Every finding on record at Emerge Nursing and Rehabilitation at Glen Cove

Based on record review and interviews during the survey, the facility failed to ensure that it implemented a person-centered care plan for each resident to meet medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. This was identified for one (1) (Resident #99) of one (1) resident reviewed for death. Specifically, Resident #99 had a physician's order for furosemide (a diuretic used to treat heart failure) to be administered on 03/14/2026, one (1) time dose, at 6:00 PM. Review of the medical record revealed no documented evidence that the medication was administered as per the physician's orders.The findings include:The facility's policy titled Transcription of Physician's Orders, dated April 2025, documented the facility shall ensure that medication and other prescribed orders are picked up, transcribed, administered and/or carried out according to the physician's orders. New physician orders will be verified for accuracy and implementation to ensure the accuracy and timeliness of implementation of all physician orders.Resident #99 was admitted with diagnoses including hypertensive heart disease with heart failure (heart does not pump blood efficiently), pulmonary hypertension (high blood pressure in the lung arteries), and diabetes mellitus. The 03/08/2026 admission Minimum Data Set assessment documented a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact.An attending physician progress note dated 03/14/2026 at 3:54 PM documented under assessment and plan: Lasix (furosemide) intravenous (directly into the vein) twice a day was extended until 03/13/2026. On 03/14/2026 reduce intravenous Lasix to 40 milligrams intravenously daily.A physician's order dated 03/14/2026 at 5:00 PM, entered by Registered Nurse Supervisor #1, documented furosemide 10 milligram/milliliter solution, inject 40 milligrams (4 milliliter) by intravenous push once daily at 9:00 AM for a diagnosis of hypertensive heart disease with heart failure. The order was signed off by the physician on 03/14/2026 at 9:15 PM. The order was discontinued on 03/20/2026.A second physician's order dated 03/14/2026 at 5:04 PM, entered by Registered Nurse Supervisor #1, documented furosemide 10 milligram/milliliter solution, inject 40 milligrams (4 milliliter) by injection route as one [time] dose on 03/14/2026 at 6:00 PM, for a diagnosis of hypertensive heart disease with heart failure. The order was signed off by the Physician on 03/14/2026 at 9:15 PM. The order was discontinued on 03/20/2026.A review of the March 2026 Medication Administration Record revealed that the 6:00 PM dose of furosemide was not administered on 03/14/2026 as per the physician's orders. The resident received furosemide twice a day on 03/13/2026 and began receiving furosemide once a day on 03/15/2026. The resident did not receive a dose of furosemide on 03/14/2026. There were no comments in the medication administration record indicating why the physician-ordered 6:00 PM dose of furosemide was not administered on 03/14/2026.A review of the medical record revealed no progress notes indicating the reason the 6:00 PM dose of furosemide on 03/14/2026 was not administered.During an interview on 04/27/2026 at 2:44 PM, Registered Nurse Supervisor #1 stated they did not know why the 6:00 PM dose of furosemide was not administered on 03/14/2026. Registered Nurse Supervisor #1 stated if the medication was not given, the reason should have been documented in the medication administration record and in the medical record. During an interview on 04/28/2026 at 8:50 AM, the Attending Physician stated they did not know why the 6:00 PM dose of furosemide was not administered to Resident #99 on 03/14/2026. The order was very specifically written, and they expected the staff to notify them if the medication was not administered as ordered.During an interview on 04/28/2026 at 9:35 AM, the Director of Nursing Services stated the facility protocol is to administer furosemide in the morning. The Director of Nursing Services stated the staff should have communicated the facility protocol with the Physician and documented the reason for not administering the furosemide.10 New York Code Rules and Regulations 415.11(c)(1)

Based on observations, interviews, and record review during survey, the facility failed to ensure that it maintained medical records that are complete and accurate. This was identified for one (1) (Resident #4) of two (2) residents reviewed for urinary tract infections. Specifically, Resident #4 had a physician order for ceftriaxone (antibiotic) by intravenous route once a day for five (5) days. The intravenous peripheral line was dislodged on 04/25/2026. The resident refused the reinsertion of the intravenous peripheral line and refused the antibiotic therapy. There was no documented evidence in the electronic medical record that a physician was notified of the dislodgement of intravenous peripheral line, the resident's refusal for the reinsertion of the intravenous peripheral line, and the antibiotic treatment. The findings include:The facility policy titled Transcription of Physician's Orders, effective 04/2025, documented the Charge Nurse/Supervisor will notify the physician of changes in the resident's condition in accordance with specific physician orders. Resident #4 was admitted with diagnoses that included urinary tract infection, chronic obstructive pulmonary disease (lung disease that restricts airflow, making it difficult to breath), and diabetes mellitus (the body resists insulin and fails to maintain normal blood sugar levels). The admission Minimum Data Set assessment dated [DATE], documented a Brief Interview for Mental Status score of 10, indicating Resident #4 had moderately impaired cognition. The Minimum Data Set assessment documented Resident #4 did not have a behavior of rejecting care. The resident had a urinary tract infection in the past 30 days, did not use antibiotics, and did not have a peripheral intravenous catheter within the look back period.A comprehensive care plan titled Infection-Urinary Tract Infection, dated 04/23/2026, documented interventions that included administering medications as ordered, intravenous ceftriaxone, observe for side effects from antibiotic therapy, report to physician, and monitor for effectiveness.A physician's order dated 04/23/2026 documented ceftriaxone 1 (one) gram in 50 milters of 5% dextrose by intravenous route once a day for five (5) days.A progress note dated 04/25/2026 documented intravenous line dislodged, the resident refused reinsertion and treatment, and the nurse supervisor was made aware.A review of the Medication Administration Record for April 2026, documented Resident #4 did not receive ceftriaxone on 04/25/2026 and 04/26/2026 as Resident #4's peripheral intravenous catheter was dislodged, and the resident refused to have a new peripheral intravenous catheter. A review of the Treatment Administration Record for April 2026, documented on 04/25/2026 the peripheral intravenous catheter was dislodged and Resident refused to have a new one re-inserted during the evening shift. On all shifts for 04/26/2026 the nurses documented the resident refused the new peripheral intravenous catheter.A review of Resident #4's medical records revealed no documented evidence that the physician was made aware of the peripheral intravenous catheter being dislodged and that the resident did not receive the physician ordered antibiotics for two days.During an interview on 04/27/2026 at 10:27 AM, Resident #4 stated they did not have a peripheral intravenous catheter any longer and did not want one. They were done with having a peripheral intravenous catheter. During an interview on 04/27/2026 at 02:19 PM, the Medical Director (Resident #4's physician) stated they were made aware by a nurse on Saturday night that Resident #4's peripheral intravenous catheter came out. The Medical Director stated they came in on Sunday and assessed the resident. The resident's condition seemed to be improved so they offered oral antibiotics, but Resident #4 refused the oral antibiotics. The Medical Director stated the new plan was to monitor Resident #4 without the antibiotics; however, they did not document their assessment and the communication with the resident in the resident's medical record.During an interview on 04/27/2026 2:26 PM, Licensed Practical Nurse #1 stated they notified the Registered Nurse Supervisor #1 that the peripheral intravenous catheter was dislodged on Saturday night, they did not notify the physician, they do not notify the physician the Nursing Supervisor would do that. During an interview on 04/28/2026 at 9:31 AM, the Director of Nursing Services stated the nurses should have documented the physician notification regarding the resident's refusal for reinsertion of the peripheral intravenous access and that the resident missed two days of antibiotics. 10 New York Code Rules and Regulations 415.22(a)(1-4)

Based on observations, record review, and interviews during the Recertification Survey initiated on 12/26/2024 and completed on 1/2/2025, the facility did not ensure the comprehensive care plan was reviewed and revised to meet each resident's current needs. This was identified for one (Resident #21) of two residents reviewed for Activities of Daily Living. Specifically, Resident #21 was observed toileting themselves on 12/26/2024. Resident #21 required staff assistance for toileting transfer and toileting care as per assessments by the Rehabilitation Department and Certified Nursing Aide Accountability Record. A Noncompliance comprehensive care plan developed in 2023 documented Resident #21 was resistive to Activities of Daily Living assistance; however, the comprehensive care plan did not include interventions to for monitoring the resident's noncompliant behavior related to toileting self. The finding is: The facility's policy and procedure titled Comprehensive Care Plan and Resident/Patient Meeting dated July 2024 documented the purpose of the [comprehensive] assessment is to accurately communicate the resident's capability to perform daily life functions and to identify significant impairment(s) in functional capacity and the plan suggested by the comprehensive care plan team for improvement/maintenance for each of the resident's primary care issues. Information including [resident's] ability to perform Activities of Daily Living, and the resident's needs for staff assistance are obtained from the comprehensive assessment and staff interviews to plan care. The Comprehensive Care Plan will be revised quarterly, annually, and as needed, within 7 days of completion of the Minimum Data Set (MDS). Resident # 21 was admitted with Diagnoses including Parkinson's Disease, Difficulty in Walking, and Colostomy Status. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderately impaired cognition. The Minimum Data Set assessment documented Resident #21 did not exhibit behaviors and rejections of care. Resident #62 required moderate assistance for toileting hygiene and maximum assistance for toilet transfer. Resident #21 had an ostomy and was continent of urine. A Behavioral Symptoms- Non-Compliance Comprehensive Care Plan related to rejection of Activity of Daily Living assistance dated 1/23/2024 documented Resident #21 required less than half assist for toileting hygiene and more than half assist for toileting transfer. Interventions included but were not limited to provide incontinent care as needed. No new interventions have been developed and implemented since 4/24/2023. The current care plan did not include interventions to monitor and supervise Resident #21's non compliance related to toileting themselves. An evaluation note dated 10/29/2024 documented that the resident continued to have periods of noncompliance with the plan of care. Staff continue to educate and encourage the resident to comply with the plan of care, the resident can be adamant about their choices despite ongoing education, and staff to continue to maintain resident's dignity and respect resident's rights. An Activity of Daily Living Comprehensive Care Plan dated 4/24/2024 documented Resident #21 required less than half assist for toileting hygiene and more than half assist for toileting transfer. Interventions included but were not limited to provide incontinent care as needed. The current care plan did not include interventions to monitor and supervise Resident #21's non compliance related to toileting themselves An annual Rehabilitation Screening dated 10/16/2024 documented that Resident #21 continued to require minimal assistance of one person for toileting hygiene and moderate assistance of one person for toilet transfer. Certified Nursing Assistant task instruction for October - December 2024 documented Resident #21 was continent of bladder and required more than half assistance (substantial/maximal assistance) for toileting tasks. Resident #21's October 2024 Certified Nursing Assistant Accountability records documented that on 21 occasions the resident was not provided assistance with toileting tasks as indicated in the resident's care plan. Resident #21's November 2024 Certified Nursing Assistant Accountability records documented that on 15 occasions the resident was not provided assistance with toileting tasks as indicated in the resident's care plan. Resident #21's December 2024 Certified Nursing Assistant Accountability records documented that on 43 occasions the resident was not provided assistance with toileting tasks as indicated in the resident's care plan. During the initial tour on 12/26/2024 at 11:28 AM, Resident #21 was observed sitting on the toilet in the bathroom inside their room and the wheelchair was in front of the resident. No staff was observed in the vicinity. Resident #21 stated they went to the bathroom themselves. During an interview on 12/26/2024 at 11:29 AM, Licensed Practical Nurse #1 stated that Resident #1 was allowed and able to toilet on their own. Licensed Practical Nurse #1 stated the resident preferred to transfer and toilet on their own. During an interview on 12/30/2024 at 2:01 PM, Certified Nursing Assistant #1 stated Resident #21 was continent of bladder. Certified Nursing Assistant #1 stated the resident's plan of care indicated that they needed assistance of one person for Activities of Daily Living including toileting but Resident #21 was capable of completing the task on their own and often did not ask for assistance. Certified Nursing Assistant #1 stated many times they observed Resident #21 toileting themselves. Certified Nursing Assistant #1 stated they encouraged the resident to ask for help. During an interview on 12/30/2024 at 2:20 PM, Registered Occupational Therapist #1 stated they assessed and evaluated Resident #21 in August 2024 and discharged the resident from skilled occupational therapy. Registered Occupational Therapist #1 stated the resident required minimum assistance of one person (Resident is able to complete 75% of the task and staff help with 25%) for toileting and transfer. During an interview on 12/31/2024 at 10:15 AM, Resident #21 was observed with tremors of bilateral hands. Resident #21 stated they took care of themselves and did not ask staff for help often. During an interview on 12/31/2024 at 1:08 PM, Registered Nurse Supervisor #1 stated they were aware that Resident #21 tried to be independent with their care and did not call staff for help. Registered Nurse Supervisor #1 stated Resident #21 was capable of toileting themselves. Registered Nurse Supervisor #1 stated there was a non-compliance care plan. Registered Nurse Supervisor #1 stated staff continued to provide verbal encouragement but was unable to state different approaches to address the ongoing non-compliance. Registered Nurse Supervisor #1 they expected staff to respond when Resident #21 pressed the call bell. Registered Nurse Supervisor #1 stated that Resident #21 should toilet with one staff present and assisting if they (Resident #21) were care planned to require minimum assistance of one person for toileting. A Nursing referred Rehabilitation Screening dated 12/31/2024 documented that Resident #21 continued to require minimal assist of one person for toileting hygiene and moderate assist of one person for toilet transfer. During a re-interview on 1/2/2025 at 12:20 PM, Registered Occupational Therapist #1 stated that they re-assessed Resident #21 on 12/31/2024. Resident #21 had tremors, was unsteady, and had difficulty wiping themselves after toileting and pulling up their pants. Registered Occupational Therapist #1 stated Resident #21 cannot toilet themselves independently and staff must be presented to offer hands-on assistance to complete the toileting care safely. During an interview on 1/2/2024 at 12:41 PM, the Director of Nursing Services stated Resident #21 should be provided one-person staff assistance during toileting as per the assessment and care plan. The Director of Nursing Services stated the care plan intervention should have been evaluated for effectiveness and the interdisciplinary team should implement other interventions such as additional education to resident to call for help and increase frequency of round for supervision to address the resident's non-compliance and to ensure the resident's safety during care. 10 NYCRR 415.11(c)(2) (i-iii)

Based on observations, record review, and interviews during the Recertification Survey initiated on 12/26/2024 and completed on 1/2/2025, the facility did not ensure that food was served in accordance with professional standards for food service safety. This was identified for one ([NAME]) of three dining rooms during the Dining Task. Specifically, the facility did not monitor the temperature of cold food items served to the residents during a lunch meal observation on 12/30/2024 at 12:22 PM. The temperature of two yogurt containers measured at 60 and 62 degrees Fahrenheit (normal range: below 41 degrees Fahrenheit.) The finding is: The facility's policy and procedure titled Food Safety/Storage/Distribution/Service/Procurement - General dated 6/2024, documented Danger Zone refers to temperatures above 41 degrees Fahrenheit and below 135 degrees Fahrenheit that allow the rapid growth of pathogenic microorganisms that can cause foodborne illnesses. Food Service/Distribution refers to the processes involved in getting food to the resident. This may include holding foods under refrigeration for cold temperature control. Refrigerated Storage: potentially hazardous foods (examples include yogurt) must be maintained at or below 41 degrees Fahrenheit. During the lunch meal service in the [NAME] dining room on 12/30/2024 at 12:22 PM, the Dietary Supervisor measured the temperature of two yogurt containers on the individual resident trays prior to being delivered from the kitchen to the dining room. The yogurt measured 60 degrees and 62 degrees Fahrenheit. The Dietary Supervisor was immediately interviewed and stated there was an increased risk for infection and/or gastrointestinal issues if the food was served outside of the proper serving/holding temperatures. During an interview on 12/30/2024 at 1:03 PM, the Food Service Director stated the temperature of the yogurt and cold food items are checked when the items are placed onto the individual resident trays and the trays are then stored in the walk-in refrigerator unit until the time of service. The Food Service Director stated that the resident trays were delivered to the dining room at approximately 11:55 AM-12 noon. The Food Service Director stated that 60 degrees Fahrenheit is not the proper serving temperature for yogurt or any cold food and should be below 42 degrees Fahrenheit. The Food Service Director the residents can get sick from the cold food served at a temperature above 42 degrees as there is an increased risk of bacterial growth. During an interview on 1/2/2025 at 12:10 PM, the Administrator stated they were not aware of an issue with the cold food items being served above the safe temperature zone prior to notification during the survey process. 10 NYCRR 415.14(h)

Based on record review and interviews during the Recertification Survey and Abbreviated Survey (NY 00307267) initiated on 9/18/2023 and completed on 9/25/2023, the facility did not ensure each resident was provided care that meets professional standards of practice. This was identified for one (Resident #191) of two residents reviewed for Urinary Catheter. Specifically, Resident #191's Foley catheter was removed on 12/1/2022 for a void trial (assesses the ability of the bladder to empty). The resident was not monitored and assessed timely after the Foley catheter was removed to determine the trial void outcome. The finding is: The facility's policy titled Voiding Trial, effective 12/1/2020, documented the nurse will obtain a physician's order to discontinue the Foley catheter and start a voiding trial; parameters for re-insertion of Foley catheter will be designated by a physician if needed; monitor output every shift for 24 hours; monitor residual output via bladder scan for 24 hours. If greater than 300 milliliters (ml) is noted, then perform straight catheterization (a tube used to empty urine from bladder intermittently) and notify the physician. Resident #191 was admitted with diagnoses including Cancer, Obstructive Uropathy, and Parkinson's Disease. The 10/13/2022 Admission Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 12, indicating the resident had moderately impaired cognition. The MDS documented the resident had an indwelling urinary catheter. A physician's order dated 11/1/2022 documented Foley Catheter Size 16 French for diagnosis of Retention of Urine. A urology consult dated 11/3/2022 documented to start a void trial on 12/1/2022 at 6 AM; an office visit was scheduled for 12/1/2022 in the afternoon. A nursing progress note dated 11/3/2022 documented the resident went to a Urology appointment on 11/3/2022 and returned to the facility alert and oriented, with no complaint of discomfort or nausea. As per the consult resident's Foley catheter was changed. Recommendations included starting a void trial on 12/1/2022 at 6 AM and the office visit was scheduled on the same day on 12/1/2022 in the afternoon. The Physician Assistant (PA) was notified. A physician's order dated 11/3/2022 documented to remove the Foley Catheter and to start a void trial, start date 12/1/2022 at 12:00 AM. A physician's order dated 12/1/2022, entered at 3:23 PM, documented to obtain a Bladder Scan every 8 hours for 72 hours, at 6:00 AM, 2:00 PM, and 10:00 PM for 3 days. There were no parameters documented in the order for re-catheterization. A nursing progress note dated 12/1/2022 at 8:08 AM documented, the resident was alert and verbally responsive. To start voiding trials this morning. The Foley catheter drained 600 cubic centimeters (cc) of dark amber urine. The Foley catheter was removed at 4:45 AM. No hematuria (blood in the urine) and no complaint of pain or discomfort. Continue to monitor urine output. Endorsed to day nurse. There were no further nursing progress notes until 12/2/2022 at 3:17 AM. A review of the Treatment Administration Record (TAR) for December 2022 documented no entry for the Bladder Scan on 12/1/2022 until 10:00 PM. The nurse's initials were entered; however, no urine volume was documented. The 24-hour report for 12/1/2022, 7:00 AM-3:00 PM shift, documented status-post Foley [removal], bladder scan every shift, urine noted this shift. There was no documentation if the Bladder Scan was performed; the amount of urine voided; or if the resident was assessed after the resident's Foley catheter was removed. The 24-hour report for 12/1/2022, 3:00 PM-11:00 PM shift, documented a Bladder Scan was completed with 230 ml (residual amount of urine in the bladder). There was no documentation of an assessment of the resident and no corresponding nurses progress notes. A medical progress note written by PA #1 dated 12/1/2022 at 12:53 PM documented the resident had the Foley catheter removed for a pending urology appointment; unfortunately, the appointment was moved from 12/1/2022 to 12/8/2022. The resident stated that they (resident) would like to leave the Foley catheter out; a bladder scan every shift (every 8 hours) was ordered. A nursing progress note dated 12/2/2022 at 3:17 AM documented the resident was in bed with a call bell within reach. The resident complained of a pain level of 6 out of 10 on the pain scale (zero being the lowest pain level and 10 being the highest level on the pain scale) in the pelvic areas. The void trial was in progress status post Foley catheter removal. The bladder was scanned at 3 AM and showed 576 cc of urine in the bladder. The pelvic and lower abdomen regions were hard to touch and distended. The resident was told to try to urinate on their own. The resident was unable to urinate. Straight catheter insertion was explained and the resident was agreeable. A straight catheter was inserted and 700 cc of yellow urine with sediment was obtained. The catheter was removed and the resident verbalized feeling relieved after the procedure. A medical progress note dated 12/2/2022 at 9:28 AM written by PA #1 documented the staff reported that the resident needed to be straight catheterized last night. They (PA #1) spoke with the resident, and the resident understood that if they (resident) needed a straight catheter again, a Foley catheter would be placed. The resident denied any other issues or concerns but was frustrated that they may need the Foley catheter again. A nursing progress note dated 12/2/2022 at 5:32 PM documented resident continued on void trial, and has a directive to re-insert the Foley catheter if the resident retains greater than 500 milliliters (ml) of urine as the resident had been straight catheterized one time during this void trial. The resident was drinking fluids as instructed. The urology appointment was scheduled for 12/8/2022. PA #1 was interviewed on 9/20/2023 at 11:40 AM and stated the void trial for Resident #191 was started on 12/1/2022 so that the Urologist could assess the resident at the scheduled appointment later in the day. PA #1 stated the facility found out that the appointment was changed to 12/8/2022 after the resident's Foley catheter was removed. The resident did not go to the Urologist on 12/1/2022 as previously scheduled. PA #1 could not recall why the resident's urology appointment was changed or who had notified PA #1 of the appointment change. Registered Nurse (RN) #4, the 11:00 PM-7:00 AM RN Supervisor who wrote a progress note on 12/1/2022 at 8:08 AM, was interviewed on 9/21/2023 at 8:13 AM. RN #4 stated they did not remember if they (RN #4) or another nurse removed Resident # 191's Foley catheter on 12/1/2022 at 4:45 AM. RN #4 stated there should have been documentation in the progress notes or the TAR regarding the bladder scan being performed during the 7:00 AM- 3:00 PM shift. RN #4 further stated the documentation should also include how the resident tolerated the removal of the Foley catheter and the amount of urine output obtained after the Foley catheter was removed. The Director of Nursing Services (DNS) was interviewed on 9/21/2023 at 11:39 AM and stated after the Foley catheter was discontinued for Resident #191, the physician's orders for the void trial and bladder scan should have included parameters including when to re-catheterize the resident based on urinary output or bladder scan results. PA #1 was re-interviewed on 9/22/2023 at 8:33 AM and stated they do not put the orders in the Electronic Medical Record (EMR). PA #1 stated they always understood as a standard of practice, nurses know they have to monitor and re-insert the catheter if the bladder scan result is 500 ml or greater urine residual in the bladder. RN #6, the unit Supervisor who entered the bladder scan order in the EMR on 12/1/2022, was interviewed on 9/22/2023 at 11:15 AM. RN #6 stated the doctor or a medical practitioner is supposed to define what the parameters are for re-insertion of the Foley catheter in the bladder scan order, because the parameters are tailored per the resident. RN #6 stated that Resident #191's physician's order did not include any parameters. RN #6 stated the directive to reinsert the Foley catcher would have to come from the PA or the doctor. RN #6 stated there is a treat in place order that nurses understand that the resident should be straight catheterized when the bladder scan shows 300 ml of urine in the bladder; however, there was a verbal directive from the PA to catheterize Resident #191 when the bladder scan showed 500 ml of residual urine. There was no documented physician's order that indicated to re-catheterize the resident if the bladder scan showed 500 ml or more of residual urine in the bladder. The DNS was re-interviewed on 9/22/2023 at 2:30 PM and stated urine output is hard to measure if a resident is incontinent, but there should have been a bladder scan done on the 7:00 AM-3:00 PM shift. The DNS also stated if the directive was to catheterize the resident when the bladder scan showed 500 ml of residual urine in the bladder, there should have been a written physician's order. The DNS stated they were not sure if an assessment of the resident during a void trial is part of the facility protocol. Licensed Practical Nurse (LPN) #8, who conducted the bladder scan during the 3:00 PM-11:00 PM shift on 12/1/2022, was interviewed on 9/25/2023 at 12:10 PM. LPN #8 stated when a resident is on void trial, they (LPN #8) would evaluate the resident for pain and distension in addition to completing the bladder scan. LPN #8 stated they could not recall if they evaluated Resident #191 after they performed the bladder scan. 10 NYCRR 415.12(d)(1)

Based on record review and interviews during the Recertification Survey and Abbreviated Survey (NY 00317548), initiated on 9/18/2023 and completed on 9/25/2023, the facility did not ensure pain management was provided to each resident who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This was identified for one (Resident #190) of three residents reviewed for pain management. Specifically, Resident #190 had a Physician prescribed as needed (PRN) pain medication, Tramadol. The facility staff administered the pain medication; however, did not consistently assess the resident's pain level prior to and after the medication administration to monitor the effectiveness of the pain medication. Additionally, all facility staff were not knowledgeable regarding the process of entering the PRN pain management evaluation protocol into the Medication Administration Record (MAR). The finding is: The facility's policy titled Pain Management, dated April 2018, documented to monitor resident response to pain management interventions; a 0-10 numeric pain scale may be utilized when defining the intensity of pain when the resident is able to verbalize the level of pain; nurses must evaluate the effectiveness of medications; and nurses must document in the electronic medical record the medication and effectiveness. Residents should be fully observed and monitored for pain and as much relevant information as possible should be obtained. Resident #190 was admitted with diagnoses including Paraplegia, Thoracic Spinal Cord Injury, and Chronic Pain Syndrome. The 5/12/2023 Admission Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS documented that the resident had frequent pain with a level of 6 out of a 10-pain scale, with zero being no pain and 10 as the worst pain. A physician's order dated 5/5/2023 documented Pain Scale Rating-Monitor and Record Pain Scale Every Shift. A physician's order dated 5/5/2023 documented to administer Tramadol (a narcotic pain reliever) 50 milligram (mg) tablet, give one tablet by oral route every 6 hours as needed (PRN) for a diagnosis of unspecified pain. A physician's order dated 5/5/2023 documented to administer Tylenol 325 mg tablet, give 2 tablets (650 mg) every 6 hours as needed for a diagnosis of unspecified pain. A Comprehensive Care Plan (CCP) titled Pain, effective 5/6/2023, documented an intervention to monitor the effectiveness of medication. A physician's order dated 5/16/2023 documented to administer Ibuprofen 200 mg tablet, give three tablets (600 mg) by oral route as needed for a diagnosis of unspecified pain. Review of the May 2023 MAR revealed Resident #190 received the Tramadol PRN on May 6, 7, 9, 11, 12, 14, 15, 17, 19, 21, 23, 24, 25, and 26; received the Tylenol on May 16, 26, and 29; and received the Ibuprofen on May 16, 17, 18, 19, 27, and 30. There was no documentation in the monitoring section of the MAR indicating an evaluation of the effectiveness of these PRN pain medications. The resident also received one-time physician orders for Tramadol 50 mg from the Emergency (E) box on May 27, 28, and 29, and the May 2023 MAR revealed that the resident received these one-time doses with no evaluation of the effectiveness of the pain medication. The Physical Medicine and Rehabilitation (PM&R) progress note dated 5/30/2023 documented Resident #190 was seen today (5/30/2023) and has a primary diagnosis of Thoracic (T) Spinal Cord Injury. The resident had T3-Lumbar (L) 3 Posterior Spinal Instrumentation and Fusion (PSIF) and intraoperatively (during surgery) had motor loss (weakness) of bilateral lower extremities. Today, the resident admitted to back pain that can reach severe levels and the pain radiates into bilateral lower extremities. The resident rated their pain at a 9 out of 10 on the pain scale. The resident reported that Tramadol was not helping and they would like a stronger medication for the pain. The Physician recommended to discontinue the Tramadol and start Oxycodone 5 mg every 6 hours as needed. The Physician recommended to continue the use of Tylenol and Ibuprofen as ordered. A physician's order dated 5/30/2023 documented to administer Oxycodone 5 mg tablet, give one tablet every 6 hours as needed for chronic pain syndrome. A nursing progress note written by Licensed Practical Nurse (LPN) #5 on 5/30/2023 at 4:16 PM documented the resident was in pain and Ibuprofen was given. The Physician Assistant (PA) saw the resident and ordered a Lidocaine patch to the lower back daily. The resident's family wanted the resident to be sent to the hospital. The doctor (PM&R) was in the facility and was able to see the resident immediately. A new order for Oxycodone 5 mg every 6 hours was received and a STAT (Immediate) dose was given at 11:00 AM. At 11:45 AM LPN #5 returned to the resident's room and the resident stated they were feeling better. A review of the 24-hour report dated 5/30/2023 for the 7:00 AM-3:00 PM shift documented Oxycodone was administered with positive effects. A review of the MAR for May 2023 revealed that the resident was administered Oxycodone on 5/30/2023 at 8:33 PM; however, there was no documentation regarding the monitoring of the effectiveness of the medication. A review of the 24-hour report dated 5/30/2023 for the 3:00 PM-11:00 PM shift documented Oxycodone was given with positive effects. A review of the MAR for 5/30/2023 during the 11:00 PM-7:00 AM shift revealed that the resident reported a pain level of 10 out of 10. Oxycodone was administered on 5/31/2023 at 3:16 AM. There was no documentation for the 11:00 PM-7:00 AM shift on the 24-hour report; there was no monitoring of the effectiveness of the pain medication in the MAR; and there were no follow-up progress notes related to the effectiveness of the pain medication in the Electronic Medical Record (EMR). LPN #5, who administered the STAT dose of Oxycodone on 5/30/2023 and gave PRN pain medications, was interviewed on 9/19/2023 at 2:57 PM. LPN #5 stated when a PRN pain medication is administered, the computer system generates a pop-up that includes the facility protocol to monitor the effectiveness of the medication. LPN #5 stated the monitoring protocol is not triggered when a one-time STAT dose of pain medication is administered. LPN #5 stated it is basic nursing to follow up to monitor the effectiveness of pain medication after pain medication is administered. LPN #5 stated on 5/30/2023 the note indicated that LPN #5 administered the Oxycodone at 11:00 AM and returned to Resident #190's room at 11:45 AM. Resident #190 told them (LPN #5) that they (Resident #190) were feeling better. Pharmacist #1 and the Pharmacy Director were interviewed concurrently on 9/20/2023 at 12:09 PM. They both stated the pharmacy received a prescription for Resident #190 for Tramadol on 5/9/2023. The pharmacy provided a total of 20 Tramadol tablets. Pharmacist #1 and the Pharmacy Director both stated that there were no other prescriptions received for Tramadol after the 20 tablets were administered. LPN #6, who administered the Oxycodone on 5/30/2023 at 8:33 PM, was interviewed on 9/20/2023 at 3:13 PM. LPN #6 stated they frequently turned and positioned Resident #190 and monitored the resident's pain; however LPN #6 did not document the resident's pain on a pain scale of 0-10. Registered Nurse (RN #4), Registered Nurse (RN) #4, the 11:00 PM-7:00 AM nursing Supervisor was interviewed on 9/21/2023 at 8:20 AM and stated on 5/31/2023 Resident #190 complained of pain measuring 10 out of 10 and they (RN #4) administered Oxycodone at 3:16 AM. RN #4 stated the Oxycodone order did not include the monitoring protocol. RN #4 stated the nurses who enter any PRN pain medication order need to be inserviced on how to accurately enter the pain medication order into the EMR; therefore, initiating the pain assessment section on the MAR. RN #4 stated there should have been follow up documented after the PRN pain medication was given and the following shift should have followed up. RN #5, who entered the PRN Tramadol order dated 5/5/2023, was interviewed on 9/21/2023 at 12:54 PM. RN #5 stated after administering a PRN pain medication the nurses are expected to follow up with the resident regarding the effectiveness of the pain medication. RN #5 stated the EMR does not allow us to add in parameters for follow-up (before and after) for PRN pain medications. RN #2, the Inservice Coordinator, was interviewed on 9/22/2023 at 10:31 AM and stated when a pain medication is given, the nurse is supposed to assess the pain level and then check back in 30 minutes to assess the resident's pain level using the pain scale. RN #2 stated it is not always expected that the pain level be obtained initially--it depends on the situation; for instance if the resident has a headache, just give Tylenol. RN #2 stated the pain assessment should be on the MAR in the monitoring section. RN #6, the unit supervisor, was interviewed on 9/22/2023 at 11:15 AM. RN #6 stated there is a way to put the protocol for pain monitoring in the EMR. RN #6 stated the nurse (RN #5) who said there was no way to enter the protocol was wrong. RN #6 stated as far as an assessment, the pain level cannot be quantified with positive effects or feeling better statements. The Director of Nursing Services (DNS) was interviewed on 9/22/2023 at 2:30 PM and stated it is acceptable to document positive effect after administering a pain medication, it means it is therapeutic (provided pain relief) and the resident is comfortable. The DNS stated the protocol for before and after pain medication evaluation can be documented in the EMR and inservice education for the nurses is needed. The DNS stated there should have been follow up after the PRN pain medications were administered. RN #2 was re-interviewed on 9/25/2023 at 11:15 AM and stated the inservice education does not include the topic of documenting the pain assessment before and after administration of pain medication in the EMR or how to properly enter the physician's order into the EMR to initiate the pre and post pain assessment protocol on the MAR. 10 NYCRR 415.12

Based on observation, record review, and interviews during the Recertification Survey initiated on 9/18/2023 and completed on 9/25/2023, the facility did not ensure drugs and biologicals were labeled in accordance with currently accepted professional principles. This was identified for 1) one (Resident #78) of five residents observed during medication administration; and 2) one (Resident #32) of one resident reviewed for choices. Specifically, 1) during the medication administration task Resident #78's Lexapro (antidepressant medication) blister pack label did not match the current physician's order nor had a change in order sticker as per the facility's policy; and 2) Resident 32 was observed with a Physician prescribed inhaler medication in their room unattended by the facility staff. The findings are: 1) The facility's policy titled Medications and Medication Labels, effective 1/2023, documented if the prescriber's directions for use change or the label is inaccurate, the nurse may place a direction change, change of order-check chart, or similar label on the container indicating there is a change in direction for use. If directions for use change, the provider pharmacy is informed prior to the next refill of the prescription so the new container will show an accurate label. Resident #78 was admitted with diagnoses including Depression, Seizure Disorder, and Metabolic Encephalopathy. The 7/28/2023 Admission Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS documented that the resident received antidepressant medications. A physician's order dated 7/29/2023, and renewed on 9/16/2023, documented Escitalopram (Lexapro) 5 milligram (mg) tablet, give one tablet once daily at 9 AM for Depression. On 9/19/2023 at 8:35 AM Resident #78's medication administration was observed performed by Licensed Practical Nurse (LPN #4). The Escitalopram blister pack used by LPN #4 had a label that did not match the physician's order and reflected Escitalopram 5 mg tablet, give 1.5 tablets by mouth daily (a total of 7.5 mg). There was no change in direction sticker on the blister pack. For each dose in the blister pack there was a 5 mg whole tablet and a half tablet (2.5 mg). LPN #4 discarded the half tablet (2.5 mg) and provided the 5 mg tablet to the resident. When LPN #4 was questioned about the discrepancy with the order and the label, LPN #4 stated they (LPN #4) called the pharmacy and was directed by the pharmacist to remove the half tablet because insurance did not allow the pharmacy to send a new blister pack while there was still enough medication left to fulfill the physician's order. LPN #4 stated they did not have the change in direction stickers and had asked a supervisor, but the supervisor did not know where the stickers were. Pharmacist #1 was interviewed on 9/19/2023 at 3:15 PM and stated usually if the new order of a medication can be fulfilled with the supply on hand at the facility, then insurance will not cover new orders and the nurses are directed to use the supply that is already available in the facility. Insurance wants the supply finished. Pharmacist #1 stated a change in direction sticker should have been placed on the blister pack by the nurse when the new order was obtained. The Pharmacy Director was interviewed on 9/20/2023 at 11:15 AM and stated when the order for Escitalopram was changed from 7.5 mg to 5 mg daily on 7/29/2023 the pharmacy received the new order; however, the data entry technician failed to process the new order appropriately and refilled the old order for 7.5 mg instead of the 5 mg Escitalopram. The Director of Nursing Services (DNS) was interviewed on 9/20/2023 at 9:36 AM and stated if there is a medication order change, the nurses are supposed to place a direction change sticker on the blister pack. 40696 2) The facility Storage of Medication policy dated 4/18/2022 documented that all medications including treatment items are stored in a locked cabinet or room inaccessible to residents and visitors. Medication is accessible only to licensed nursing personnel. Resident #32 was admitted to the facility with the diagnoses of Chronic Obstructive Pulmonary Disease, Respiratory Failure and Heart Failure. The 5-day Minimum Data Set (MDS) assessment dated [DATE] documented Resident #32 had a Brief Interview for Mental Status assessment score of 13, indicating intact cognition. The physician's order dated 9/3/2023 documented to administer Spiriva Respimat (a bronchodilator that relaxes muscles in the airways and increases air flow to the lungs) 2.5 micrograms (mcg) /actuation solution for inhalation. Inhale 2 puffs (5 mcg) by inhalation route once daily at the same time each day every day at 9:00 AM. The September 2023 Medication Administration Record documented Licensed Practical Nurse (LPN) #2 administered Spiriva Respimat on 9/19/2023 and the medication was administered by LPN #1 on 9/21/2023. The Respiratory Dysfunction care plan dated 7/27/2023 documented that Resident #32 was at risk for respiratory distress related to Chronic Obstructive Pulmonary Disease and Asthma. The interventions included to administer medications and to monitor for signs and symptoms of respiratory distress. Resident #32 was observed seated in a wheelchair in their room with a Spiriva inhaler on the overbed table on 9/19/2023 at 10:07 AM. Resident #32 stated that they (Resident #32) self-administer the medication and takes two puffs once a day. Review of Resident #32's medical records revealed that there was no assessment or care plan for self-administration. Licensed Practical Nurse (LPN) #1 was interviewed on 9/21/2023 at 1:10 PM. LPN #1 stated that they (LPN #1) were regularly assigned to Resident #32 during the day shift. LPN #1 stated that Resident #32 does not self-administer the Spiriva inhaler and the medication should be in the medication cart, and not in Resident #32's room. LPN #1 looked through the medication cart and stated that the Spiriva inhaler was not in the medication cart. LPN #1 was then observed to enter Resident #32's room and exit the resident's room with the Spiriva inhaler. LPN #2 was interviewed on 9/22/2023 at 11:50 AM. LPN #2 stated that on 9/19/2023, LPN #2 opened the Spiriva inhaler and gave the inhaler to Resident #32. LPN #2 was then called by another staff member and stepped out of the room to assist with another resident. LPN #2 stated they left Resident #32 with the inhaler. The Director of Nursing Services (DNS) was interviewed on 9/22/2023 at 2:29 PM. The DNS stated that the nurses are expected to administer the inhaler, clean it, and place it back into the medication cart. The DNS stated that the nurses should not have left the Spiriva inhaler in Resident #32's room. 10 NYCRR 415.18 (d) and 415.18(e)(1-4)

Based on observation, record review, and interviews during the Recertification Survey, initiated on 9/18/2023 and completed on 9/25/2023, the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections. This was identified for one (Resident #193) of two residents reviewed for Pressure Ulcers. Specifically, on 9/21/2023 Licensed Practical Nurse (LPN) #3 was assisted by Registered Nurse (RN) #2 with the wound care treatment for Resident #193. RN #2 was observed placing the resident back onto the soiled barrier after the resident's unstageable coccyx (tailbone) pressure ulcer was cleansed therefore, allowing the pressure ulcer to come in contact with the soiled barrier. The wound was not re-cleansed before the treatment was applied. The finding is: The facility's policy titled Infection Control, effective 2/2022, documented the organization uses a coordinated process to reduce the risks of endemic and epidemic nosocomial infections in residents and health care workers. The primary purposes of this facility's infection control policies and procedures are to establish guidelines to follow to provide a safe and sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. Establish guidelines to follow in implementing Standard Precautions for the handling of blood, body fluids, secretions, excretions, mucous membranes and nonintact skin. Resident #193 was admitted with diagnoses including Seizure Disorder, Intracranial Hemorrhage, and Hemiplegia. The 9/11/2023 Admission Minimum Data Set (MDS) assessment documented no Brief Interview for Mental Status (BIMS) score as the resident rarely or never makes self understood. The MDS documented that the resident had an unstageable pressure ulcer. A Comprehensive Care Plan (CCP) titled Presence of Coccyx Pressure Ulcer, effective 9/1/2023, documented the resident was seen by the wound care physician on 9/13/2023. The wound was identified as unstageable pressure ulcer measuring 7 centimeters (cm) x 6.5 cm x 0.5 cm, with 99% slough (dead tissue), 1 % granulating (healthy growing) tissue. The interventions included to monitor for signs and symptoms of infection such as increased redness, warmth, drainage, foul odor, etc. A physician's order dated 9/13/2023 documented to apply Santyl (enzymatic debridement agent) 250 unit/gram topical ointment, apply by topical route to coccyx; cleanse wound with wound cleanser followed by Santyl and Calcium Alginate (an absorbent dressing), and silicone-bordered dressing every day and when needed, for diagnosis of pressure ulcer, unstageable. On 9/21/2023 at 10:42 AM Resident #193's wound care treatment was observed, performed by Licensed Practical Nurse (LPN#3) and assisted by Registered Nurse (RN #2, the Infection Preventionist and Inservice Coordinator. The resident had an air mattress that auto-turned and positioned the resident, and RN #2 positioned the resident on the resident's right side, exposing the coccyx/sacral area. RN #2 held the resident in that position while the wound treatment was being performed. LPN #3 placed a clean barrier on the mattress directly under the wound area. LPN #3 removed the old dressing. There was a moderate to large amount of slough and serosanguinous (blood tinged) drainage on the dressing. The wound contained mostly slough. LPN #3 cleansed the wound with spray wound cleanser, which drained out of the wound and onto the barrier. The soiled barrier was not removed. After the wound was cleansed, while LPN #3 was performing hand hygiene, RN #2 allowed the resident to lie on their back in a supine position, allowing the cleansed wound to come in contact with the soiled barrier. The surveyor brought the observation to the attention of RN #2; however, the wound was not re-cleansed and the wound treatment continued to completion. RN #2 was interviewed on 9/21/2023 at 11:43 AM and stated the resident was heavy and the mattress was auto-turning. RN #2 stated the resident only went back a little bit but allowing the resident to go back on the soiled barrier was not an acceptable procedure. RN #2 stated from their vantage point, RN #2 could not see where the wound was, but did not think that allowing the cleansed wound to come in contact with the soiled barrier created an infection potential. RN #3, the wound care nurse, was interviewed on 9/21/2023 at 2:00 PM and stated the wound definitely should not have come in contact with the dirty barrier. RN #3 stated they (RN #3) would have removed the barrier after cleaning the wound. The Director of Nursing Services (DNS) was interviewed on 9/22/2023 at 2:30 PM and stated the wound should have been re-cleansed after it came in contact with the soiled drape. 10 NYCRR 415.19(a)(1-3)

Based on record review and interviews during the Recertification Survey completed on 8/19/2021, the facility did not ensure that each resident received treatment and care in accordance with professional standards of practice for 1 (Resident #179) of one resident reviewed for Choices. Specifically, Resident # 179 was seen for an Orthopedic consult on 7/29/21 and returned to facility the same day with a recommendation from the Physician to begin oral antibiotics. The consultation report was misplaced and the resident did not begin the antibiotic regimen in a timely manner, until 8/3/2021, five days after the recommendation was made. The finding is: The facility's policy and procedure titled Consultation and Diagnostic Services, dated 8/13/2021, documented that consults will be placed in the bin marked consults upon patient return and the unit Registered Nurse (RN)/Licensed Practical Nurse (LPN) must review all consults. Resident #179 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 7/27/2021 Initial Nursing Assessment documented that the resident was alert and oriented to person, place, and time. Resident # 179 was interviewed on 8/15/2021 at 10:28 AM and stated that they (Resident #179) received an Antibiotic late that was recommended by the Orthopedic surgeon on 7/29/2021. An Orthopedic consultation report dated 7/29/2021 recommended [MEDICATION(S)] (an antibiotic) 100 milligrams (mg), two times a day for 10 days. A nursing progress note dated 7/29/2021 at 4:39 PM, written by LPN #1, documented that Resident #179 returned from the Orthopedic appointment. There was no documentation in the nurse's note regarding the recommendations on the consult. Review of the July 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A follow up Orthopedic consultation report dated 8/3/2021 recommended [MEDICATION(S)] (an antibiotic) 100 mg, two times a day. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing progress note dated 8/3/2021 at 6:43 PM, written by RN #1, documented that Resident #179 was previously seen by the Orthopedic surgeon on 7/29/2021 and was to begin a course of oral [MEDICATION(S)]. The note documented that the resident was seen again by the orthopedic surgeon on 8/3/2021 with orders to continue the course of antibiotics. RN #1 was interviewed on 8/17/2021 at 12:07 PM. RN #1 stated that when Resident #179 returned from the Orthopedic consult on 7/29/2021 RN #1 was not present. RN #1 stated there was a disconnect in receiving the resident back on the unit during the night shift and the written consult was not seen. RN #1 stated that they (RN #1) did not inquire about the written consult or see a consult. RN #1 stated the antibiotic was supposed to be started on 7/29/21. RN #1 stated that the 7/29/2021 consult was eventually found in an office that is shared by 4 staff members. RN #1 stated that the Certified Nursing Assistant (CNA) that goes out with the resident is supposed to hand the paperwork to the nurse upon return. The Director of Nursing Services (DNS) was interviewed on 8/17/2021 at 1:40 PM. The DNS stated a Quality Assurance Performance Improvement (QAPI) project was initiated regarding consultations and staff are in the process of being inserviced, but inservice education is not completed. The DNS stated prior to the QAPI project, there was no designated place to put the consults. LPN #1 was interviewed on 8/17/2021 at 2:16 PM. LPN #1 stated that they (LPN #1) were in training and were shadowing LPN #2 the night of 7/29/2021 and did not recall seeing or inquiring about any paperwork when Resident #179 returned from the consult. CNA #1 was interviewed on 8/17/2021 at 2:17 PM. CNA #1 stated that they (CNA #1) accompanied Resident #179 to the physician's office on 7/29/2021. CNA #1 stated that when they returned from the Physician's office, the unit clerk instructed CNA #1 to put the consult paper with other papers on the desk. The unit clerk was interviewed on 8/17/2021 at 2:33 PM. The unit clerk stated that they (the unit clerk) did not remember receiving paperwork from CNA#1 regarding the Orthopedic consult for Resident # 179. The unit clerk further stated if a CNA gave paperwork to the unit clerk, the unit clerk would give the paperwork to the nurse in charge to review. LPN #2 was interviewed on 8/17/2021 at 2:59 PM. LPN #2 stated that they (LPN #2) did not see or inquire about consult paperwork upon Resident #179's return from the Orthopedic visit on 7/29/2021. RN Supervisor (RN #2) was interviewed on 8/17/2021 at 3:13 PM. RN #2 stated the process is for the CNAs to hand the consult to the nurse. RN #2 further stated that they (RN #2) were not given anything on the night of 7/29/2021. 415.12

Based on observations, record review and interviews during the Recertification Survey completed on 8/19/2021, the facility did not ensure Intravenous (IV) fluids (fluids that were administered directly into a vein) were administered consistent with professional standards of practice and in accordance with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Specifically, Resident #61 was observed receiving IV fluids on 8/15/2021 without a documented physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The finding is: The facility's Medication Management: Administration - Intravenous General policy dated January 2019 documented the nursing staff was responsible to check physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #61 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] #61 had a Brief Interview of Mental Status (BIMS) Score of 12 which indicated the resident had moderately impaired cognition. The MDS documented that Resident #61 did not receive fluid via IV or tube feeding in the past 7 days of the look back period. The Comprehensive Care Plan (CCP) for Nutrition and Hydration dated 7/22/2021 documented Resident #61 had potential for alternation in nutrition/hydration status related to [CONDITION(S)]. Interventions included to monitor the resident for signs and symptoms of Dehydration, and to monitor fluid intake and laboratory values. The Basic Metabolic Panel (a blood test that measures sugar level, electrolytes, fluid balance and kidney function) laboratory result dated 8/11/2021 indicated an elevated Blood Urea [MEDICATION(S)] (BUN) level of 31 milligram per deciliter (mg/dL) (Normal Reference range is 7-23 mg/dL); and Creatinine level of 1.83 mg/dL (Normal Reference range is 0.5-1.3 mg/dL). The Urinalysis (a urine test) result dated 8/11/2021 found abnormal slightly turbid (cloudy, opaque, or thick with suspended matter) amber- colored urine. A moderate level of blood was also detected in the urine. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing progress note dated 8/15/2021 at 7: 18 AM, written by Licensed Practical Nurse (LPN#4), documented that Resident # 61 was receiving IV fluids via a midline catheter. Resident # 61 was observed on 8/15/2021 at 10:23 AM, sleeping in bed with a bag of [MEDICATION(S)] 5% 1/2 Normal Saline running at 100 cc as indicated on the flow meter attached on the tubing. Resident #61's family member entered Resident #61's room at 10: 25 AM. Resident #61's family member saw the IV fluid running and stated that resident has become confused and dehydrated after refusing to eat or drink, and developed Urinary Tract Infection that led to hospitalization . Resident #61's family member stated that the facility was providing Resident #61 with IV fluids now for rehydration. Resident # 61 and the family member were observed on 8/15/2021 at 2:05 PM in Resident # 61's room. The IV fluid was discontinued. Resident #61's family member stated that the staff said the course of IV fluids was completed and therefore discontinued. RN #5 was interviewed on 8/16/2021 at 10:55 AM and stated that based on the 24 hour report, RN #5 discontinued both IV fluids and IV antibiotics in the afternoon on 8/15/2021. RN #5 stated they (RN#5) believed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] LPN #4 was interviewed on 8/16/2021 at 11:50 AM and stated that based on the 24 hour report, Resident #61 continued to receive IV fluid the entire shift from 11 PM to 7 AM from 8/14/2021 to 8/15/2021. LPN #4 stated that Resident #61's IV fluid was still running when LPN #4 left work in the morning on 8/15/2021. RN #5 was re-interviewed on 8/17/2021 at 9:27 AM and stated Resident #61's IV fluid order was extended for 2 days on 8/13/2021 by the Physician and was written in the 24 hour report; however, RN #5 did not find a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #6 was interviewed on 8/17/2021 at 10:09 AM and stated that they (RN#6) received the Physician's verbal order to extend Resident #61's IV fluid for 2 more days on 8/13/2021. RN #6 stated they did not enter the order into the medical record. RN#6 stated that administration would not have been documented in the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] The Director of Nursing Service (DNS) was interviewed on 8/17/2021 at 10:25 AM. The DNS stated that nursing staff should check the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DNS stated there was no active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The Attending Physician, who was also the Medical Director, was interviewed on 8/17/2021 at 3:15 PM. The Medical Director stated a verbal order was given to RN #6 to continue [MEDICATION(S)] 5% 1/2 Normal Saline at 100 cc/hr for 48 more hours from 8/13/2021 to 8/15/2021. The Medical Director stated that they (the Medical Director) were not aware that the order was not in place. The Medical Director wrote an order on 8/15/2021 at 10:42 PM to give [MEDICATION(S)] 5% 1/2 Normal Saline infuse 100 milliliters by Intravenous route every hour for 48 hours 8/13-8/15 to document that they had given a verbal order to continue IV fluid hydration on 8/13/2021. 415.12(k)(2)

Based on record review and interview during the Recertification Survey completed on 8/19/2021, the facility did not ensure that the facility assessment included what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. Specifically, the facility assessment did not include the overall number of facility staff needed to ensure sufficient number of qualified staff to meet each resident's needs. The finding is: The Facility assessment dated [DATE] documented that the level of care must be sufficient for each resident to attain or maintain their highest practicable physical, mental and psychosocial well-being at all times. Based on the resident population and their needs for care and support, the following are always taken into account: 1. the acuity of the patient population, 2. the functional level of the patient and services provided, 3. employee illness, 4. employee termination, 5. the quality, education and training of the staff. Review of the Facility Assessment in its entirety revealed that there was no overall number of facility staff needed included in the assessment to ensure the resident's needs were being met. The Administrator was interviewed on 8/19/2021 at 12:36 PM. The Administrator stated that the facility assessment did not include specific staffing ratios or level of staff required because it is based on acuity. The Administrator stated that the staffing is adjusted according to the changes in the resident population and their needs. There is no specific information on thresholds for staffing in the facility assessment and no information regarding how to the facility will adjust according to acuity. The Administrator stated that staffing is adjusted with the staffing coordinator to determine if more or less staffing is needed. The facility assessment does not specify the minimum staffing levels to make that determination. 415.13(a)(1)(i-iii)

Based on observations, interviews, and record review during the COVID-19 Focused Infection Control Survey conducted on 02/17/2021, the facility did not ensure that the residents environment remained as free of accident hazards as possible. Specifically, numerous chemical agents were found unattended or unsecured on 2 of 3 resident units during the initial unit tour. The findings are: The facility policy and procedure dated 10/2017 titled, Storage Areas documented that All hazardous materials are locked in a storage area. During the initial tour of the(NAME)Unit (a Long-Term Care/Sub-Acute Unit) on 2/17/2021 at 11:45 AM, 12 boxes were observed on the floor near the delivery entrance at the end of the corridor. The boxes were stacked, against the wall in close proximity to the janitor's closet, which was left open. The 12 boxes on the floor included 8 cases of floor cleaning chemicals and various cleaning solutions as described below: Neutral Cleaner Concentrate- 3 cases Fresh Scent Deodorizer Concentrate- 1 case Non-Acid Disinfectant Bathroom Cleaner- 1 case Glass Cleaner and Protector Concentrate- 1 case HB Quad Disinfectant Cleaner Concentrate-1 case Peroxide Cleaner Concentrate- 1 case On 2/17/21 at 11:50 AM, an observation of the unlocked janitor's closet on the(NAME)Unit revealed the following items on the shelving: H2Orange-16 1 item Neutral Cleaner- 1 item 3M Deodorizer-24 items The Original Kitchen Cleanser- 12 items Glass Cleaner-11 items Lemon Polish 11 items Lysol Foaming-1 items The Director of Housekeeping was present during the observation and was interviewed at that time. He stated that the delivery the boxes was received and left on the floor late yesterday (2/16/2021) evening and should not have been left unsecured. He stated that the janitor's closet, which contained hazardous chemicals, should have been locked. He further stated that the observed items were potentially hazardous to residents if ingested. An invoice slip dated of 2/16/2021 identified the products that were observed on the floor. The Material Safety Data Sheets (MSDS) for the products were provided by the Director of housekeeping. MSDS data revealed potential harmful effects of the identified products as follows: Glass Cleaner: Central Nervous System depression and Gastrointestinal irritation. Neutral Cleaner: Gastrointestinal irritation and Respiratory Tract irritation HB Quad Disinfectant Cleaner Concentrate: Gastrointestinal corrosion, corrosive skin and [MEDICAL CONDITION] During an observation of the Park Unit on 2/17/2021 at 11:58 AM, the janitor's closet was observed unlocked. The following items were observed inside the closet: Lysol Foam-1 item H2 Orange-1 item Neutral Cleaner-1 item The Original Kitchen Cleanser- 2 items Glass Cleaner-2 items Spray Buff-2 items MSDS data revealed potential harmful effects of the identified products as follows: Glass Cleaner: Central Nervous System depression and Gastrointestinal irritation. 3M Deodorizer: Gastrointestinal irritation and Respiratory Tract irritation Neutral Cleaner: Gastrointestinal irritation and Respiratory Tract irritation Housekeeper #1 was interviewed on 2/17/2021 at 12:10 PM and stated that the janitor's closet was not locked. He stated that he usually keeps the closet locked but he forgot to lock it when he picked up the plastic bags. He stated the closet is supposed to be locked at all times because chemicals are stored in the closet. The Director of Housekeeping was interviewed on 2/17/2021 at 6:20 PM and stated that all housekeepers received in-service education regarding the significance of keeping the janitor closets locked at all times. The Director of Housekeeping was not sure why the closet door was left unlocked. The janitor's closet should never be unsupervised when unlocked because there is a potential for harm to the residents if they were to access the chemicals. 10 NYCRR 415.12(h)(1)

Based on observation, interviews and record review, during a COVID-19 Focused Infection Control Survey conducted on 2/17/2021 the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of COVID-19. Specifically, the facility cohorted Resident #1 who tested positive for COVID-19 with Resident #2 who tested negative for COVID-19 in the same room. The findings are: The Centers for Disease Control and Prevention (CDC) guidance titled, Responding to Coronavirus (COVID-19) in Nursing Homes, updated 4/30/2020 documented the following: - Ensure the resident with new-onset suspected or confirmed COVID-19 is isolated and cared for using all recommended COVID-19 PPE. -If the resident is confirmed to have COVID-19, regardless of symptoms, they should be transferred to the designated COVID-19 care unit. -Roommates of residents with COVID-19 should be considered exposed and potentially infected and, if at all possible, should not share rooms with other residents unless they remain asymptomatic and/or have tested negative for [CONDITION(S)]-CoV-2 14 days after their last exposure (e.g., date their roommate was moved to the COVID-19 care unit). The New York State Department of Health DAL (Dear Administrator Letter), dated April 29, 2020, documents the following: As care pertains specifically to COVID-19, state and federal rules and regulations require nursing homes must adhere to appropriate safety measures including, but not limited to: Having protocols to separate residents into cohorts of positive, negative, and unknown as well as separate staffing teams to deal with COVID-positive residents and non-positive residents. In order to effectuate this policy, nursing home facilities should transfer residents within a facility, to another long-term care facility, or to another non-certified location if they are unable to successful[[NAME]] separate out patients in individual facilities. The New York State Department of Health Advisory, COVID-19 Cases in Nursing Homes and Adult Care Facilities, dated 3/13/20 and updated 7/10/20, documents that when there are positive COVID-19 cases in a nursing home: Do not float staff between units. Cohort residents with COVID-19 with dedicated (Healthcare Provider) HCP and other direct care providers. Minimize the number of HCP and other direct care providers entering rooms. The facility's policy titled Covid-19 Virus - Confirmed Cases dated 2/2/2021 documented it is the policy of the facility to mitigate and minimize any spread of the virus. Prompt detection and effective triage and isolation of potentially infectious patients are essential to prevent unnecessary exposures among patients and healthcare personnel. The facility will cohort residents with positive COVID-19 and has designated rooms on a unit for this reason. Upon notification of a laboratory confirmed Positive COVID-19 a red sign will be placed on the resident's room door to indicate the resident has been placed on droplet and contact precaution. Residents are cohorted based on positive COVID-19, negative COVID-19 or unknown COVID-19 status. The electronic mail communication between the facility and the NYSDOH Epidemiologist dated 2/2/2021 documented that after improvement of symptoms, no fever and 14 days since the first positive test, only one negative test is required to clear a resident from isolation and transfer off the positive COVID-19 cohort. This can be a rapid test or a Polymerase Chain Reaction (PCR) test. Resident #1 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #1 had severely impaired cognition. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The COVID-19 PCR Test collected on 2/2/2021 and reported on 2/3/2021 documented Resident #1 was Positive for COVID-19. The Point of Care (POC) Rapid [MEDICATION(S)] Test dated 2/16/2021 documented Resident #1 was positive for COVID-19. The Nursing Progress note (NPN) dated 2/16/2021 documented the resident had a POC swab completed. The resident remained positive for COVID-19. Resident #1's room was changed to cohort with another positive COVID-19 resident. Resident #2 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment dated [DATE] documented the Brief Interview for Mental Status (BIMS) score of 14 indicating the resident had intact cognition. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/10/2021 [MEDICATION(S)] (antibiotic) every 12 hours for 7 days and on 2/11/2021 [MEDICATION(S)] (antibiotic) via intravenous route every 8 hours for 7 days were ordered for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The PCR test for COVID-19 collected on 2/8/2021 and reported on 2/9/2021 documented Resident #2 was positive for COVID-19. The POC Rapid [MEDICATION(S)] test dated 2/10/2021 documented Resident #2 was positive for COVID-19. The NPN dated 2/10/2021 documented the resident had a positive PCR test result on 2/9/2021 and the resident was moved to the COVID-19 unit. The POC rapid [MEDICATION(S)] test dated 2/16/2021 documented Resident #2 was negative for COVID- 19. The NPN dated 2/16/2021 documented the POC rapid [MEDICATION(S)] test was negative. However, Resident #2 remained on a 14-day quarantine until 2/22/2021 due to a previous positive PCR test. During an observation on 2/17/2021 at 11:15 AM, a red sign was observed outside Resident #1 and Resident #2's shared room door indicating the residents in the room were on droplet precautions. The Registered Nurse Manager (RNM) was interviewed on 2/17/2021 at 11:30 AM and at 12:30 PM and stated that the Park Unit has one COVID-19 positive room that is shared by Resident #1 and Resident #2. Resident #1 is positive for COVID-19 and Resident #2 is negative for COVID-19. Both residents were asymptomatic and had a POC test on 2/16/2021. Resident #1 results came back positive for COVID-19 and Resident #2 was found to be negative for COVID-19. Resident #2 continued to be on quarantine until 2/22/2021 based on the previous positive PCR test result that was collected on 2/8/2021 and is still considered positive for COVID-19. The RNM stated that Resident #2 is still in an infectious state and is still shedding the virus. The Director of Nursing Services (DNS) was interviewed concurrently with the Infection Control Preventionist (ICP) on 2/17/2021 at 4:13 PM. The DNS stated on 2/16/2021 a POC Rapid [MEDICATION(S)] Test was performed on Resident #1 and Resident #2. Resident #1 resulted positive for COVID-19 and Resident #2 resulted negative for COVID-19. Both residents were moved to a shared room on 2/16/2021 after the POC test results were received. The DNS stated that Resident #2 was within the 14-day quarantine period and was still considered positive for COVID-19. The DNS stated that the facility policy regarding cohorting indicates to cohort positive COVID-19 residents with other positive COVID-19 residents and negative COVID-19 residents with other negative COVID-19 residents. The Administrator was interviewed concurrently with the DNS on 2/17/2021 at 5:09 PM. The Administrator stated that the facility policy for discontinuing a resident off precautions includes three criteria: lack of fever, improvement of respiratory symptoms, and 14 days since the first positive test with one negative COVID-19 test. If the resident meets the criteria the resident will then be moved from a positive cohort to a negative cohort. The facility did not consider placing Resident #1 and Resident #2 on separate rooms because Resident #2 did not meet all three criteria, and both were still considered positive COVID-19. 415.19(a)(1-2),(b)(1)

Based on observation, interview and record review, for an abbreviated survey (NY 365), the facility did not ensure that an investigation of an accident was thoroughly investigated. The finding is: The Accident/Incidents: Reporting of resident occurrence facility policy dated 10/2018 documented that each accident and/or incident that has been sustained by a resident has been documented in complete and accurate records to comply with State and Federal mandates. The policy documented that Nursing makes sure all involved parties have completed a statement. Resident #1 was admitted to the facility with the [DIAGNOSES REDACTED]. The Significant Change in Status Minimum (MDS) data set [DATE] documented that Resident #1 had a Brief Interview for Mental Status (BIMS) assessment score of 6, indicating severely impaired cognition. The Minimum Data Set(MDS) documented that Resident #1 required extensive assistance of two persons for bed mobility and total dependence of two persons for transfers. Resident #1 did not move from seated to standing position during the assessment period. Resident # 1 was not steady and was only able to stabilize with staff assistance. Resident #1 had upper and lower extremity impairment on one side. The 2 Padded Side Rail Care Plan dated 2/24/19 documented that Resident #1 utilized 2 half side rails for [MEDICAL CONDITION] precaution. As per assessment, device was an enabler and the device improve resident's physical or emotional status by enabling bed mobility. The accident/incident report dated 8/15/20 documented that on 8/13/20 at 5:00PM, Certified Nursing Assistant (CNA) #1 reported to nursing supervisor that resident was observed with face leaning on the nightstand. CNA #1 reported that Resident #1 appeared to be attempting to get out of bed; Resident #1's legs were hanging on the side of the bed. Registered Nurse (RN) #1 responded immediately and reported that upon arrival, Resident #1 was observed lying on her back and presented alert with reddened eyelid with no signs or symptoms of discomfort. The investigation concluded that the incident was isolated. Resident #1 was transferred from Park Unit after hospitalization and was in the process of transferring back to her previous room. Within a short time frame of reapplication of padded side rails, Resident #1 was observed attempting to get out of bed and was noted by CNA #1 with feet hanging off the bed and face leaning on nightstand. It has been determined that resident is unaware of her proximity to the edge of bed, call bell within reach and not activated, bed was in lowest locked position. The Immediate corrective actions included reapplication of padded side rails, floor mats in place and bed in lowest position. Resident #1 was transferred to the hospital at the request of a family member to have a CT of the head. Resident returned to facility with negative results and safety precautions were reimplemented upon arrival. CNA #1's statement documented that the last time she saw Resident #1 was at 4:45PM when she toileted her. Resident #1 was observed calling out in bed on 10/9/20 at 11:13AM. Resident #1 was not interviewable. Resident #1's bed was against the wall on one side in a low position with bilateral padded side rails and a mat on the ground. The Nurse Educator was interviewed on 9/28/20 at 12:24PM. The Nurse educator stated that she only received statements from the RN #1 and the CNA #1. The Nurse Educator stated that she did not establish the times in which the sequence of events occurred. The Nurse educator did not know how long Resident #1 was left without her side rails and if there were any safety provisions in the interim. The Nurse Educator was re-interviewed on 10/9/20 at 12:33PM. The Nurse Educator stated that she conducted the investigation for Resident #1's incident on 8/13/20. She stated that she did not know which maintenance worker removed the padded siderail and did not obtain a statement from that individual for the investigation. The Director of Nursing was interviewed on 10/9/20 at 4:08PM. The DNS stated that the investigation was not thorough due to the missing statement from the maintenance worker and the time sequence of events that resulted in Resident #1's injury. 415.4(b)(3)

Based on observation, record review and interview, for an abbreviated survey (NY 365) the facility did not ensure that each resident receive assistance devices to prevent accidents. Specially, the facility did not apply Resident #1's ½ padded side rails as ordered by the physician. The finding is: The Side Rail Assessment facility policy dated 3/2019 documented that the facility will ensure correct installation, use and maintenance of bed rails. Resident #1 was admitted to the facility with the [DIAGNOSES REDACTED]. The Significant Change in Status Minimum Data Set ((MDS) dated [DATE] documented that Resident #1 had a Brief Interview for Mental Status (BIMS) assessment score of 6, indicating severely impaired cognition. The MDS documented that Resident #1 required extensive assistance of two persons for bed mobility and total dependence of two persons for transfers. Resident #1 did not move from seated to standing position during the assessment period. Resident # 1 was not steady and was only able to stabilize with staff assistance. Resident #1 had upper and lower extremity impairment on one side. Resident #1 was observed crawling out in bed on 10/9/20 at 11:13AM. Resident #1 was not interviewable. Resident #1's bed was against the wall on one side in a low position with bilateral padded side rails and a mat on the ground. The 2 Padded Side Rail Care Plan dated 2/24/19 documented that Resident #1 utilized 2 half side rails for [MEDICAL CONDITION] precaution. As per assessment, device was an enabler and the device improve resident's physical or emotional status by enabling bed mobility. The MD Orders dated 8/2/20 documented ½ Padded side rails for [MEDICAL CONDITION] precaution. The side rail assessment dated [DATE] documented that Resident #1 was not aware of bed boundaries. The assessment documented that Resident #1 required side rails for [MEDICAL CONDITION]. The CNA Care profile (undated) documented: ed Enabler- Right/Left Padded rails and arm rest covers. The accident/incident report dated 8/15/20 documented that on 8/13/20 at 5:00PM, Certified Nursing Assistant (CNA) #1 reported to nursing supervisor that resident was observed with face leaning on the nightstand. CNA #1 reported that Resident #1 appeared to be attempting to get out of bed; Resident #1's legs were hanging on the side of the bed. Registered Nurse (RN) #1 reported that upon arrival, Resident #1 was observed lying on her back and presented alert with reddened eyelid with no signs or symptoms of discomfort. The findings of the investigation concluded that the incident was isolated. The report documented that within a short time frame of reapplication of padded side rails, Resident #1 was observed attempting to get out of bed and was noted by CNA #1 with feet hanging off the bed and face leaning on nightstand. Resident #1 was transferred to the hospital to have a CT of the head with no injuries. CNA #1's statement documented that the last time she saw Resident #1 was at 4:45PM when she toileted her. The Nurses Progress note dated 8/13/2020 at 10:23 PM documented that RN #1 was called to room by CNA #1. CNA #1 stated Resident #1 was observed with face leaning against nightstand. CNA #1 stated Resident #1 was still on the bed but attempting to get out of the bed. Resident #1 was alert, noted with reddened area on right eyelid, no sign or symptoms of pain or discomfort when area palpated. MD was made aware and orders were made for ice pack to affected area x 48 hours then apply warm compresses. The Nurses progress note dated 8/14/2020 at 11:57 am. Resident #1 was seen by Primary Medical Doctor (PMD). Recommendations are to have CT of the head without contrast to rule out (r/o) hematoma. Resident stable. CNA #2 was interviewed on 9/25/20 at 2:24PM. CNA #2 stated that she was making a last round before dinner with CNA #1 and observed that Resident #1 had her head against the nightstand and her legs were hanging on the side of the bed. She assisted CNA #1 with placing her back into the bed. She could not recall if there was a side rail in place at the time. RN #1 was interviewed on 9/25/20 at 3:24PM. CNA #1 and CNA #2 reported to her that Resident #1 attempted to get out of the bed without assistance and she was observed to be leaning on the nightstand. RN #1 stated that she checked the resident for injuries and noted a reddened area over the right eyelid. RN#1 stated that the padded side rail was not in place which was used a precaution for [MEDICAL CONDITION]. CNA #1 was interviewed on 9/28/20 at 11:40AM and stated that on 8/13/20 she was assigned to Resident #1. She was making rounds with CNA #2 and observed Resident #1 with both of her legs hanging off the bed and her head was between the pillow and the nightstand. She stated that Resident #1 always had a side rail in place in the past but did not know why there wasn't one in place at that time. CNA #1 confirmed that she toileted the resident 15 minutes prior and placed her back into bed and moved on to make rounds. The Nurse Educator was interviewed on 9/28/20 at 12:24PM and stated she conducted the investigation for Resident #1's incident on 8/13/20. She stated that she indicated no cause to believe neglect because CNA #1 was not at fault. She stated that Resident #1 was in the process of being moved from one room to another. She stated that maintenance removed the side rails to install them into the next bed she would occupy. The Nurse Educator stated that there was a break in the plan of care when Resident #1 was left without her safety device. The Director of Nursing (DNS) was interviewed on 10/9/20 at 4:08PM and stat that there was a break in the plan of care identified by the facility which resulted in Resident #1's injury. 415.12(h)(1)

Based on record review and staff interviews during the Recertification Survey the facility did not ensure that care was implemented in accordance with each resident's Comprehensive Care Plan (CCP) for one (Resident #251) of one resident reviewed for [MEDICAL CONDITION]. Specifically, Resident #251 had a physician's orders [REDACTED]. The finding is: Resident #251 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 4/2/19 Admission Minimum Data Set (MDS) assessment documented Resident #251 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS did not identify that the resident rejected care. The MDS also documented Resident #251 has a [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The schedule in the order was for the resident's weight to be taken during the 7 AM-3 PM shift. A Comprehensive Care Plan (CCP) effective 3/27/2019 titled, [MEDICAL CONDITION]: [MEDICAL CONDITION] had an intervention to monitor weight as ordered-notify MD of weight changes of 1-2 pounds per day. Review of the Certified Nursing Assistant (CNA) Accountability Record (CNAAR) for (MONTH) 2019 revealed no directions for daily weights. Review of weight monitoring documentation in the electronic medical record revealed no weight recorded for 3/28/19, 3/29/19, 3/31/19, 4/2/19, 4/4/19, 4/5/19, 4/6/19, and 4/8/19. Review of the paper daily weight log revealed no weights for 3/27/19, 3/28/19, 3/29/19, 3/30/19, and refusals for 3/31/19, 4/2/19, 4/5/19, and 4/8/19. In addition, comparison of the paper daily weight log and the electronic weight monitoring record revealed discrepancies in weights. Review of nursing progress notes revealed the following: - 3/27/19, daily weights in progress; - 4/1/19, weight=258.6 pounds; - 4/2/19, seen by cardiology, no new orders. The resident's CNA was interviewed on 4/15/19 at 1:04 PM. She stated she started working with the resident on 4/10/19. She stated the resident gets weighed every day and the CNA records the weight on the daily weight paper log. She stated the paper log indicates the residents who are on daily weights and the CNAs are responsible to review the paper log. A CNA who was assigned to the resident prior to 4/10/19 was interviewed on 4/16/19 at 12:28 PM. She stated the resident was weighed every day and the weights were recorded on the weight paper log. She stated the CNA records the weight on the weight paper log and the nurse enters the weight into the computer. She stated some days the resident refused to be weighed. She stated that the CNA is responsible to write refused on the log and tells the nurse. The Registered Dietician was interviewed on 4/16/19 at 12:36 PM. She stated the facility's policy is that any new resident with a [MEDICAL CONDITION] [DIAGNOSES REDACTED]. She stated she reviews the clip board that the CNAs record the weights on and the dates that had no weights were because the resident refused to be weighed. She stated that it should have been documented that the resident refused and follow up with the resident should have been done if the resident was refusing weights. She also stated that there are a lot of weights to be done and that the discrepancy in weights between the paper log and the electronic log was due to human error. The Registered Nurse (RN) unit supervisor was interviewed on 4/16/19 at 2:41 PM. She stated the process is for the CNA to weigh the resident and record the weight on the daily weight paper log and then the Licensed Practical Nurse (LPN) logs the weight into computer. The entry in the paper log should not be blank. If the resident refused, it should say refused and the LPN should investigate further. If the resident is refusing, there should be a progress note and the doctor should be notified. The LPN that was assigned to the resident on 3/28/19 during the 7 AM-3 PM shift was interviewed on 4/17/19 at 11:24 AM. The LPN stated on 3/28/19 there was no weight recorded in the electronic log or the paper log. He stated if a weight is not done the nurse is supposed to go back to CNA and tell them that it has to be done or the nurses can take the resident's weight. The Director of Nursing Services (DNS) was interviewed on 4/17/19 at 11:39 AM. She stated if the resident was refusing daily weights it should be brought up to the Dietician, discussed with the doctor, and a note should be written. 415.11(c)(1)

Based on record review and staff interview during the recertification survey, the facility did not ensure the implementation of an effective discharge process for one (Resident #49) of one resident reviewed for Discharge Planning. Specifically, the facility did not implement a discharge process for Resident #49 following the resident's family stating that they would not be able to care for the resident at home and that they wanted another other Skilled Nursing Facility (SNF) closer to their home to be contacted for possible long term care (LTC). The finding is: Resident #49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly 30-day Minimum Data Set (MDS) assessment dated [DATE] documented the resident was usually understood and could usually understand. The resident had severely impaired cognitive skills for daily decision making with long and short term memory problems. Section Q - Participation in Assessment and Goal Setting, documented that the resident's family participated in the assessment and that an active discharge planning was already occurring for the resident to return to the community. The Discharge Preparation Comprehensive Care Plan (CCP) dated 11/2/18 was updated on 1/31/19 by the facility's per diem Social Worker (SW) and documented that the resident's original discharge plan was to return to her home with her family, but recently the family stated that they could no longer take the resident home. The Social Worker continues to work with the family to find a suitable placement for the resident and that an additional SNF had been contacted for possible LTC. There was no other documentation in the resident's medical record after 1/31/19 which addressed the status of the resident's discharge planning. The per diem SW was interviewed on 4/16/19 at 12:40 PM and stated that the Director of Social Work was directly in charge of contacting the SNF to see if it was suitable for the resident to be transferred there as she was pending approval from Medicaid. The per diem SW stated that she assumed that that the Director of Social Work would have written a note regarding the resident's discharge planning status. The Director of Social Work was interviewed on 4/16/19 at 12:50 PM and stated that when the resident was first admitted to the facility they had community Medicaid and she had to wait for it to be changed to long term Medicaid. The Director of Social Work stated that the resident's Medicaid changed on 3/26/19 and on 4/3/19 she made a request to the Assistant Director of Nursing (ADNS) to fill out a PRI (Patient Review Instrument) so it could be sent to the only facility that the resident's family wanted them to be transferred to. The Director of Social Work stated that the ADNS never filled out the paperwork for her. The Director of Social Work stated that the PRI would be sent to the facility today (4/16/19) and that she should have updated the resident's medical record to reflect the status of the resident's discharge. The ADNS was interviewed on 4/17/19 at 9:35 AM and stated that she did not remember being asked by the Director of Social Work to fill out a PRI for the resident. The ADNS stated that she had just become certified around that time to complete PRIs and had never done one for the facility at that time. The ADNS stated that the previous Director of Nursing Services (DNS) used to do them for the facility. The ADNS stated that if a PRI needed to be filled out she would have called another Nurse from a different building who was certified to come over and utilize them to do a PRI. The acting DNS was interviewed on 4/18/19 at 10:45 AM and stated that she could not recall anyone asking her to complete a PRI for this resident. The acting DNS stated that as soon as she was asked to have one completed, she instructed her ADNS to complete one. 415.11(d)(3)

Based on observation, record review, and staff interviews during the Recertification Survey the facility did ensure that residents who require [MEDICAL CONDITION] care receive services consistent with standards of practice and have a baseline comprehensive person-centered care plan developed for [MEDICAL CONDITION] care. This was identified for 1 ( #249) of one resident reviewed for [MEDICAL CONDITION] care. Specifically, Resident #249 was admitted to the facility with a [MEDICAL CONDITION], however, there were no Physician's orders for the care and monitoring of the [MEDICAL CONDITION], the nursing care that was provided was documented inconsistently, and there was no documented evidence the facility was aware that the family was providing [MEDICAL CONDITION] care. The finding is: The facility's undated policy titled [MEDICAL CONDITION] Stoma Care documented that care will be performed daily by the resident and/or by the licensed nurse/designee and recorded in the electronic medical record. Resident #249 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission nursing assessment dated [DATE] documented that the resident was alert and oriented to person, place, and time and had a [MEDICAL CONDITION] to the left abdomen. Review of the medical record revealed that there was no physician's order for care of the [MEDICAL CONDITION]. A Comprehensive Care Plan (CCP) titled [MEDICAL CONDITION]/[MEDICAL CONDITION] effective 4/17/19 documented an intervention to change ostomy bag every shift and as needed. Review of the electronic Treatment Administration Record (TAR) revealed no documentation related to [MEDICAL CONDITION] care or that the ostomy bag was changed. Review of nursing progress notes revealed the following: - 4/10/19, no documentation of [MEDICAL CONDITION] care; - 4/11/19, 6 AM [MEDICAL CONDITION] care rendered, 12 PM [MEDICAL CONDITION] intact, no complications, 3 PM [MEDICAL CONDITION] intact; - 4/12/19, no documentation of [MEDICAL CONDITION] care; - 4/13/19, no documentation of [MEDICAL CONDITION] care; - 4/14/19, 6 AM [MEDICAL CONDITION] care rendered, no documentation for remainder of day; - 4/15/19, 6 AM [MEDICAL CONDITION] care rendered, no documentation for remainder of day. The resident's Certified Nursing Assistant (CNA) was interviewed on 4/16/19 at 9:47 AM. She stated the resident has a [MEDICAL CONDITION]. The CNA also stated that she does not do the [MEDICAL CONDITION] care and the resident does not do it. The resident's Licensed Practical Nurse (LPN) medication/treatment nurse was interviewed on 4/16/19 at 9:49 AM. She stated that she floats and does not see the resident every day. She stated either the medication nurse or the nurse supervisor is supposed to do the [MEDICAL CONDITION] care. She stated that she inspects the [MEDICAL CONDITION] and does [MEDICAL CONDITION] care during her shift and that the ostomy bag is changed as needed. She stated she has not changed the ostomy bag. She further stated [MEDICAL CONDITION] care is supposed to be documented in the electronic Treatment Administration Record (TAR). The LPN reviewed the electronic medical record and was unable to find documentation of [MEDICAL CONDITION] care. The LPN who was assigned to the resident on 4/15/19, on the 7 AM-3 PM shift, was interviewed on 4/16/19 at 1:00 PM. She stated that when she saw the resident that morning (4/15/19) she inspected the [MEDICAL CONDITION] and determined that [MEDICAL CONDITION] care was unnecessary because the ostomy bag was empty and she believed the care was already done during the previous 11 PM-7 AM shift. She stated the resident went out during her shift for a medical appointment and returned during her shift. She further stated that she did not check the [MEDICAL CONDITION] when the resident returned. The 11 PM-7 AM shift LPN charge nurse who was assigned to the resident on 4/9/19, 4/10/19, 4/11/19, 4/13/19 and 4/14/19 was interviewed on 4/16/19 at 1:33 PM. She stated that she does the [MEDICAL CONDITION] care if it is needed, for instance if the ostomy bag is full or if it is leaking. She stated that the nurse is supposed to check the [MEDICAL CONDITION] every shift. The Director of Nursing Services (DNS) was interviewed on 4/16/19 at 1:59 PM. She stated the order for [MEDICAL CONDITION] care should have been in place upon admission. She stated she was going to talk to the admitting Registered Nurse (RN) to find out why the order was not put in at the resident's admission. The resident's [MEDICAL CONDITION] was observed with the Assistant Director of Nursing (ADNS) on 4/16/19 at 2:11 PM. The [MEDICAL CONDITION] was intact and there was no leaking or signs of irritation or infection. The resident stated that his family member changed the [MEDICAL CONDITION] appliance and did the [MEDICAL CONDITION] care last night (4/15/19 evening). Review of the medical record revealed that there was no documentation that the facility was aware that the resident's family was providing [MEDICAL CONDITION] care. The resident's family member was interviewed on 4/17/19 at 8:51 AM. She stated she has been doing the [MEDICAL CONDITION] care regularly when she comes in and that she has supplies. She stated that she changed the appliance on the evening of 4/15/19 and told the nurse to make note of it. She stated that when the resident was admitted a staff nurse did the [MEDICAL CONDITION] care, but since that time she has been doing the [MEDICAL CONDITION] care and no one in the facility has observed her do the care. The DNS was re-interviewed on 4/17/19 at 9:19 AM. She stated that the resident's family member has to come in and demonstrate that she can do the [MEDICAL CONDITION] care. She stated that this needs to be documented and care planned. She also stated that she spoke to the admission RN, and the admission RN stated that not including the [MEDICAL CONDITION] care in the orders was an oversight. The Physician was interviewed on 4/17/19 at 10:58 AM. He stated he was not sure what the policy was for [MEDICAL CONDITION] care, but changing and emptying of the bag is a routine nursing intervention. He stated there should be an order in place to to do the [MEDICAL CONDITION] care and how often to change the appliance. 415.12(k)(3)

Based on observation, record review, and staff interviews conducted during a recertification survey, 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 1 of 4 residents (#39) observed during a medication administration. Specifically, the vendor pharmacy did not deliver and did not notify the facility in a timely manner of a rejected prescription for an anti-hypertensive medication (Losartan) of Resident #39 resulting in a missed dose of the medication. The finding is: Resident #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 8/16/17 Admission Minimum Data Set (a resident assessment tool)documented that the resident scored 10 out of 15 on the Brief Interview for Mental Status (used to measure orientation and memory recall which suggested that the resident had moderate cognitive impairment. The physician's orders [REDACTED]. A medication administration observation was conducted on 9/26/17 at 9:38 AM for Resident #39. The Licensed Practical Nurse (LPN) medication nurse #1 had taken the resident's blood pressure and stated it was 128/76. The LPN did not administer the Losartan and stated that it was not available. The LPN stated that the pharmacy has not delivered the medication. The LPN further stated that it was a 9:00 AM medication and it was not permissible to administer it more than an hour before 9 AM (8 AM) or no more than an hour after 9 AM (10 AM). The LPN medication nurse #1 was further interviewed on 9/26/17 at 10:36 AM and stated that the Losartan had not been received yet from the pharmacy. The Medication Administration Record [REDACTED]. The Registered Nurse (RN) Charge Nurse was interviewed 9/27/17 at 9:18 AM and she stated that there was an issue with the insurance company regarding the Losartan prescription. A representative from the vendor pharmacy, that delivers the facility's medications, was interviewed on 9/28/17 at 8:30 AM and stated that the Losartan order was received from the facility on 9/25/17 but the order was rejected and not delivered because the medication was non-refillable due to a variety of reasons. She stated that moving forward a notification system will be developed to notify the facility's Director of Nursing Services (DNS) if a medication is rejected. The representative stated that the pharmacy did not notify the facility that the medication was non-refillable. The DNS was interviewed on 9/28/17 at 1:27 PM and she stated that a new system will be in place so that if a medication is rejected the pharmacy will notify the DNS and the Assistant DNS. 483.45 (a)(b)(1)

Based on record review and interview conducted during a recertification survey, the facility did not ensure that medical records for 1 of 5 residents (#126) reviewed for unnecessary medications were maintained in accordance with the accepted professional standard and practice. Specifically, the neurological examination record was not consistently completed as documented evidence that monitoring of the resident's mental status following a fall that resulted in an injury was conducted. The finding is: Resident #126 has [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS; a resident assessment tool) dated 8/14/17 documented that the resident's Brief Interview for Mental Status (used to measure the residents orientation and memory recall) score was 5 out of 15 which suggested that the resident had severe cognitive impairment. This MDS further documented that the resident had no previous fall history. The Accident/Incident Report dated 9/25/17 at 1:45 PM documented that the resident sustained [REDACTED]. Following an investigation of the incident, the facility recommended the following interventions including referral of the resident to rehabilitation, supervising the resident's area when out of bed, and to conduct neurological checks. A Neurological Examination Record was initiated on 9/25/17 at 2:00 PM and listed that the frequency of the neurological check to be done every 15 minutes for the first hour, every 30 minutes for 2 hours, every hour for 4 hours, and every shift for 24 hours. The Neurological Examination Record documented that the resident was examined on the following times: 2:00 PM, 2:15 PM, 3:00 PM, 3:30 PM, 4:00 PM, and 8:00 PM. The first hour, the resident was examined 3 out of 5 times. The next two hours, the resident was examined 2 out of 4 times. The next four hours, the resident was examined 1 of 4 times. There was no documented evidence that the 24-hour neurological check to be conducted every shift was done. The Nurses' Note dated 9/26/17 through 9/27/17 had no documented evidence that neurological checks were done during the recommended time frame for neurological monitoring. The Registered Nurse (RN) Unit Manager was interviewed on 9/29/17 at 11:00 AM and she stated that the assigned nurse should have followed the neurological checks frequency as documented in the list. The Director of Nursing Service was interviewed on 9/29/17 at 11:30 AM and stated that the neurological checks were not followed as per the record. The assigned Licensed Practical Nurses were not available for interview. 415.22(a)(1-4)

Based on observation, staff interviews and record review during an abbreviated and partial extended survey the facility failed to ensure that policies and procedures were developed for the prevention of elopement. The facility failed to identify residents at risk for elopement, ensure a safe environment, provide adequate supervision and monitoring to protect the health and safety of each resident. Specifically, one (Resident #1) of six residents reviewed with a history of unsafe wandering was admitted to the facility from the hospital after being found wandering in the community with a head injury. The facility was aware the resident was known to wander within the facility and frequently verbalize a desire to leave, but failed to assess the resident as an elopement risk. On 3/17/13 the resident was noted missing but a missing resident code was not activated per facility policy. The resident gained access to the kitchen through the main entrance door which was supposed to be locked and exited the building through an exterior door. The resident was found outside clinging to the wall of the building. This resulted in no known actual harm with the potential for serious harm that is Immediate Jeopardy and Substandard Quality of Care for six residents identified as at risk for elopement. Complaint Number: NY 996 The findings are: The undated Policy and Procedure on Accidents/Incidents: Investigation of Resident Occurrence documented that the facility will investigate accidents and incidents to determine methods of preventing future occurrences, trends and patterns and etiology of a specific occurrence. The undated Elopement/Wandering Assessment Procedure for Prevention (EWAPP) documented that an interdisciplinary care plan will be initiated, an order obtained for a wander guard and the resident's photograph placed in the elopement book located on the resident's unit, reception desk, Administrator's and supervisor's office. The EWAPP lacked documented evidence of educational training to staff regarding psychosocial risk and behavioral triggers of residents that may lead to elopement. The undated Policy and Procedure on Elopement: Resident Assessment and Missing Resident documented that if a resident is reported missing at off-hours, the RN Supervisor is in charge and shall establish a command center by announcing "Code Orange," arranging search teams mobilizing personnel from all departments. Once the resident has been located the RN Supervisor/Designee will conduct a full body check to assess the resident for any signs and/or symptoms of injury or any other physical/mental findings; documentation regarding the elopement will be recorded in the nurse's note as well as in the Physician and Social Worker's progress note. Notification to the New York State Department of Health will be done within 24 hours. Resident #1 is [AGE] years old and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (a universal assessment tool) dated 3/14/13 documented that the resident's cognition was moderately impaired; walking is not steady, only able to stabilize with staff assistance. The Hospital Medical History & Examination dated 12/6/12 documented that the resident was admitted to the hospital confused after being found by a neighbor wandering in the street without pants on and had sustained a head laceration. The Hospital Psychiatric Evaluation dated 12/7/12 and Physical Therapy Evaluation dated 12/8/12 documented that the resident was admitted to the hospital after being found wandering outdoors. The facility's undated Elopement/Wandering Assessment documented that the resident was assessed not to be a significant risk for elopement/wandering because the resident was not comatose nor able to exit the building unassisted. The Nursing assessment dated [DATE] documented that the resident was admitted to the facility able to ambulate independently but unsafely. The Nurse's Notes (NN) dated 12/18/12 documented that the resident was admitted from the hospital very confused; found by neighbors after a head injury from a fall. The Physical Therapy Evaluation dated 12/18/12 documented that the resident was able to ambulate 35 feet with difficulty in turning and festinating gait (accelerating, short, shuffling steps) in narrow spaces. The Comprehensive Care Plan (CCP) for Falls/Injury dated 12/18/12 documented that the resident was at risk for falls/injury. The CCP for Abuse Reporting dated 12/19/12 documented that the resident will remain free from all forms of abuse, neglect and mistreatment. The Psychosocial History and Initial assessment dated [DATE] documented that the resident was admitted with short-term memory and long-term memory impairments and had a recent head injury due to a fall. The Psychiatry Consultation dated 12/31/12 documented that the resident was wandering at night. The CCP for Falls/Injury was updated on 2/16/13 to include 30 minute monitoring of the resident. The CCP for Anemia dated 3/17/13 documented a goal that the resident's wandering will be decreased. The 24 Hour Report dated 3/17/13 lacked documented evidence of any occurrence regarding this resident during the day, evening or night shift. The Accident/Incident (A/I) Report dated 3/17/13 documented that, around 8:45 PM, the resident was observed entering the kitchen, left the building and exited the side door. The resident was found by a CNA (Certified Nursing Assistant) and nurse; the resident was brought back in with no distress noted and condition stable. The A/I documented that the doctor was notified and provided instructions to monitor behavior and place a wander guard (electronic alarm bracelet) on the resident. The physician's orders [REDACTED]. The NN dated 3/18/13 for the 7:00 AM to 3:00 PM nursing shift documented that the resident was noted trying to leave the facility; wander guard applied to right wrist. The undated NN (following the above dated NN) documented a late entry note for the 3/17/13 3:00 PM to 11:00 PM nursing shift that the resident was noted with periods of confusion and very restless after dinner. The resident was observed leaving the dining room, went to the kitchen; staff followed him and redirected him. The resident was very combative so staff walked with him along side of the facility and managed finally to get him back on the floor in stable condition. The Resident Incident Investigation Report dated 3/20/13 documented that the lock on the kitchen door was found to be faulty; the Administrator discussed the faulty door lock with maintenance and the lock was fixed. The facility determined that this incident was not an elopement since the LPN (Licensed Practical Nurse) had observed the resident at the top of the hallway wheeling his wheelchair towards the kitchen area. The findings did not indicate that any abuse, neglect or mistreatment occurred. The Social Service Notes and Evaluation dated 3/22/13 documented that the resident's family requested a transfer to another long-term care facility due to the resident's wandering behavior. The Notice of Transfer/discharge date d 3/28/13 documented that the resident was transferred to another facility on said date. An interview was conducted with the 7:00 AM to 3:00 PM Registered Nurse Unit Coordinator (RNUC) on 4/1/13 at 10:11 AM. The RNUC stated that Resident #1 had multiple falls, was combative and was always saying, 'I wanna leave this place' and had a history of [REDACTED]. The RNUC thought that the resident had a wander guard since January 2013 and was reviewing the medical record to find documentation but was unable to locate that documentation. The RNUC stated that a physician's orders [REDACTED]. The RNUC was unsure whether or not the resident had an elopement assessment performed and stated that an elopement assessment "is done on admission and as needed." An interview was conducted with the Director of Social Services (DSS) on 4/1/13 at 10:39 AM. The DSS stated that Resident #1 always wandered but she did not know if the resident had a history of [REDACTED]. The resident was at the facility for a short-term stay but the resident's family requested that the resident be transferred to another long-term care facility due to his wandering behavior. During a subsequent interview with the RNUC on 4/1/13 at 10:45 AM, he stated that he had just spoken with his supervisor who said that the resident did not have a wander guard until 3/18/13 because the resident had been wandering safely in the facility. The resident did not have a wander guard until the RNUC placed it on him on 3/18/13. An interview was conducted with an assigned 7:00 AM to 3:00 PM CNA #1 on 4/1/13 at 10:54 AM. CNA #1 stated that Resident #1 wandered everywhere and was always on the move. The resident would be placed at the nursing station but would always leave. She did not think the resident was on any specific monitoring and would not know if the resident was an elopement risk unless he had a wander guard. An interview was conducted with the Front Desk Receptionist (FDR) on 4/1/13 at 11:27 AM. She stated that, at the front desk, there are only pictures of residents who have a wander guard and she would not know if a resident is at risk for elopement unless that resident had a wander guard. She provided a list of residents with wander guards; the list documented that Resident #1's wander guard was activated on 3/18/13 but she did not know why. The FDR stated that the surveillance monitor at the front desk is not usually viewed unless a wander guard alarm goes off sounding a buzzer on the wall behind the desk; the FDR would then look at the monitor. An interview was conducted with the Recreation Aide (RA) on 4/1/13 at 12:01 PM. She stated that she tried to keep Resident #1 active but the resident would normally wander away from an activity; she would find the resident at times by the time clock talking about going out to get his car. The RA did not know if the resident was an elopement risk and stated that the resident started wearing a wander guard last week but she was never told the reason for this. The RA further stated, "He was very confused and thought he had a car outside, so he would go towards the door to try to leave." An interview was conducted with the Assistant Director of Nursing (ADON) on 4/1/13 at 12:10 PM. She stated that she was aware that something happened with the resident on 3/17/13 in the kitchen but did not know the exact details. The Director of Nursing (DON) was not at work and the ADON stated that the A/I Report was locked in the DON's desk for investigation and was not accessible. A telephone interview was conducted with the DON on 4/1/13 at 1:08 PM. The DON stated that ADON made her aware of the surveyor's request for the 3/17/13 A/I Report but the DON had not yet completed an investigation. She believes Resident #1 was observed going towards the kitchen door on 3/17/13 and the resident was immediately found outside the back door which is enclosed by a fence. Since the resident was observed, the DON did not consider the occurrence as an elopement. The DON further stated that prior to this occurrence, "He never made an attempt to leave or verbalize a desire to leave to my knowledge." On 4/1/13 at 1:20 PM the outside kitchen door was observed to exit onto a path with a fence which is not enclosed. The path leads directly into the parking lot. An interview was conducted with a 3:00 PM to 11:00 PM CNA #2 on 4/1/13 at 1:41 PM. CNA #2 stated that she was in the dining room after dinner and Resident #1 was among a few other residents in the dining room. She left the dining room shortly after 7:00 PM on 3/17/13 and recalled seeing the resident; another CNA, CNA #4, was in the dining room. CNA #2 was unable to account how much time had elapsed but stated that, quite a while later, she heard a lot of commotion by staff in the hallway and realized that staff was looking for the resident. She did not hear anything announced about a Code Orange and did not take part in the search for Resident #1. She stated, "Everyone knows (Resident #1) because he's always talking about getting out of here." CNA #2 further stated that she did not know what an "elopement" was and that, "if someone (a resident) wanders they're supposed to have an alarm on them. Otherwise, how would we know?" An interview was conducted with a 3:00 PM to 11:00 PM CNA #3 on 4/1/13 at 2:10 PM. CNA #3 stated that she was in the employee break room sometime after 8:30 PM on 03/17/13 when the LPN came in asking if Resident #1 had been seen; she had not seen the resident. CNA #3 stated that she did not know that the resident was actually missing and was never asked to search for the resident. When she returned from her break, she was told by the nursing supervisor (RNS #2) that the resident had been found in the kitchen. CNA #3 stated that she did not know if the resident was at risk for elopement "but he always wanted out of here." An interview was conducted with a 3:00 PM to 11:00 PM CNA #4 on 4/1/13 at 3:11 PM. CNA #4 stated that she was in the dining room after dinner until around 7:30 PM on 03/17/13; she recalled seeing Resident #1 but was sure that, when she left the dining room at 7:30 PM, the resident was not there. CNA #4 stated that the resident "often wandered off " and she did not think anything of him not being in the dining room at that time. She took care of a couple of other residents and then went on her break. She was not aware the resident was missing until much later in the evening when she heard staff talking about the resident being found in the kitchen. An interview was conducted with a 3:00 PM to 11:00 PM CNA #5 on 4/1/13 at 3:21 PM. CNA #5 stated that she was never assigned to take care of Resident #1 but "knew who he was because he was always looking to get away." On 3/17/13 she heard staff talking about a resident missing but stated, "I never searched. I didn't know I had to." An interview was conducted with the Food Service Director (FSD) on 4/2/13 at 9:15 AM. The FSD stated that there are two dietary aides on duty until 7:30 PM each night and they ensure that the inside and outside kitchens doors are locked upon leaving because there is no other kitchen staff on duty until the next morning. He stated that he is not aware of any resident ever entering the kitchen or going through the rear outside door. The surveyor observed the kitchen area with the FSD, who stated, "I would find it hard to believe that a resident made it safely through here (kitchen) without getting hurt." The FSD further stated that there have been no changes to the locks on the kitchen doors. An interview was conducted with a 7:00 AM to 3:00 PM with the Registered Nurse Supervisor (RNS #1) on 4/2/13 at 9:37 AM. RNS #1 stated, "If they (residents) have a desire to leave, then we initiate a wander guard. Otherwise, we consider this an enclosed environment so we allow wandering." RNS #1 then stated that Resident #1 was not known to want to leave. An interview was conducted with the 3:00 PM to 11:00 PM Licensed Practical Nurse (LPN) on 4/2/13 at 10:01 AM. The LPN stated that she did not know if Resident #1 had a history of [REDACTED]. where he was." She stated that after 8:00 PM all residents are back on the floor either in their rooms or at the nursing station; she did not recall whether or not she had seen Resident #1 on 3/17/13 at that time. The LPN stated that around 8:45 PM on 3/17/13 she was at the nursing desk with RNS #2 and CNA #6 said that she did not see the resident. A formal search for the resident was not started but the LPN decided to start looking in other resident rooms. The LPN made her way off the unit and, from a distance, thought she saw something pass by the kitchen area but could not identify what it was; she continued looking in the Physical Therapy room and other areas until she came to the conference room. A faint chirping sound was coming from across the hall in the kitchen, so she entered the kitchen and found the resident's wheelchair and chair alarm sounding but the resident was not there. The LPN went out the rear kitchen door and saw CNA #6 with the resident, who "was trying to hold on to the brick wall of the building saying he was looking for his car." She helped CNA #6 get the resident back into the facility through the kitchen and returned the resident to the nursing station, giving him ice cream and a banana. The LPN stated that she was not sure if RNS #2 assessed the resident or if the doctor was called. The next day, 3/18/13, she noticed that a note was not written by RNS #2 in the resident's medical record and the LPN wrote a note. She reviewed her note and stated that it was not accurate because "by this time staff were saying he (resident) was found in the kitchen. I think I got confused in my writing." The LPN further stated, "I never observed him (resident) go into the kitchen." An interview was conducted with the 3:00 PM to 11:00 PM RNS #2 on 4/2/13 at 10:34 AM. RNS #2 stated that Resident #1 "was missing for a little bit" but she did not activate a Code Orange for missing residents "I didn't think he left the building." She was unable to explain why she did not think the resident left the building. The resident was returned to the nursing unit by the LPN and CNA #6, who found the resident outside the building. She stated that the resident did not have any visible injuries but evaded answering the surveyor when she was questioned if she performed a full body assessment of the resident. RNS #2 did not document an assessment in the medical record. RNS #2 stated that she thought the resident always had a wander guard but was not sure if the resident was at risk for elopement. RNS #2 stated, "He (resident) wanders into different spaces but I'd have to look back in the chart to know if he was at risk (for elopement)." An interview was conducted with a Dietary Aide (DA) on 4/2/13 at 11:16 AM. The DA stated that he closed the kitchen on 3/17/13 and locked all doors 7:30 PM. When he returned the next morning, the kitchen door was open and unlocked. There was no one in the kitchen but the he did not question anyone about the door being unlocked. Later in the day on 3/18/13, he heard rumors that the nursing supervisor during the evening shift had opened the door. An interview was conducted with the Director of Maintenance (DOM) on 4/2/13 at 11:29 AM. The DOM stated that there are seven exterior doors, 6 of which are wander guard alarmed. However, the exterior door in the kitchen is not alarmed. He was not aware of a resident getting into the kitchen. When asked regarding kitchen door locks being fixed, he stated that the Administrator asked him to change the locks on the kitchen doors yesterday, 4/1/13, in the afternoon and he plans to change the locks on 4/2/13. The inside kitchen door leading to a resident hallway was observed by the surveyor on 4/2/13 at 12:53 PM to have a shaky handle lock and would not close without forceful pressure. An interview was conducted with the Physical Therapist (PT) on 4/2/13 at 11:40 AM. The PT stated that Resident #1 was able to ambulate from the day of admission but was unsafe. The resident was known to wander the halls and talk about leaving; she could not say whether or not the resident was an elopement risk. The PT further stated, "He (resident) needed supervision at all times for safety. He could probably manage to walk somewhere but would inevitably fall at some point if he did." An interview was conducted with a 3:00 PM to 11:00 PM Registered Nurse (RN #1) on 4/2/13 at 11:56 AM. RN #1 stated that he sometimes coordinates the unit but, on 3/17/13, he was functioning as a medication nurse. He was passing medications and heard staff talking in the hall about Resident #1 being missing, but he continued to pass medications because "no one called a Code Orange." He did not know the resident had left the building and was later told by RNS #2 that the resident was found in the kitchen. RN #1 stated, "He (resident) wandered everywhere. He would go near doors and always talked about leaving but I don't think he ever did." When asked regarding the resident's elopement risk status RN #1 stated, "Well, he wandered but I didn't assess him. I don't think he had a wander guard, so he probably wasn't at risk but I'm not sure." An interview was conducted with the Attending Physician (AP) on 4/2/13 at 1:59 PM. The AP stated that Resident #1 had very impaired judgment and exhibited elopement behavior but he usually leaves the supervision of residents up to the facility's protocol. He was never asked to order a wander guard for the resident. The AP stated that he was unaware of the resident being missing, being in the kitchen or leaving the building and did not receive a call from nursing on 3/17/13 regarding the resident missing. An interview was conducted with the 11:00 PM to 7:00 AM Registered Nurse (RN #2) on 4/2/13 at 2:12 PM. RN #2 stated that she came on duty at 11:00 PM on 3/17/13 and was not told of any incident involving Resident #1. She stated that the resident would wander a lot of times through the night but she did not know if he was an elopement risk. An interview was conducted with the Medical Director (MD) on 4/2/13 at 2:35 PM. The MD stated that he knew Resident #1 was confused but he was unaware that the resident had left the building. The MD further stated that he was not aware of any specifics regarding policies on elopement because he does not have an office at the facility. He referred the surveyor to the DON for the discussion of policies. An interview was conducted with the assigned 3:00 PM to 11:00 PM CNA #6 on 4/2/13 at 3:00 PM. CNA #6 stated that on 3/17/13, shortly after 7:00 PM, she took her break out of the facility and did not return until almost 8:00 PM. She stated that normally residents are back on the unit at that time and she went to care for a resident. When she went to check on Resident #1 she could not find him and told the LPN around 8:45 PM. She knew the resident wandered, so she went looking for the resident in other areas of the building. When she was passing the kitchen, she heard an alarm coming from the kitchen and motioned to the LPN down the hall to come in to the kitchen, where she found the resident's wheelchair. She went to the rear door in the kitchen and saw the resident holding tightly onto the outside brick wall and trying to move further along the wall. The LPN brought the resident's wheelchair and the resident sat down. CNA #6 wheeled the resident back to the nursing station and told RNS #2 where she had found the resident. She stated that RNS #2 talked to the resident at the nursing station and left the floor. A little while later, RNS #2 returned to the unit and asked her to write a statement. The next day she told the DON where she found the resident. An interview was conducted with the In-Service Coordinator (ISC) on 4/2/13 at 3:20 PM. The ISC stated that the staff receives annual training which specifies that, if a resident is at risk for elopement, the resident will have a wander guard and the wander guard must be checked during each nursing shift to ensure it is functioning properly. If a resident is noted missing, a Code Orange should be announced to all staff. The ISC further stated that if a resident did not have a wander guard, there is no staff training regarding elopement with respect to residents without wander guards. During a subsequent interview with the DON on 4/2/13 at 3:40 PM, the DON stated that on 3/17/13 around 10:00 PM she was called at home by RNS #2, who explained that the LPN and CNA #6 had found the resident in the kitchen. She stated that it was her understanding that, when the resident was found in the kitchen, the resident was combative and went out the back door, which was observed by the two staff members. The DON advised RNS #2 to document the occurrence carefully because, since the resident was observed, it was not necessarily an elopement. She did begin an investigation but had not completed. She also stated she had lost some of the statements the staff gave her regarding the incident. The DON stated that she was aware of Resident #1's wandering history in the community prior to his admission to the facility, but did not consider it a factor in his elopement risk assessment because the resident was in a structured environment and did not verbalize a desire to leave or wander toward an exit within the facility. The DON further stated, "We all viewed him (resident) as being safe because he never verbalized that he wanted to go home." An interview was conducted with the Administrator on 4/2/13 at 4:03 PM. The Administrator stated that on 3/18/13 the DON told him that, during the previous evening, Resident #1 was seen by staff going into the kitchen and outside the facility but was brought back in to the facility safely. He stated this was not reportable to the state agency because the resident was detected going in to the kitchen. He further stated the the door frame for the exterior door in the rear of the kitchen appeared to be loose, so he had large bolts drilled into the frame in an effort to secure it. With respect to the interior kitchen door, "Those locks were changed the next day (3/18/13)." 415.12 (h) (1) (2)

Based on observation, staff interviews and record review during an abbreviated and partial extended survey it was determined that the administration of the facility failed to have a system in place to ensure each resident reached and maintained the highest practicable level of physical and psychosocial well-being. The Administrator failed to protect the health and safety of each resident. Specifically, Resident #1 was admitted to the facility with a known history of Elopement/Wandering in the community, was known to wander within the facility and frequently verbalized a desire to leave to facility staff. The Resident was not provided the necessary supervision to protect/safeguard his health and safety. Resident #1 accessed the kitchen after hours through an unlocked main entrance door and exited the building through an exterior door. He was found clinging to the outside wall of the building. The Administration failed to perform a thorough investigation to determine the root cause of the incident to prevent further instances of unsafe wandering and failed to identify system failures related to residents who are at risk for unsafe wandering and/or elopement. This has the potential to affect the health and safety of six (6) residents who have been assessed by the facility at risk for elopement This resulted in no known actual harm with the potential for serious harm that is Immediate Jeopardy. Complaint Number: NY 996 Cross References: F 323 - Accidents & Supervision F 501 - Medical Director F 520 - Quality Assessment & Assurance. The findings are: An interview was conducted with the Assistant Director of Nursing (ADON) on 4/1/13 at 12:10 PM. The ADON stated that she was aware that something happened with the resident on 3/17/13 in the kitchen but did not know the exact details. The Director of Nursing (DON) was not at work and the ADON stated that the A/I Report was locked in the DON's desk for investigation and was not accessible. A telephone interview was conducted with the DON on 4/1/13 at 1:08 PM. The DON stated that the ADON made her aware of the surveyor's request for the 3/17/13 A/I Report but the DON had not yet completed an investigation. The DON stated that she believes Resident #1 was observed going towards the kitchen door on 3/17/13 and the resident was immediately found outside the rear door, which leads to an area enclosed by a fence. Since the resident was observed by staff, the DON did not consider the incident as an elopement. The DON further stated that prior to this occurrence, "He never made an attempt to leave or verbalize a desire to leave the facility, to my knowledge." On 4/1/13 at 1:20 PM the exterior kitchen door was observed to exit onto a path with a fence which is not enclosed. The path leads directly into the parking lot. An interview was conducted with the Director of Maintenance (DOM) on 4/2/13 at 11:29 AM. The DOM stated that there are seven outside doors, 6 of which are wander guard alarmed. The exterior kitchen door is not alarmed. The DOM stated that he was not aware that a resident a gotten into the kitchen. When asked regarding kitchen door locks being fixed, the DOM stated that the Administrator asked him to change the locks on the kitchen doors yesterday, 4/1/13, in the afternoon. The DOM was planning to change the locks on 4/2/13. On 4/2/13 at 12:53 PM, the inside kitchen door leading to a resident hallway was observed to have a shaky handle lock and would not close without forceful pressure. An interview was conducted with the In-Service Coordinator (ISC) on 4/2/13 at 3:20 PM. The ISD stated that the staff receives annual training that specifies that, if a resident is at risk for elopement, they will have a wander guard, which must be checked on every nursing shift to ensure it is functioning properly. If a resident is noted missing, a Code Orange should be announced for all staff to be aware. If a resident does not have a wander guard, there is no existing staff training regarding these residents with respect to elopement. During a subsequent interview with the DON on 4/2/13 at 3:40 PM the DON stated that on 3/17/13 around 10:00 PM, she was called at home by the RNS #2, who explained that the LPN and CNA #6 had found the resident in the kitchen. The DON stated that it was her understanding that, when the resident was found in the kitchen, the resident was combative and went out the back door, which was observed by the two staff members. The DON advised the RNS #2 to document the occurrence carefully since the resident was observed and, as a result, it would not be considered an elopement. The DON stated that she did begin an investigation but had not completed it. She further stated she lost some of the statement facility staff had provided her regarding the incident. The DON stated that she was aware of Resident #1's wandering history in the community but did not consider it a factor in his elopement risk assessment because the resident was in a structured environment and did not verbalize a desire to leave or wander toward an exit within the facility. The DON further stated, "We all viewed him as being safe because he never verbalized that he wanted to go home." An interview was conducted with the Administrator on 4/2/13 at 4:03 PM. He stated that on 3/18/13 the DON told him that, during the prior evening, Resident #1 was witnessed going into the kitchen and outside the facility, but was brought back in to the facility safely. The Administrator stated that this was not reportable to the state agency because the resident was detected by staff as he was going in to the kitchen. He stated that the door frame around the exterior kitchen door appeared loose, so he had large bolts drilled into the frame in an effort to secure it. With regard to the inside kitchen door, "Those locks were changed the next day (3/18/13)." 415.26

Based on record review and staff interviews during an abbreviated and partial extended survey, the Medical Director failed to ensure that the facility provided care in accordance with current standards of practice to meet the needs of residents. Specifically, the Medical Director failed to ensure that policies and procedures were in place to prevent elopement of residents and to monitor and supervise residents with a history of elopement or wandering behavior. The failure to implement policies and procedures for prevention of elopement, monitoring and supervision of residents resulted in Resident #1's elopement from the facility. This resulted in no known actual harm with the potential for serious harm that is Immediate Jeopardy for Resident #1 and for six residents identified as at risk for elopement by the facility. Cross References: F 323 - Accidents & Supervision, F 490 - Administration, F 520 - Quality Assessment & Assurance. Complaint Number: NY 996 The findings are: An interview was conducted with the Assistant Director of Nursing (ADON) on 4/1/13 at 12:10 PM. The ADON stated that she was aware that something happened with the resident on 3/17/13 in the kitchen but did not know the exact details. The Director of Nursing (DON) was not at work and the ADON stated that the A/I Report was locked in the DON's desk for investigation and was not accessible. The ADON provided copies of the facility's policies on elopement and stated, "The wander guard is what we use for prevention of elopement." An interview was conducted with the Medical Director (MD) on 4/2/13 at 2:35 PM. The MD stated that he knew Resident #1 was confused but the MD was unaware that the resident had left the building. The MD further stated that he was not aware of any specifics regarding policies on elopement because he does not have an office at the facility. The MD referred the surveyor to the DON for the discussion of policies. During an interview with the DON on 4/2/13 at 3:40 PM, the DON stated that she was aware of Resident #1's wandering history in the community but did not consider it a factor in his elopement risk assessment because the resident was in a structured environment and did not verbalize a desire to leave the facility or wander toward an exit within the facility. The DON stated that, if the resident did verbalize a desire to leave, a wander guard would have been placed on the resident according to policy. However, there is no other policy for prevention of unsafe wandering and/or elopement. The DON further stated, "We all viewed him (Resident) as being safe because he never verbalized that he wanted to go home." 415.15 (a)

Based on record review and staff interviews conducted during an abbreviated and partial extended survey, the facility failed to provide a quality assessment and assurance program that functions to develop and implement appropriate plans of actions to readily identify issues with the potential to cause serious harm to the health and safety of residents at risk for elopement/wandering. Specifically, one Resident (#1) reviewed for assessment and quality of care was admitted from a hospital with a history of being found wandering in the community with a head injury. The Resident frequently verbalized a desire and intent to leave the facility. He eventually was able to exit the building through an exterior door in the facility's kitchen and was found clinging to the outside wall of the building. The QAA Committee failed to conduct quality assessment and assurance to ensure the development and implementation of policies and procedures for the prevention of elopement, and the monitoring and supervision of residents with a known history of elopement/wandering. The QAA Committee also failed to identify system failures related to residents who are at risk for elopement/wandering. This resulted in no known actual harm with the potential for serious harm that is Immediate Jeopardy for six residents identified by the facility as at risk for elopement. Cross References: F 323 - Accidents & Supervision, F 490 - Administration, F 501 - Medical Director. Complaint Number: NY 996 The findings are: During an interview with the DON on 4/2/13 at 3:40 PM, the DON stated that she was aware of Resident #1's wandering history in the community but did not consider it a factor in his elopement risk assessment because the resident was in a structured environment and did not verbalize a desire to leave and did not wander toward an exit within the facility. The DON stated that residents are discussed in morning report with all department heads. If a resident did verbalize a desire to leave, a wander guard would be placed on the resident according to facility policy. However, there is no other policy for prevention of unsafe wandering and/or elopement. The DON further stated, "We all viewed him (Resident) as being safe because he never verbalized that he wanted to go home." An interview was conducted with the Administrator on 4/2/13 at 4:03 PM. The Administrator stated that on 3/18/13 the DON told him that, during the previous evening, Resident #1 was seem by staff going into the kitchen and exiting the facility through a rear door, but was brought back into the facility safely. The Administrator stated that this was not reportable to the state agency because the resident was detected going into the kitchen, so the facility did not consider this an elopment or a reportable event. He stated the door frame around the exterior kitchen door appeared to be loose, so he had large bolts drilled into the frame in an effort to secure it. The inside kitchen door locks were changed the next day, 3/18/13. The Administrator further stated that the only QA he is aware of is a yearly staff in-service on elopement. 415.27(a-c)