When asked for proof of this delivery none was available. She stated that the driver is to scan the bar code on the packing slip. She stated that the driver carries a small device that scans the bar code and that this may have not been done by the driver. She stated that a ten day supply was sent on Monday 05/22/17. Proof of this deilvery was provided. On 05/24/17 at 12:50 PM the QA person for Specialty Pharmacy was interviewed. It was stated that a outside vendor picks up meds, from pharmacy located in New Jersey and delivers them. The delivery person carries a device that scans the bar code on the packing slip. The devices are important because this is data that is collected and imported into the pharmacy system for proof of delivery. We have had this problem before with the devices in the past and we contact the vendor company to address the problem. The pharmacy contract states that the facility has a designated window of time of 24 hours to report delivery discrepancies and the pharmacy will resend those meds at no cost to the facility. The issue seems to be that the driver is not scanning delivery receipts. It is up to pharmacy to review this information and determine of we want to continue to do business with the vendor. This seems to be an ongoing problem with the driver and has been known to us. It is up to pharmacy as to how they want to handle this. The delivery person is to scan the receipt that is attached to the med bag and signed by the receiving nurse. Interview with the Director of Nurse on 05/24/17 at 3:10 pm stated that her staff are to report any medication issues to the nurse managers especially if they are being told by pharmacy if a delivery has already been made. The nurses are to order once a resident has a least a three day supply left. They have been inservices on how to do this on sigma. The doctor is to be made aware immediately if a resident is not getting there prescribed medication. This way the doctor can do something else or order something else. Also the nurse are to be monitoring and documenting the status of the resident in the meanwhile. Reporting and communicating to oncoming shifts is important and keeps everyone aware of what to anticipate. Review of the facility policy for unavailable medications' documented, it is the policy that each individual receive the necessary medication as ordered by the Primary Medical Doctor (PMD) .when medications are not available, the PMD will be notified who will adjust medication regime accordingly .nurse must notify supervisor nurse must notify Pharmacy nurse document in the progress note that the medication is unavailable and that the PMD is notified .the supervisor is responsible for contacting the pharmacy if any problems regarding delivery .the nurse must document on 24 hour report sheet . Review of Specialty Pharmacy contract dated November 2016 documented, .Provide products in a prompt and timely manner .collaborate with the facility to coordinate pharmacy documentation processes . 415.18(a) .

Based on observation and interview, the facility did not ensure that residents were fed in a manner to enhance their dignity. Specifically, residents were fed while staff were standing over them. This was evident for 1 of 5 resident floors (4th floor). The finding is: On 5/24/17 from 12:39 PM to 12:55 PM, the 4th floor lunch was observed. Five staff members, consisting of 4 Certified Nursing Assistants (CNAs) and 1 Licensed Practical Nurse (LPN #2), were observed feeding residents while standing over them. One of the CNAs finished feeding one resident while standing and then began feeding another resident while standing. The Registered Nurse (RN) was observed trying to encourage a resident to eat by attempting to feed the resident while standing over them. On 5/24/17 at 3:18 PM, LPN#2 was interviewed and stated that she should be seated while feeding residents in order to be face to face with them. She stated that being seated enables staff to be at eye level so they can speak to the resident and see inside the resident's mouth. She further stated that she was standing because there were no stools left, and there were only 4 stools in the dining room. On 5/24/17 at 3:22 PM, the RN Unit Manager #1 was interviewed and stated that staff should be seated while feeding so that the resident can be made comfortable, making the meal more enjoyable. She further stated that with the number of staff present today, there were not enough stools available, but she normally encourages her staff to sit while feeding. The RN also stated that she was trying to encourage the resident to eat, and if the resident started accepting the food, she would have obtained a chair to sit in. On 5/25/17 at 1:10 PM, CNA #1 was interviewed and stated staff should sit and feed the residents, but yesterday there were not enough chairs in the dining room. She further stated that normally there are only 4 CNAs on the floor, but yesterday there were more people feeding. On 5/25/17 at 1:17 PM, CNA #2 was interviewed and stated that she is a rehab aide, but she comes to the floors during meals to assist with feeding. She further stated that she should sit while feeding so that she can make eye contact and interact with the resident. She stated that being seated also makes it easier to wipe the residents face as needed and have a better view of the resident so that any concerns, such as choking, can be identified. 415.5(a)

Based on resident and family interview, record review, and staff interviews, the facility did not ensure that a resident was allowed to interact with members of the community inside the facility at the time of her choosing. Specifically, a resident's spouse was told he had to leave during a visit due to the hour. This was evident for 1 of 3 residents reviewed for Choices (Resident #96). The finding is: The Policy and Procedure for Visiting Hours documented Visiting hours are 24 hours 7 days per week. The policy further documented that family members are encouraged to visit between the hours of 11 AM and 9 PM, and family members who wish for extended visiting hours will be advised to speak to the Social Worker or Administration to place a request. The Social Worker will notify the Interdisciplinary Team of any extended visiting hours and inform the front desk/receptionist. Resident #96 is a resident, admitted [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had intact cognition. On 5/22/17 at 9:55 AM, the resident was interviewed and stated that visiting hours end at 9:00 PM, but she was told by the Director of Nursing (DON) that 24 hour visiting was permitted as long as others are not disturbed. The resident further stated that one time her spouse was visiting, and the evening shift nurse, Licensed Practical Nurse (LPN) #1, told her spouse that he had to leave because it was after 9:00 PM. The resident stated that they did not argue with the nurse and her spouse left. They never reported the incident to anyone. On 5/25/17 at 1:26 PM, the resident's spouse was interviewed and stated that he was in the room sitting when LPN #1 told him that it was time to leave because it was after 9:00 PM. He stated that he was just sitting and not being loud or disruptive. He meant to speak to the social worker about it, but he has not spoken to them yet. He said he was not aware that he needed to be on any special list to visit at anytime. He stated he was confused because he sees other visitors coming in late. The facility Admission Packet documented: While our visitation hours are 24/7, our preferred visiting hours are from 9:00 AM to 8:00 PM. This is to ensure the privacy and comfort of each and every resident in our facility. All visitors must sign in and sign out in the visitors' log located at the reception desk in the lobby. This procedure is an essential part of ensuring the security of the building and the safety of all residents. If you or another family member are not able to visit during regular visiting hours, special accommodations can be made. Speak to your social worker for assistance. On 5/24/17 at 4:14 PM, A bulletin board where visiting hours were posted was observed by the front door of the facility. Visiting hours were 11 AM to 9 PM. The board noted to see social work about exceptions. On 5/24/17 at 11:06 AM, LPN #2 was interviewed and stated if visitors come after hours, the front desk has to inform the Registered Nurse (RN) Supervisor before letting them in. She further stated if family members are already visiting, they stay until they are ready to leave,and the facility staff does not throw anyone out. She stated she was not aware that the resident's husband was told to leave. On 5/24/17 at 11:11 AM and 11:27 AM, RN Unit Manager #1 was interviewed and stated visiting hours are anytime. There are people who need to come late. She stated visitors are not thrown out, and she has never heard of any issues with visitors not being able to stay late. The visiting hours are 11 AM to 9 PM, but people are allowed to come after 9 PM. She stated that visitors may also stay after 9 PM. On 5/24/17 at 3:50 PM, LPN #1 was interviewed and stated visiting hours end at 9pm, and visitors are reminded of the time upon entry into the facility. He further stated that at 9:00 PM, security does an overhead page to remind visitors of the time and to inform them that visiting hours are over. He also reminds visitors on the unit that it is time to leave and to please wrap up their visit. He stated it is the facility policy for visitors to leave at that time. On 5/24/17 at 4:16 PM, the Security Guard for the evening shift was interviewed and stated visiting Hours are 11am to 9 pm. At 9pm, he makes an announcement that visiting hours are over, and he requests that visitors make their way to the lobby. He further stated that after 9pm, he calls the nursing supervisor to get approval for all visitors. He stated there is a list of pre-approved visitors outside the posted visiting hours at the security desk that is provided by Social Work. The Security Guard stated that if the nursing supervisor did not know about the late visitor, the visitor could be turned away, but most of the time, they will let the visitor in for 10 minutes or so. On 5/26/17 at 8:45 AM, the DON was interviewed and stated visiting hours are 24/7, but we prefer people to visit in between 11 to 9 PM. We tell people to speak to social work and get on the list if they would like to visit outside the recommended hours. Staff are not instructed to make visitors leave who are not being disruptive or interfering with care. She stated that she can see how the list can be misleading when the visiting hours are 24/7, and residents should not be denied visitors because their name is not on the list. They will need to clarify the policy and procedure with staff. 415.5(b)(1-3)

Based on interviews and record review the facility did not ensure that resident's plan of care and medical doctor's order was followed. Specifically, Resident #24 did not receive medications ordered by the physician for two days. As a result the resident's plan of care to address pain and discomfort was not followed. This was evident for one (1) resident out of a Sample of 31 residents reviewed for adherence to plans of care and physicians orders. The finding is: Resident # 24 was admitted on [DATE] with diagnosisthat included, disease of the spinal cord; muscle spasms; general muscle weakness and neuro[DIAGNOSES REDACTED] optica ( inflammation and demyelination optic nerve and spinal cord, also known as NMO), chronic pain. Review of the Comprehensive Care Plan (CCP) for Pain, dated 04/10/17 documented, avoid activities that aggravate or exacerbate pain, resident on pain medication, updated 05/22/17 to include: re-assessed the resident for pain due to missing one day of [MEDICATION NAME]. The physician order dated 05/50/17 documented medications including, [MEDICATION NAME] 200 milligrams twice a day 9:00 am and 5:00 pm for muscle spasms On 05/22/17 at 9:45 am resident # 24 informed the SA that she is still waiting to receive her medication [MEDICATION NAME] since yesterday Sunday (05/21/17). She stated that she is been told repeated that this past weekend that pharmacy has not delivered it because they are located in New Jersey. She stated that the nurses also have told her that pharmacy will deliver it on the next delivery but it never came. On 05/22/17 at 11:40 am the SA observed a ten (10) day supply of [MEDICATION NAME] 200 mg by mouth given twice a day was delivered and received by the unit nurse manager who then signed the packing slip. On 05/22/17 at 11:45 am the resident received her medication. Upon a second interview with the resident on 5/23/17 she informed the SA that she finally received her medication on Monday 05/22/17 close to 12:00 PM. She stated that she is not asked about pain and that the doctor came in to see her on Monday in the afternoon after she got her medication. He listened to my chest, my blood pressure and asked how I was doing. I told him that the tingling in my hands was subsiding and that I felt cramps to my hands. He did not ask about pain and I offered none. His visits are only a few seconds long. The Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. to dispense on next run. On 05/21/17 at 5:00 pm not administered. Awaiting delivery. PMD (primary medical doctor) aware. On 05/22/17 at 9:00 am not administered. Awaiting delivery PMD aware. The MAR for 05/22/17 timed at 11:45 am documented Carbamezepine 200 mg by mouth was administered. The Nursing Progress notes from 05/19/17 - 05/21/17 found no documented evidence that medication was unavailable. There was no documented evidence of ongoing assessment due to the resident not receiving her medication as it related specifically to her condition and [DIAGNOSES REDACTED]. The nurse progress note dated 05/22/17 documented, did not get her medication for [DIAGNOSES REDACTED] .resident in no acute distress .no complaint of pain .wants her medication before going to therapy . LPN #2 (Licensed Practical Nurse) was Interviewed on 05/23/17 at 9:30 AM. LPN#2 was on duty on Friday 05/19/17during the day shift. LPN #2 stated that she called the pharmacy during the afternoon on 05/19/17 to reorder the Carbamezepine because the resident had only three pills remaining. The Pharmacy informed her that a thirty (30) day supply was sent on May 5, 2017. The Pharmacy staff told her that they would get back to her because they would have to be reimbursed. LPN #2 stated that when issues of medication arise, or when there is a pharmacy issue she is to notify her supervisor. She stated that she did not do this. LPN #2 stated that she did not report this to the oncoming shift. She stated that the resident had enough medication for Friday 05/19/17 and Saturday 05/20/17. LPN #3 was interviewed on 05/23/17 at 11:15 AM. LPN #3 was on duty during the day shift on Saturday 05/20/17. LPN #3 stated that medications are to be reordered five to seven days before the resident is out of medication. She stated that she called the pharmacy, but not about this medication. She stated that she recalls the there were enough medications in the blister pack. LPN #4 was interviewed on 05/24/17 at 9:42 AM. LPN #4 was on duty during the evening shift on Saturday 05/20/17. LPN #4 stated that she called the pharmacy about the need for the above medication and was told that a delivery would be made in the evening. LPN #4 did not report to the supervisor that the resident had run out of the carbamezapine. LPN #5 was Interviewed on 05/24/17 at 11:15 AM. LPN #5 was on duty during the day shift on Sunday 05/21/17. LPN #5 stated that the pharmacy did not deliver the medication carbamazapine. LPN #5 stated that she was told to expect a delivery and none was made. She stated that she called the pharmacy in the afternoon and was told that the facility would be billed and that a delivery would be made in the evening. She stated that she informed the resident that her medication would be delivered in the afternoon. She stated that the resident was ok and did not complain of being in pain. She denied that the resident rang the call bell frequently to request her medication. She stated that she checked in frequently to reassure her that her medication would be delivered. The LPN stated that she did not report this issue to her supervisor, or the physician. She stated that she informed the nursing staff on the incoming evening shift to expect the delivery of the carbamezapine. LPN #6 was Interviewed on 05/24/17 at 3:35 PM. LPN #6 was on duty during the evening shift on Sunday 05/21/17. LPN #6 stated that she was informed by the day shift nurse that the resident did not receive her 9:00 AM medication carbamezapine and to expect a pharmacy delivery in the evening. She stated that she checked in with the resident often because she was worried that the resident did not receive her medication. She stated that the resident looked uncomfortable and that the resident told her that she was having tingling and spasms and might have been in pain. She stated that she called the pharmacy and was told that a midnight delivery would be made. LPN #6 stated that she did not follow up with her supervisor and that the doctor was not notified. She stated that she informed the oncoming night shift to expect a delivery of the residents medication. RN #1 was interviewed on 05/22/17 at 10:30 AM. RN #1 is the Nurse Manager for the 1st floor. RN #1 stated that she was just informed this morning that an issue of medication for this resident had occurred over the weekend. She stated that she spoke to the medical doctor and called the pharmacy to request a stat (immediate) delivery of this medication. She stated that she was told by the pharmacy that a delivery for this medication had been made on May 5th. RN #1 stated that she looked in on the resident who expressed that she needed her medication before going to therapy today. RN #1 stated that the resident did not tell her that she was in any pain. RN #1 further stated that the nurses are to report medication issues to the supervisor and that the doctor should be made aware. She stated that this is not a typical pain medication and therefore no pain scale is used. She stated that the resident is asked daily if she is in pain and that it is documented in the daily notes. She stated that medications are to be reordered at least three days prior to the resident running out. Nurses can call or use the computer to reorder. She stated that it is important that nurses report when medications are unavailable, and other pharmacy issues. She stated failure to do so has the potential to affect scheduled medication administration times and treatment schedules. On 05/24/17 at 12:30 pm the pharmacy customer service agent was interviewed. She was stated that she refills MEDICATION ORDERS FOR [REDACTED]. The first order was requested and received on 04/07/17 with delivery made on 04/08/17 for 30 days. On 05/03/17 60 pills (30 day supply) was delivered as a request was placed by phone for the same medication. When asked for proof of delivery none was available. She stated that no receipt is available for proof of this delivery / transaction. She stated that outside vendor called outside vendor is contracted out to make deliveries. She stated that a call was received on 05/05/17 by a nurse saying that the medication was not available. We re-sent a 30 day supply. When asked for proof of this delivery none was available. She stated that the driver is to scan the bar code on the packing slip. She stated that the driver carries a small device that scans the bar code and that this may have not been done by the driver. She stated that a ten day supply was sent on Monday 05/22/17. Proof of this deilvery was provided. Interview with the Director of Nurse on 05/24/17 at 3:10 pm stated that her staff are to report any medication issues to the nurse managers especially if they are being told by pharmacy if a delivery has already been made. The nurses are to order once a resident has a least a three day supply left. They have been inservices on how to do this on sigma. The doctor is to be made aware immediately if a resident is not getting there prescribed medication. This way the doctor can do something else or order something else. Also the nurse are to be monitoring and documenting the status of the resident in the meanwhile. Reporting and communicating to oncoming shifts is important and keeps everyone aware of what to anticipate. Review of the facility policy for unavailable medications' documented, it is the policy that each individual receive the necessary medication as ordered by the Primary Medical Doctor (PMD) .when medications are not available, the PMD will be notified who will adjust medication regime accordingly .nurse must notify supervisor nurse must notify Pharmacy nurse document in the progress note that the medication is unavailable and that the PMD is notified .the supervisor is responsible for contacting the pharmacy if any problems regarding delivery .the nurse must document on 24 hour report sheet . 415.11(c)(3)(ii) .

Based on observation interview and record review the facility failed to ensure that necessary care and services were provided to maintain the residents highest practical physical mental and psychological well being. Specifically, resident # 24 was not assessed for pain when her medication became unavailable. This was evident for one (1) resident out of 2 reviewed for Pain Management. (Resident # 24). The finding is: Resident # 24 was admitted on [DATE]. The medical record documented the following diagnoses; included, disease of the spinal cord; muscle spasms; general muscle weakness and neuro[DIAGNOSES REDACTED] optica ( inflammation and demyelination optic nerve and spinal cord, also known as NMO), chronic pain. On 05/22/17 at 9:45 am resident # 24 informed the SA (State Surveyor) that she had been waiting waiting to receive her [MEDICATION NAME] medication since Sunday (05/21/17). She stated that she had repeatedly been told that the pharmacy has not delivered the medication because they are located out of state. She stated that the nurses also have told her that pharmacy will deliver it on the next delivery but it never came. The resident stated that this medication helps her with her hand spasms and pain. The resident stated that she also receives [MEDICATION NAME] for her spasms, but that the carbamezapine which is the [MEDICATION NAME] medication provides her with the greatest relief from pain and discomfort due to the spasms in her hand, back and feet. She stated that she has been on this medication since her discharge from the hospital, approximately three (3) months. The resident was observed sitting in her wheelchair, beside her bed with tightened facial muscles and grimacing. Her hands were in front of her and appeared rigid, partially closed hands appeared stiff and fingers slightly curled. The resident was presenting with fast jerky hand movements as she spoke. She stated that when she does not get this medication she feels an increase in pain and tingling to her hands, feet and back. She stated that her hands begin to feel tingling, her hands curl, and become rigid and then has uncoordinated or jerky hand movements. She stated that when she does not get her medication she feels pain and increase tingling of her hands. She stated that she finds it hard to open her hands and feels discomfort and pain. She stated that she finds it hard to brush her teeth, and comb her hair. She stated that she does not want to create a problem but that she needs to have this medication before therapy as this allows her to participate in her treatments which require strength and endurance. Review of the Minimum Data Set ((MDS) dated [DATE] documented clear speech, understood, understand, brief interview of mental status score of 15 out of 15, who requires extensive staff assist for activities of daily living needs. Pain assessment interview documented pain frequency occasionally, verbal indicator mild. Should the Staff assessment for pain be conducted, no. Review of the Comprehensive Care Plan (CCP) for Pain, dated 04/10/17 documented, avoid activities that aggravate or exacerbate pain, resident on pain medication, updated 05/22/17 to include: re-assessed the resident for pain due to missing one day of [MEDICATION NAME]. Review of the Nursing Progress Notes dated 05/21/17 and 05/22/17 documented, no pain. On 05/23/17 at 11:35 am the resident was observed during physical therapy. The resident was observed on a stationary bike using her upper body arms hands legs and feet. Her facial muscles were relaxed and she was smiling. The resident was later interviewed and stated that she received her medication close to 12:00 PM on 05/22/17. She stated that she was not able to go to therapy on this day because her muscles were rigid, hands were curled, her pain level felt like ten (10). The resident stated that on Sunday 05/21/17 kept on ringing the bell to ask about her medication and was repeatedly told by the nurses that pharmacy had not delivered it. She stated that she was not asked if she was in pain and she told the staff that she was. She stated that when she gets her medication her pain level decreases to one (1) or two (2). She stated that she did not go to therapy on Monday 05/22/17 because this requires strength and endurance on her part to use some kind of clay with her hands to treat the spasms she get to her fingers. She stated that this treatment helps with her hand stiffness and helps her to open her hands. She stated that her condition is a form of [MEDICAL CONDITION] and inflammation in her spine. She stated that she was getting spasms to her hands and fingers about fifteen (15) times a day which would last about ten (10) to fifteen (15) seconds. She stated that the spasms include pain. The spasms come on a a tingling sensation. The medication has made me feel so much better and given my quality of life, a reduction in tightness and curling of my hands and toes. As soon as I received the medication I feel better, my muscle are more relaxed. On Sunday 05/21/17 I kept ringing the call bell and was told the medication would be here by 9:00 am then told by 4 or 5 PM then the shift changed. Then I was told that it would be here by midnight. Meanwhile my pain is eight or nine and I feel my muscle tighten and I am in tears. She stated that she told the staff that she was in pain and needed her medication. On Monday 05/22/17 I told the nurse that I wanted to go home. She stated that the therapist came to on Monday to bring her to therapy and I told her that I could not go because I was in pain and that I did not get my medication on Sunday and on Monday as scheduled. She stated that she finally received her medication on Monday 05/22/17 close to 12:00 PM. She stated that she is not asked about pain and that the doctor came in to see her on Monday in the afternoon after she got her medication. He listened to my chest, my blood pressure and asked how I was doing. I told him that the tingling in my hands was subsiding and that I felt cramps to my hands. He did not ask about pain and I offered none. His visits are only a few seconds long. Review of the Medical assessment dated [DATE] documented, no arthralgia, myalagia. .general body spasms .responding to [MEDICATION NAME]. Review of Physician interim note dated 05/22/17 documented, .history of body spasms .who apparently did not receive carbamezepine yesterday. Patiient claims she had minor cramps to her fingers last night .no severe spasms. The physician orders for medication date 05/50/17 documented the following: [MEDICATION NAME] 200 milligrams twice a day at 9:00 AM and 5:00 PM for muscle spasms Review of the Medication Administration Record [REDACTED]. Reason: 05/21/17 9:00 am pharmacy called. to dispense on next run. On 05/21/17 at 5:00 PM not administered. Awaiting delivery. PMD (primary medical doctor) aware. On 05/22/17 at 9:00 am not administered. Awaiting delivery PMD aware. The Medication Administration Record [REDACTED]. Review of Nursing Progress notes from 05/19/17 - 05/21/17 found no documented evidence that medication was unavailable. There was no documented evidence of ongoing assessment due to the resident not receiving her medication as it related specifically to her condition and [DIAGNOSES REDACTED]. LPN #2 (Licensed Practical Nurse) was Interviewed on 05/23/17 at 9:30 AM. LPN#2 was on duty on Friday 05/19/17during the day shift. LPN #2 stated that she called the pharmacy during the afternoon on 05/19/17 to reorder the Carbamezepine because the resident had only three pills remaining. The Pharmacy informed her that a thirty (30) day supply was sent on May 5, 2017. The Pharmacy staff told her that they would get back to her because they would have to be reimbursed. LPN #2 stated that when issues of medication arise, or when there is a pharmacy issue she is to notify her supervisor. She stated that she did not do this. LPN #2 stated that she did not report this to the oncoming shift. She stated that the resident had enough medication for Friday 05/19/17 and Saturday 05/20/17. LPN #3 was interviewed on 05/23/17 at 11:15 AM. LPN #3 was on duty during the day shift on Saturday 05/20/17. LPN #3 stated that medications are to be reordered five to seven days before the resident is out of medication. She stated that she called the pharmacy, but not about this medication. She stated that she recalls the there were enough medications in the blister pack. LPN #4 was interviewed on 05/24/17 at 9:42 AM. LPN #4 was on duty during the evening shift on Saturday 05/20/17. LPN #4 stated that she called the pharmacy about the need for the above medication and was told that a delivery would be made in the evening. LPN #4 did not report to the supervisor that the resident had run out of the carbamezapine. LPN #5 was Interviewed on 05/24/17 at 11:15 AM. LPN #5 was on duty during the day shift on Sunday 05/21/17. LPN #5 stated that the pharmacy did not deliver the medication carbamazapine. LPN #5 stated that she was told to expect a delivery and none was made. She stated that she called the pharmacy in the afternoon and was told that the facility would be billed and that a delivery would be made in the evening. She stated that she informed the resident that her medication would be delivered in the afternoon. She stated that the resident was ok and did not complain of being in pain. She denied that the resident rang the call bell frequently to request her medication. She stated that she checked in frequently to reassure her that her medication would be delivered. The LPN stated that she did not report this issue to her supervisor, or the physician. She stated that she informed the nursing staff on the incoming evening shift to expect the delivery of the carbamezapine. LPN #6 was Interviewed on 05/24/17 at 3:35 PM. LPN #6 was on duty during the evening shift on Sunday 05/21/17. LPN #6 stated that she was informed by the day shift nurse that the resident did not receive her 9:00 AM medication carbamezapine and to expect a pharmacy delivery in the evening. She stated that she checked in with the resident often because she was worried that the resident did not receive her medication. She stated that the resident looked uncomfortable and that the resident told her that she was having tingling and spasms and might have been in pain. She stated that she called the pharmacy and was told that a midnight delivery would be made. LPN #6 stated that she did not follow up with her supervisor and that the doctor was not notified. She stated that she informed the oncoming night shift to expect a delivery of the residents medication. RN #1 was interviewed on 05/22/17 at 10:30 AM. RN #1 is the Nurse Manager for the 1st floor. RN #1 stated that she was just informed this morning that an issue of medication for this resident had occurred over the weekend. She stated that she spoke to the medical doctor and called the pharmacy to request a stat (immediate) delivery of this medication. She stated that she was told by the pharmacy that a delivery for this medication had been made on May 5th. RN #1 stated that she looked in on the resident who expressed that she needed her medication before going to therapy today. RN #1 stated that the resident did not tell her that she was in any pain. RN #1 further stated that the nurses are to report medication issues to the supervisor and that the doctor should be made aware. She stated that this is not a typical pain medication and therefore no pain scale is used. She stated that the resident is asked daily if she is in pain and that it is documented in the daily notes. She stated that medications are to be reordered at least three days prior to the resident running out. Nurses can call or use the computer to reorder. She stated that it is important that nurses report when medications are unavailable, and other pharmacy issues. She stated failure to do so has the potential to affect scheduled medication administration times and treatment schedules. The nurse progress note dated 05/22/17 and timed at 5:51 PM documented: that the writer of the note met with the resident at 9:00 AM to discuss medications. Resident verbalized that she did not receive [MEDICATION NAME] on 5/21/17. The writer documented that the resident was not in any acute distress and did not complaint of any pain. The note also documented the receipt of the carbaamazepine On 05/22/17 at 11:40 AM the SA observed a ten (10) day supply of [MEDICATION NAME] 200 mg by mouth given twice a day was delivered and received by the unit nurse manager who then signed the packing slip. On 05/22/17 at 11:45 am the resident received her medication. The Occupational Therapy note dated 05/22/17 and timed at 2:39 PM documented that tthe OT went to see the resident at 9:00 AM and observed the resident agitatied. The resident reported that she had not received her medication since Sunday and notified nurse manager. The OT wrote that they saw the resident again at 11:30 AM no treatment was provided. The OT wrote that they visited with the resident again at 1:30 PM, the resident reported that she was feeling better. Bedside therapy was provided. Interview with the Occupational therapist (OT) on 05/24/17 at 10:25 am stated that the resident has [MEDICATION NAME] [DIAGNOSES REDACTED] which is an infection in the spine and this decreases her coordination. She stated that she went to pick up the resident on Monday 05/22/17 between 9: 00 and 9: 30 am and observed the resident sitting in her wheelchair in her room and appeared agitated. She noticed that her hands were rigid and slightly closed and uncoordinated finger and hand movements. I asked her what was wrong and she said that she did not receive her medications for her spasms on Sunday and when I saw her she had not received her medications at this time. She looked upset and very uncomfortable. She stated that she was in pain. The OT stated that she went to the nurse manager and asked why her med's were not given and she told her she would get back to me. The resident refused therapy at this time because she was in pain. I informed the nurse manager that therapy could not take place at this time because the resident was in pain. She said she returned at 11:30 am to see the resident and the resident had not received her medication yet. She was very upset and stated that she wanted to go home. The resident stated that she was in pain and uncomfortable. She was having uncoordinated movements of the fingers still with rigidity. She observed her getting her medication at 11:45 am when the nurse came in. She said sheI returned at 1:30 PM and she looked much better, her hands were less rigid and she was calmer and not as upset. She was no longer having uncoordinated movements. She said she chose not to perform any rigid exercise because she had just gotten her medication and some of our exercises include use of stationary bike while standing, a pulley, progressive exercise that require a lot of strength. She said she used her professional judgment and chose to perform therapeutic exercise at bedside. The resident was agreeable to this and stated that she had tingling in her hands. No rigidity is involved at bedside I did light therapeutic exercise. She was given 2 pound weight versus 4 pound weights which she normally uses. She did a 30 minute session. She said she reported this to her supervisor and documented in her notes. The Physical Therapist note dated 5/22/17 documented that the resident was seen at the bedside for physical therapy. The resident reported having muscle spasms in arms and legs and difficulty to participate with funcitional mobility especially abmulation. Resident performed assisted active range of motion in both lower extremities and positioning along with safety education and pacing and energy conservation techniques. Interview with Physical therapist (PT) on 05/24/17 at 11:30 am and stated that he went to see the resident at 3:00 PM on 05/22/17 and she told him that she was not feeling well. The PT said he saw her in the morning and she was not her usual self. When she is on the unit we do progressive exercise and use 3 pound weights. She was not in good condition this day to do exercise. She would need 100 % focus and on Monday she was not able to concentrate. Not having her medications affected her treatment and her ability to focus on her therapy. Interview at 9:20 am on 05/24/17 with the assigned day shift Certified Nurse Aide (CNA) on duty on 05/21/17 and on 05/22/17 stated that on 05/21/17 she went to perform morning (am) care. She stated that the resident needs extensive assistance and is transferred out of bed with one person into a wheelchair. She stated that the resident likes to get of of bed early as this is her routine and enjoys her therapy. The CNA stated that the resident told her she did not want to be touched and that she had not gotten her medication. The CNA stated that is was not the residents usual manner. She did not want me to touch her. She stated that this was unusual for her to refuse am care. She stated that later on during the day the resident allowed her to help her out of bed. She stated that on Monday 05/22/17 she cared for the resident and that she seemed fine. CNA #1 was interviewed on 05/22/17. CNA # was on duty during the evening shift. She stated that the resident was not crying or complaining and found nothing unusual about the resident. She stated that she provided PM care did not notice anything the matter with the resident. The MD (Medical Doctor) was interviewed on 05/23/17 at 1:50 PM. The MD stated that he is the treating physican since the resident's admission. He stated that the resident has a disease that manifests itself with spasms which affect her entire body particular her bladder, her hands and her spinal cord. The MD stated that he has seen her a few times to listen to her lungs, take her pulse and ask her, how are you doing?. The MD denied that the resident has complained of pain during his visits. However, the MD also stated that he has not asked her if she is experiencing pain. The MD stated that he expects patients to tell me if they are having pain. I did not associate her having pain with her spasms and was not mentioned to me. I was not previously made aware that she did not get her medication all day Sunday and part of Monday. I was made aware of this today by the nurse manager. I visited her today Monday afternoon, once she received her medication and she told her hands felt tingly,. I expect that when a problem with medication come up that I am made so that I can reorder something else. Interview at 9:20 am on 05/24/17 with the assigned day shift Certified Nurse Aide (CNA) on duty on 05/21/17 and on 05/22/17 stated that on 05/21/17 she went to perform morning (am) care. She stated that the resident needs extensive assistance and is transferred out of bed with one person into a wheelchair. She stated that the resident likes to get of of bed early as this is her routine and enjoys her therapy. The CNA stated that the resident told her she did not want to be touched and that she had not gotten her medication. The CNA stated that is was not the residents usual manner. She did not want me to touch her. She stated that this was unusual for her to refuse am care. She stated that later on during the day the resident allowed her to help her out of bed. She stated that on Monday 05/22/17 she cared for the resident and that she seemed fine Interview on 05/24/17 at 12:30 pm with the pharmacy customer service personnel stated that she refills MEDICATION ORDERS FOR [REDACTED]. The first order was requested and received on 04/07/17 with delivery made on 04/08/17 for 30 days. On 05/03/17 60 pills (30 day supply) was delivered as a request was placed by phone for the same medication. When asked for proof of delivery none was available. She stated that no receipt is available for proof of this delivery / transaction. She stated that outside vendor called wellness express is contracted out to make deliveries. She stated that a call was received on 05/05/17 by a nurse saying that the medication was not available. We re-sent a 30 day supply. When asked for proof of this delivery none was available. She stated that the driver is to scan the bar code on the packing slip. She stated that the driver carries a small device that scans the bar code and that this may have not been done by the driver. She stated that a ten day supply was sent on Monday 05/22/17. Proof of this deilvery was provided. . Interview with the Director of Nurse on 05/24/17 at 3:10 pm stated that her staff are to report any medication issues to the nurse managers especially if they are being told by pharmacy if a delivery has already been made. The nurses are to order once a resident has a least a three day supply left. They have been inservices on how to do this on sigma. The doctor is to be made aware immediately if a resident is not getting there prescribed medication. This way the doctor can do something else or order something else. Also the nurse are to be monitoring and documenting the status of the resident in the meanwhile. Reporting and communicating to oncoming shifts is important and keeps everyone aware of what to anticipate. Review of the facility policy for unavailable medications' documented, it is the policy that each individual receive thenecessary medication as ordered by the Primary Medical Doctor (PMD) .when medications are not available, the PMD will be notified who will adjust medication regime accordingly .nurse must notify supervisor nurse must notify Pharmacy nurse document in the progress note that the medication is unavailable and that the PMD is notified .the supervisor is responsible for contacting the pharmacy if any problems regarding delivery .the nurse must document on 24 hour report sheet . Review of Specialty Pharmacy contract dated November 2016 documented, .Provide products in a prompt and timely manner .collaborate with the facility to coordinate pharmacy documentation processes . 415.12 .

Based on observation and staff interviews during the Recertification survey, the facility did not ensure that all drugs were labeled in accordance with currently accepted professional principles, including the expiration date when applicable. This was identified during the Medication Storage Task review on the 4th floor. Specifically, There was a vial of Humalog that was opened and dated but had expired past the 28 days. This was evident for 1 of 5 of medication storage units inspected. The finding is: During an observation on [DATE] at 7:45AM on the 4th floor, in the medication refrigerator contained 1 vial of Humalog labeled ,[DATE] and the date of the survey was ,[DATE], 36 days had passed since the vial has been opened. On [DATE] immediately after observing the expired vial, the Licensed Practical Nurse (LPN) was interviewed and the LPN stated I believe Humalog can be discarded 42 days after being opened. The LPN further stated that there should be a list of all medications and only nursing has the list and it is only for the regular nursing staff. Then he stated was a regular staff member of the facility. On [DATE] at 2:06 PM the Registered Nurse Manager (RN) on the 4th floor was interviewed and the RN stated that all opened insulin needs to be discarded after 28 days. There is no official list in the nursing Department. Also, any nurse can reorder the medication so it is the responsibility of any nurse that sees the vial has expired to discard after the 28 days and re-order the new insulin. The manufacturer of Humalog Insulin documents that recommended use of (opened) Humalog vials and the Humalog KwikPen insulin must be dated when opened and discarded after 28 days, even of the vials still contain the medicine. 415.18 (d)

Based on record review and interview the facility did not ensure that an ophthalmology consultation was provided to two of four residents reviewed for vision (Residents #120 and #211) in order to maintain vision abilities. Specifically, eye (ophthalmology) consultation was not provided to assess for possible use of vision assistive devices or evaluate current vision status for these residents. The findings are: 1. Resident #120 has [DIAGNOSES REDACTED]. The resident was interviewed on 3/10/16 at 2:04 PM and stated that since arriving at the facility approximately three years ago, she had requested assistance from two Social Workers in obtaining eye appointment to have cataract evaluation and possible cataract surgery. The resident stated that the appointment was never made and that she is still waiting for cataract surgery. The vision section of the Quarterly Minimum Data Set (MDS; a resident assessment tool) of 12/27/15 documented that the resident has highly impaired vision (object identification in question, but eyes appear to follow objects) and that corrective lenses were in use. The 12/1/15 Vision Care Plan documented interventions that included, but are not limited to, provide vision examinations as necessary, resident to ambulate with a stick and conduct ongoing assessment for vision impairment. The physician's orders [REDACTED]. The 12/8/15 optometry evaluation documented that Resident #120 was evaluated on 12/8/15. The report stated that the resident has dense cataract on both eyes and recommended for evaluation for possible surgical intervention. There was no documented evidence in the resident's clinical record submitted by the facility that an evaluation for possible surgery for [REDACTED]. The unit Registered Nurse manager was interviewed on 3/16/16 at 1:40 PM and stated that she was not sure why the ophthalmology referral has not been done. The Director of Nursing was interviewed on 3/16/16 at 2:25 PM and stated that she was not sure why the follow up ophthalmology referral was not done. The DON stated that it should have been done per the optometrist's recommendation. 2. Resident #211 has [DIAGNOSES REDACTED]. The Quarterly MDS of 2/10/16 revealed that the resident scored scored 7 out of 15 on the BIMS test which suggested that the resident had severely impaired cognitive skills in daily decision making. This MDS further documented that the resident's vision was impaired (sees large print, but not regular print in newspapers/books) and had no corrective lenses in use. The care plan for Visual Function, which was last updated on 9/3/15, included the following interventions: provide ongoing assessment of vision impairment and provide vision exams as necessary. The current physician's orders [REDACTED]. The unit RN manager was interviewed on 3/16/16 at 10:45 AM and stated that if the consultation order was not scanned into the electronic medical record (Sigma Care), then it will be found in the nursing office. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) were interviewed on 3/16/16 at 11:00 AM and at 12:40 PM, respectively and they both stated that consultation request form could not be located. Both the ADON and DON stated that they will continue to search for the consultation request in the nursing office. At approximately 1:00 PM on the same date, the ADON reported back to the surveyor and stated that she found a referral for the resident to see the ophthalmologist on 4/15/15. The ADON stated that the resident refused to go to the appointment at that time. The ADON stated that no follow up was made up to this time, to determine whether the resident had changed her mind in order to reschedule the appointment. There is no documented evidence that an ophthalmology consult was ever done. 415.12(3)(b)

Based on record review and interview conducted during a recent recertification survey, the facility did not provide the necessary services for two of four residents reviewed for vision (Resident #120 and #211). Specifically, additional ophthalmology consultation for possible surgical intervention was not obtained for Resident #120 per physician's orders [REDACTED].#211 for evaluation of the residents' current vision status. The findings are: 1. Resident #120 has [DIAGNOSES REDACTED]. The resident was interviewed on 3/10/16 at 2:04 PM and stated that since arriving at the facility approximately three years ago, she had requested assistance from two Social Workers in obtaining eye appointment to have cataract evaluation and possible cataract surgery. The resident stated that the appointment was never made and that she is still waiting for cataract surgery. The vision section of the Quarterly Minimum Data Set (MDS; a resident assessment tool) of 12/27/15 documented that the resident has highly impaired vision (object identification in question, but eyes appear to follow objects) and that corrective lenses were in use. The 12/1/15 Vision Care Plan documented interventions that included, but are not limited to, provide vision examinations as necessary, resident to ambulate with a stick and conduct ongoing assessment for vision impairment. The physician's orders [REDACTED]. The 12/8/15 optometry evaluation documented that Resident #120 was evaluated on 12/8/15. The report stated that the resident has dense cataract on both eyes and recommended for evaluation for possible surgical intervention. There was no documented evidence in the resident's clinical record submitted by the facility that an evaluation for possible surgery for [REDACTED]. The unit Registered Nurse manager was interviewed on 3/16/16 at 1:40 PM and stated that she was not sure why the ophthalmology referral has not been done. The Director of Nursing was interviewed on 3/16/16 at 2:25 PM and stated that she was not sure why the follow up ophthalmology referral was not done. The DON stated that it should have been done per the optometrist's recommendation. 2. Resident #211 has [DIAGNOSES REDACTED]. The Quarterly MDS of 2/10/16 revealed that the resident scored scored 7 out of 15 on the BIMS test which suggested that the resident had severely impaired cognitive skills in daily decision making. This MDS further documented that the resident's vision was impaired (sees large print, but not regular print in newspapers/books) and had no corrective lenses in use. The care plan for Visual Function, which was last updated on 9/3/15, included the following interventions: provide ongoing assessment of vision impairment and provide vision exams as necessary. The current physician's orders [REDACTED]. The unit RN manager was interviewed on 3/16/16 at 10:45 AM and stated that if the consultation order was not scanned into the electronic medical record (Sigma Care), then it will be found in the nursing office. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) were interviewed on 3/16/16 at 11:00 AM and at 12:40 PM, respectively and they both stated that consultation request form could not be located. Both the ADON and DON stated that they will continue to search for the consultation request in the nursing office. At approximately 1:00 PM on the same date, the ADON reported back to the surveyor and stated that she found a referral for the resident to see the ophthalmologist on 4/15/15. The ADON stated that the resident refused to go to the appointment at that time. The ADON stated that no follow up was made up to this time, to determine whether the resident had changed her mind in order to reschedule the appointment. There is no documented evidence that an ophthalmology consult was ever done. 415.11 (c) (3) (ii)

Based on interview and record review, the facility did not provide sufficient preparation and orientation to residents to ensure safe and orderly discharge from the facility. This was evident for 1 out of 3 residents (Resident #1). Specifically, the facility did not consider the preferences of the resident when determining a discharge location and did not inform the receiving facility of the resident ' s required level of assistance with care. The resident was discharged to a facility that did not provide the clinical services required to ensure the safety of Resident #1. Subsequently, the resident displayed feelings of anxiety, dehumanization and depression related to the discharge process. This resulted in actual harm that is not Immediate Jeopardy. Complaint #NY 218 Findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) 3.0 (a resident assessment tool) dated 6/8/12 identified that the resident had moderately impaired cognition. The MDS identified that the resident required one person physical assistance with bed mobility, transferring, dressing, toileting and performing personal hygiene. The physician's orders [REDACTED]. A Social Service Admission assessment dated [DATE] documented that the resident " was living in a shelter prior to injury & does not want to return there. " A Psychology Services Intake Initial Consultation dated 6/12/12 documented that the resident was very agitated, anxious and depressed. The note documented that the resident was " very fearful and worried about future - doesn ' t want to go back to shelter. " A Social Services progress note dated 6/19/12 documented that the Director of Social Services, Social Worker and Psychologist met with the resident to inform her of the pending discharge from the facility. The progress note documented that the resident " was very weepy and depressed due to imminent discharge " and that Resident #1 did not want to be discharged . The Social Worker documented that the resident was discharged because the Managed Care Medicaid company would no longer pay for her services at the facility and that the facility " needed to find an appropriate placement in the community for the resident. " The shelter was chosen because the resident was known to the shelter and there was an elevator. A Supervising Medical Doctor (MD) note dated 6/20/12 5:30PM documented that the resident was scheduled to be discharged to a shelter tomorrow. The MD documented that the discharge was not safe due to the resident ' s need for injectable anti-coagulation, non-ambulatory status, lack of social support and non-weight bearing status. The MD documented that social work would re-evaluate pending an orthopedic consultation. A Physical Therapy Discharge Summary dated 6/21/12 identified that the resident required minimum physical assistance of 1 staff member for transfers due to non-weight bearing status. The summary stated that the resident was educated on hip precautions. The physical therapy comments section recommended continued Physical Therapy upon discharge. An Occupational Therapy Discharge Summary, dated 6/21/12 documented that the resident required minimal assistance with dressing and was dependent in " home making. " The summary identified that the resident was non weight bearing. The Interdisciplinary Discharge Plan, dated 6/21/12 documented that the resident was discharged to a shelter due to " insurance no longer covering resident ' s stay. " On 6/26/12 at 12:25PM an interview was conducted with the facility Managed Care Coordinator. The Managed Care Coordinator stated that the resident had Medicaid Managed Care. She stated that the case manager from the Managed Care Company informed her that since the resident had not been making enough progress in rehabilitation, the insurance company would no longer cover her stay. The Managed Care Coordinator stated that the resident needed orthopedic consultation to document her progress, but the facility was not able to get an appointment until 6/26/12. The Managed Care Coordinator stated that since the insurance coverage was originally scheduled to end on 6/19/12 they decided to discharge the resident to a shelter. On 6/26/12 at 11:20AM, the Social Worker assigned to the resident was interviewed. The Social Worker stated that on 6/19/12, the Managed Care Coordinator informed social work that the resident ' s insurance no longer covered her care starting that day and the resident had to be discharged . According to the Social Worker, the Director of Social Work called the managed care company and obtained a 3 day extension. The Social Worker stated that on 6/19/12 she had a meeting with the resident along with the Psychologist and the Director of Social Work. The Social Worker described the resident as " depressed " and " crying. " The Social Worker stated that during the meeting, the resident said she did not want to be discharged to the shelter. The Social Worker stated that after the resident left, she called the Director of the Shelter to let her know that the resident was on her way. At that time, she informed the Director of the Shelter that the resident required assistance with ADL ' s and that the Director of the Shelter told her that they do not provide that level of care. The social worker stated " what can I tell you? It was not a safe discharge. " On 7/30/12 at 3:50PM a telephone interview was conducted with the Psychologist. The Psychologist stated that he attended the meeting with the resident, Social Worker and Director of Social Work to discuss the resident ' s discharge. The Psychologist stated that during the meeting the resident was " nervous, weepy and stated that she did not want to leave the facility and have to go to a shelter. " On 6/28/12 at 2:32PM an interview was conducted with the Director of Social Work. The Director of Social Work stated that on 6/19/12 she met with the resident along with the Social Worker and Psychologist to inform the resident that she was going to be discharged . She stated that the Psychologist was present because the resident was tearful. The Director of Social Work acknowledged that the resident did not want to return to the shelter. When asked why she continued to pursue the discharge, despite the resident ' s wishes, she stated that " the residents always say that. " The Director of Social Work stated that she spoke to the Director of the Shelter about Resident #1 ' s pending discharge. She stated that the Director of the Shelter agreed to accept the resident back. The Director of Social Work stated that medical services were going to be provided by the shelter, but she did not specify which services or who had arranged the services. The Director of Social Work stated that this was a safe discharge plan. She stated that the MD has a different definition of a safe discharge plan. On 6/26/12 at 2:55PM a telephone interview was conducted with the Director of the Shelter. The Director of the Shelter stated that when the facility enquired about discharging Resident #1 back to the shelter, " they told us she was in a wheelchair, but not much more. " The Director of the Shelter stated that she received documentation from the facility regarding the resident ' s status, but that none of the documentation indicated that Resident #1 was non-weight bearing, at risk for falling or required injections. The Director of the Shelter stated that she spoke to the Director of Social Work prior to Resident #1 ' s discharge. According to the Director of the Shelter, the facility Director of Social Work informed her that the resident wished to return to the shelter, but did not inform her of the level of assistance required. The facility did not state that the discharge was related to an insurance issue. The Director of the Shelter stated that when the resident arrived she " looked worse than we had ever seen her look, which was pretty bad. " The resident was complaining of pain in the hip and was transferred to the hospital to remove the staples from her surgical wound. The Director of the Shelter said that the shelter does not accept residents who need assistance with transfers or personal care. Residents who require a home attendant or home health aide are sent to facilities that can accommodate a higher level of care. In an interview on 6/27/12 at 11:30AM the resident stated that the facility " threw (her) out. " The resident was tearful throughout the interview. She stated that " all of a sudden " she was called to a meeting and informed that she did not have any insurance and was going to be discharged . She stated that when they informed her of the discharge, she was shocked, scared and crying. She stated " I wanted to stay there for my leg and recover from surgery and get healthier and then get discharged . I cannot get therapy and treatment in the shelter. " She stated that she was in a lot of pain when discharged . She informed the staff that she was in pain, but they stated that they could not afford to keep her at the facility. The resident tearfully stated " I felt so little, I did not feel like a human being. I felt like a dog in the street. " 415.3(h)(1)(v)

Quality of Care/Treatment-All other Quality of Care/Treatment-Substantiated Findings: Based on staff interview and record review, during an abbreviated survey, the facility did not ensure that each resident received the necessary care and services to maintain their highest practicable physical well-being in accordance with the plan of care. This was evident for 1 out of 3 sampled residents (Resident #1). Specifically, on 10/27/11 Resident #1 ' s laboratory results revealed a critical level for Hemoglobin and the facility did not follow- up on the critical value until 10/30/11. On 10/30/11 the resident was transferred to the hospital, diagnosed with [REDACTED]. This resulted in actual harm that is not Immediate Jeopardy. Complaint ID # NY 758 The findings include: Resident #1 was a [AGE] year old female initially admitted to the facility on [DATE]. The resident ' s [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment 3.0 (a resident assessment tool) dated 09/27/11, documented that the resident had severe cognitive impairment. She required extensive assistance in most areas of Activities of Daily Living (ADL ' s). The Anti-Coagulant Use Comprehensive Care Plan (CCP) dated 6/8/11 identified that the resident was on Aspirin (81 mg) and at risk for excessive bruising/bleeding. The facility interventions included monitoring laboratory results. An interim MD order dated 10/27/11 included a laboratory order for a Complete Blood Count (CBC). The laboratory result dated 10/28/11 included a critical laboratory value for Hemoglobin of 5.8g/dl (reference range 11.5-16.0g/dl). There was no documentation in the nursing notes or 24 hour report regarding this critical laboratory value. The nurse ' s note dated 10/30/11 documented that the resident was transferred to the hospital as per MD due to severe [MEDICAL CONDITIONS] and Hemoglobin of 5.8g/dl. A review of Resident #1 ' s hospital record dated 10/30/11-11/4/11 revealed that the resident was hospitalized for [REDACTED]. The facility ' s policy and procedure titled " Laboratory Diagnostic and Therapeutic Services, " dated 09/04 documented that abnormal laboratory results are reported immediately by phone to the physician/nursing home pending written report. On 4/20/12 at 11:00 AM a telephone interview was conducted with a representative from the vendor laboratory. The representative stated that the critical laboratory result for Resident #1 was sent to the facility on [DATE] and the result was called in to Registered Nurse Supervisor (RNS) #1 at 5:48PM. On 4/20/12 at 11:20AM a telephone interview was conducted with RNS #1, who worked on 10/28/11. She stated that on 10/28/11 she received the notification from the laboratory of Resident #1 ' s critical value. She stated that she called the MD and left him a voicemail message regarding Resident #1 ' s critical value for Hemoglobin. She also stated that the charge nurse (LPN #2) was informed and that the information was endorsed to the night supervisor (RNS #2) for follow up. On 4/24/12 at 3:00PM a telephone interview was conducted with LPN #2, who worked the evening shift on 10/28/11. LPN #2 stated that he did not remember the RNS informing him of the resident ' s critical Hemoglobin level. He stated that the laboratory calls the RNS or the charge nurse of the floor with any abnormal laboratory results. On 4/22/12 at 10:30AM a telephone interview was conducted with RNS #2, who was the night supervisor on 10/28/11. RNS #2 stated that she did not recall receiving notification from RNS #1 that Resident #1 had a critical result for Hemoglobin. On 4/20/12 at 11:08AM a telephone interview was conducted with the MD. Regarding the critical laboratory value from 10/28/11, the MD stated that he did not receive a call from the facility regarding the abnormal Hemoglobin result on 10/28/12 for Resident #1. The MD stated " if I knew it I ' ll send her to the hospital right away. " The MD stated that he noticed the abnormal laboratory result during his follow-up visit on 10/30/12. The MD stated that on 10/30/12 he transferred resident to the hospital. The Director of Nursing (DON) was interviewed on 4/18/12 at 2:00 PM. The DON stated that the facility has protocol in place for monitoring laboratory orders. The DON stated that the MD is responsible to follow up on the results of the blood works they ordered. 415.12