Every finding on record at Fishkill Center for Rehabilitation and Nursing

Based on observations, record review and interviews, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible; and that each resident received adequate supervision to prevent accidents for one (1) of three (3) residents (Resident #1) reviewed for accidents. Specifically, a review of the facility's fall risk assessment revealed that on 08/12/2025, Resident #1 was identified as a high risk for falls and further review of the resident's medical record revealed that the facility failed to implement interventions to prevent the resident from potential falls or to mitigate harm from actual falls. On 09/27/2025, Resident #1, had a fall and was found in their room on the floor and sustained a swollen right eye, a hematoma to the right side of their forehead and a scratch to their right forearm. Resident #1 was transferred to the emergency room for further evaluation. This failure to implement interventions to prevent and or mitigate harm from falls resulted in actual harm to Resident #1 that was not Immediate Jeopardy. The findings are:The facility policy titled Fall Risk Intervention Protocol last reviewed 02/12/2025 documented it is the policy of the facility to ensure every resident is treated in a manner that reduces the risk of falls and fall related injuries. To achieve this, the following interventions are in place. Interventions can and should be implemented as soon as necessary. After a fall risk assessment is completed, a score of greater than seven (7) would require review and implementation of the fall risk intervention protocol. The listed interventions that could be implemented included to note fall risk on care summary and nursing should place the resident on high alert fall safety observation (every 30 minutes or one (1) hour). Resident #1 was admitted with diagnoses including but not limited to cerebral infarction (an area of brain tissue death caused by lack of blood flow and oxygen), aphasia (a language disorder caused by brain damage) and altered mental status (a sudden or significant change in a person's usual brain function). A Quarterly Minimum Data Set (a resident assessment tool) dated 08/13/2025 documented Resident #1 had severe cognitive impairment with altered level of consciousness. The resident had unclear speech and was sometimes understood. The resident had functional limitations to their upper and lower extremities on one (1) side and used a wheelchair for locomotion. The resident was dependent for eating, toileting, bed mobility and transfers, and did not have a history of falls. Resident #1's Risk for Falls care plan last reviewed 08/12/2025 documented Resident #1 was at risk for falls related to their medical diagnoses and poor trunk control. Interventions listed included: ensure call bell is always within reach and is answered in a timely manner, bed in lowest position and provide a clutter free environment with adequate lighting. Review of an Activities of Daily Living care plan last revised on 08/12/2025 documented Resident #1 was dependent for bed mobility. Interventions listed included: position in bed using proper alignment and reposition for comfort, two (2) quarter side rails up when in bed as bed enablers for mobility. Review of Resident #1's care profile dated 07/09/2025 revealed Resident #1 had no fall selected under safety precautions. Review of a Fall Risk assessment dated [DATE] documented Resident #1 had a fall risk score of 12, indicating they were at risk for falls. The facility Fall Risk Assessment instruction documented if the total score is ten (10) or greater, the consumer should be considered at high risk for potential falls. A prevention protocol should be initiated immediately and documented on the care plan. Review of an Interdisciplinary Siderail Screen and Evaluation dated 08/13/2025 documented Resident #1 was receiving side rails to utilize as enablers for bed mobility. The resident was to have bilateral quarter side rails when in bed. The Interdisciplinary Siderail Screen documented Resident #1 would use the side rails to adjust themself in bed or transfer out of bed and their representative requested the use of the siderails to enable bed mobility. The facility Accident/Incident report documented on 09/27/2025 at 12:15 AM, Resident #1 was observed lying on the floor in their room with the following injuries noted: right eye swollen, right side of forehead hematoma (bruise) and a scratch to the right forearm. The investigative summary documented the root cause was increased confusion, resident reported falling out of bed after attempting to self-transfer. Interventions listed were Occupational Therapy screen and bilateral bolster placement to assist resident with determining depth perception of bed. Immediate safeguards are in place to keep the resident safe and prevent reoccurrence.Review of Resident #1's care profile dated 10/01/2025 did not reflect Resident #1 was on fall precautions for safety. During a telephone interview on 11/14/2025 at 2:22 PM, Certified Nurse Aide #3 stated they were assigned to Resident #1 on the night of their fall on 09/27/2025. They found Resident #1 the day before the fall trying to get out of the bed with half of Resident #1's body hanging off the bed and they informed Licensed Practical Nurse #3 about it. Certified Nurse Aide #3 stated the nurse responded, Resident #1 does not move so where are they going?. Certified Nurse Aide #3 stated prior to the fall, Resident #1 had a low bed for safety measures. During an interview on 11/14/2025 at 1:47 PM, Certified Nurse Aide #2 stated Resident #1 was able to turn in bed with assistance and the resident could turn to the right side better than to their left side. Certified Nurse Aide #2 stated Resident #1 is unable to really turn with their right side so they do not know if the resident would be able to turn themself to the point of falling out of bed. During a telephone interview on 11/14/2025 at 3:06 PM Licensed Practical Nurse #2 stated they were called to the unit and Resident #1 was observed on the floor next to their bed with their head facing the foot of the bed and their feet facing the head of the bed. Licensed Practical Nurse #2 stated Resident #1 did not have any shoes or socks on and had bare feet and stated the resident stated they were getting up and trying to get their belonging. Licensed Practical Nurse #2 stated on assessment, Resident #1 had swelling to their eye and they notified the Nurse Practitioner #2 and completed the Accident/Incident report. Licensed Practical Nurse #2 stated they had not seen Resident #1 move around in bed prior to this incident. Although the resident was able to move around in bed a little, to their knowledge Resident #1 had never tried to get out of bed prior to this incident. During an interview on 11/17/2025 at 10:43 AM, Licensed Practical Nurse #5 stated before the fall incident, Resident #1 had side rails and safety checks in place. Licensed Practical Nurse #5 stated safety checks are completed every 30 to 40 minutes to ensure the resident is okay when they are out of bed. Licensed Practical Nurse #5 stated safety checks are not documented on a form where direct care staff signs off. Licensed Practical Nurse #5 stated presently, if a resident is a fall risk, then there is a form with 30-minute checks that the staff must complete to ensure the resident is seen every 30 minutes. Licensed Practical Nurse #5 stated if a resident had a fall risk score that was ten (10) or greater, they would be placed on 30-minute monitoring. Licensed Practical Nurse #5 stated Resident #1 was able to turn in bed with moderate assistance depending on how the resident was feeling. Resident #1 was not capable of climbing out of bed and they would not say the resident was dependent for turning from left to right in bed. Licensed Practical Nurse #5 stated residents with a high fall risk score will have the bed in the lowest position and a floor mat would be used. Resident #1 does have a floor mat at their bedside. Licensed Practical Nurse #5 reviewed Resident #1's chart and did not see a physician's order for the floor mat reflected and they stated the intervention should have been implemented when the incident occurred. Licensed Practical Nurse #5 stated they do not know if Resident #1 had floor mats in place on the night of the incident. During an interview on 11/17/2025 at 1:47 PM, the Director of Nursing stated the standard safety measures implemented when a resident is a fall risk are: bed in lowest position, call bell within reach and an every two (2)-to-four (4)-hour check and toileting schedule. The Director of Nursing stated additional interventions would be resident based and implemented on assessment. If Resident #1 was observed by staff to be halfway in bed and halfway out of their bed, at that point the resident should be considered at an increased risk for falling. During a telephone interview on 11/24/2025 at 10:50 AM Resident #1' s Representative stated they filed a complaint because Resident #1 supposedly fell out of bed, but the staff observed the resident trying to get out of bed and they did nothing about it. Resident #1's Representative stated they were informed, the Friday before the fall, that the resident was restless and was telling the staff they needed to go to work. Resident #1's Representative stated they were informed Resident #1 was trying to physically get out of bed, and they asked why the resident did not have side rails. Resident #1's Representative stated after the fall incident on 09/27/2025, the facility put siderails on the resident's bed and they saw them when they visited. Resident #1 did not have side rails up on their bed in August 2025 and they never requested for Resident #1 to have side rails. Resident #1's Representative stated staff saw Resident #1 trying to get out of bed, so why did they not put measures in place to prevent the fall out of bed. The resident ended up in the emergency room with a black eye and they felt it was a situation of neglect on the part of the facility. Resident #1's Representative stated they had a quarterly meeting with the facility the week prior to the interview and they asked questions regarding safety protocols in place going forward. The facility informed them they have safety protocols in place now for Resident #1 including floor mats and padding on their side rails. During a telephone interview on 12/23/2025 at 9:43 AM, the Director of Nursing stated Resident #1's fall risk assessment score, which was greater than ten (10), makes the resident at high risk for falls. The Director of Nursing stated after the fall on 09/27/2025 Resident #1 was scored a 14 on their fall risk assessment and the interventions implemented on the resident's care plan before the fall were appropriate. The Director of Nursing stated they were not aware that the night before the fall, Resident #1 was observed by staff trying to get out of their bed. The Director of Nursing stated Resident #1 did not have a fall prior to 09/27/2025 and that is why fall precautions were not checked off on the resident's care profile. The Director of Nursing stated the care profile provides a cheat sheet for the certified nurse aides and would document special things regarding the resident. The Director of Nursing stated they do not have an answer for why fall precautions is not checked off on the resident care profile for October 2025 after the fall. During a telephone interview on 12/26/2025 at 10:49 AM, Registered Nurse #3 stated they were the previous unit manager on unit, but they were not the unit manager at the time Resident #1 fell. They were aware of the fall and the resident was on fall precautions. Registered Nurse #3 stated Resident #1 scored a 14 on the fall risk assessment they completed on 08/12/2025 which meant they were a high risk for falls. Registered Nurse #3 stated when Resident #1 was identified as a high risk for falls, they did not update the residents care profile. Registered Nurse #3 stated if a resident was determined to be a fall risk, the staff is informed of the residents fall risk and fall precaution measures are documented on the resident's care plan. Registered Nurse #3 stated the fact that Resident #1 is totally dependent and has limited mobility would be a good reason to document fall precautions as a safety measure on the resident's care profile. The unit manager is responsible for updating resident care profiles. Registered Nurse #3 stated the care profile completed on 10/01/2025 was done by the Director of Nursing after Resident #1's fall and they see that the Director of Nursing did not document fall precautions as a safety measure for Resident #1. Registered Nurse #3 stated the certified nurse aides know when a resident is a fall risk because they are told verbally, and they can also see the information in the special considerations section at the bottom of the resident's care profile. 10 NYCRR 415.12(h)(2)

Based on record review and interview during an abbreviated survey (2650093) the facility did not ensure the comprehensive care plans were reviewed, updated, and revised for 2 out of 3 residents (Resident #1, Resident #3) reviewed for care planning. Specifically, (1) Resident #1's cognitive impairment care plan had not been reviewed or updated since 10/18/2024. (2) Resident #3's cognitive impairment care plan had not been reviewed or updated since 08/27/2024.The findings are:The facility Comprehensive Care Planning policy last reviewed 02/14/2025 documented the interdisciplinary team: reviews care plans at a minimum of quarterly to ensure that all goals and interventions are current, appropriate and accurate and updates care plans as needed with changes in treatment, needs and conditions.1)Resident #1 was admitted with diagnoses including but not limited to Cerebral Infarction, Aphasia and Altered Mental Status.A Quarterly Minimum Data Set, dated [DATE] documented Resident #1 had severe cognitive impairment with an altered level of consciousness. The resident had unclear speech and sometimes was understood and sometimes not understood. A review of the care plan for impaired cognition revealed it was last reviewed on 10/18/2024. Although, it documented Resident #1 had a decline in their cognition and established a goal that the resident would maintain their present level of mental awareness. Interventions listed included speak to the resident in a clear manner, orienting the resident to your identity, ensure residents safety, dignity and rights and anticipate needs. However, the care plan had not been reviewed or updated in accordance with the most current comprehensive or quarterly assessment. As a result, there were no documented evidence if the goals had been met or if interventions were effective. 2) Resident #3 was admitted with diagnoses including but not limited to Dementia, Anxiety disorder and Unspecified Fracture of Upper End of Right Humerus.A Quarterly Minimum Data Set, dated [DATE] documented Resident #3 had a Brief Interview of Mental Status score of 99 with moderately impaired cognitive decision-making skills. The resident required supervision for eating, moderate assistance for toileting and was independent for bed mobility and transfers.A review of the care plan for impaired cognition revealed it was last reviewed on 08/27/2024. It documented Resident #3 had a mental illness and impaired decision-making ability. Interventions listed included speak to the resident in a clear manner, orienting the resident to your identity, ensure residents safety, dignity and rights and anticipate needs. There was no documented evidence that the care plan had been reviewed and updated in accordance with the most recent quarterly or comprehensive assessment. As a result, there is no evidence that established goals were met or that interventions were effective. During an interview on 11/17/2025 at 10:43 AM Licensed Practical Nurse #5 stated the unit managers (Registered Professional Nurses) are responsible for updating the residents care plans, but the Social Worker usually updates the cognitive care plan for the residents.During an interview on 11/17/2025 at 11:42 AM the Social Worker stated they are responsible for updating the care plans for cognitive impairment and they are updated on a quarterly and annually basis as well as with any significant changes. The Social Worker stated Resident #1's cognitive impairment care plan was last updated on Friday, 11/14/2025. The Social Worker reviewed the care plan and stated they can see that the care plan looks like it had not been reviewed since 2023 or 2024. The Social Worker stated the goals are always updated and they are not sure why the updates and revisions are not reflecting on the document. The Social Worker stated the care plan meeting documentation are supposed to carry over to the care plan after the meeting via electronic medical record system. They were not sure why previous care plan meeting documentation did not transfer. Their meeting on Friday, 11/14/2025, did transfer over to the care plan. The Social Worker stated a care plan meeting is always done when a goal is updated. During an interview on 11/17/2025 at 1:47 PM the Director of Nursing reviewed Resident #1's care plan and stated they see that the care plans look like they were not reviewed, but the Social Worker needs to connect their meeting notes in Visual (the electronic medical record) system because the care plans coincide with the quarterly assessments and the care plan meetings.10 NYCRR 415.11 (c)(2)(i-iii)

Based on record review and interviews during an abbreviated survey (2650093), the facility did not ensure the residents representative were informed when there was a significant change in the resident's physical condition for 1 out of 3 residents (Resident #1) reviewed for notification. Specifically, Resident #1's had a fall and sustained injuries to the face, eyes and head on 09/27/2025. The family representative was not notified timely of the change in condition and physical status until they visited the resident on 10/30/2025. The findings are: The facility Accident and Incident policy last reviewed 02/12/2025 documented all accidents and incidents will be investigated and documented. The nurse manager or supervisor will notify the family or significant others regarding the accident or incident. Resident #1 was admitted with diagnoses including but not limited to Cerebral Infarction, Aphasia and Altered Mental Status. A Quarterly Minimum Data Set, dated [DATE] documented Resident #1 had severe cognitive impairment with an altered level of consciousness. Resident #1's impaired cognition care plan last reviewed 10/18/2024 documented the goal was that Resident #1 would maintain their present level of mental awareness. Interventions included to speak to the resident in a clear manner, orient the resident to your identity, ensure residents right, safety, dignity, safety and anticipate needs. Review of the accident/incident report dated 09/27/2025 at 12:15 AM documented Resident #1 was observed lying on the floor in their room with the following injuries noted: right eye swollen, right side of forehead hematoma and a scratch to the right forearm measuring 13cm. Resident #1's representative was called at 12:50 AM and a voice message was left. Review of Resident #1's face sheet revealed the incorrect representative was listed as the emergency contact. The other listed family representees were not called. There was no documented evidence that the facility followed up calls when messages left for the wrong contact was not responded to. There was no documented evidence that other listed family representatives were reached by the facility to inform them about the fall. During a telephone interview on 11/14/2025 at 3:06 PM, Licensed Practical Nurse #2 stated they and the Nurse Practitioner called Resident #1's representative, but there was no answer, so they left a message for them to call back the facility. Licensed Practical Nurse #2 stated Resident #1's representative did not call the facility back before they left their shift at 7:00 AM. Licensed Practical Nurse #2 stated they usually leave a message for the representatives to call back, and the Nurse Practitioner stated they would try to reach the representatives again. During an interview on 11/17/2025 at 10:43 AM, Licensed Practical Nurse #5 stated Resident #1's representative was notified, but there was a discrepancy as the first person on the face sheet was called instead of the right person. Licensed Practical Nurse #5 stated when Resident #1's representative came to the facility to visit Resident #1 they stated they were never informed about the fall incident, because the facility staff had been calling the wrong person. Licensed Practical Nurse #5 stated they recently had a care plan meeting with Resident #1's representative on 11/14/2025 and when the fall incident was brought up, the representative stated the wrong person had been contacted and that was an issue. Resident #1's representative was not happy about the wrong person being contacted.During an interview on 11/17/2025 at 11:42 AM, the Social Worker stated Resident #1's representatives did not voice any concerns regarding the resident's recent fall. The Social Worker stated that there was an issue with contacting the first person designated on Resident #1's face sheet s they would never return their calls or get back to them. On October 31, 2025, they spoke with another representative and made them the point of contact. During a telephone interview on 11/24/2025 at 10:50 AM, Resident #1' s representative stated the facility called another family representative regarding the fall incident who lives out of state in New Mexico over the weekend, but they did not receive a call although they were also listed as a contact on the face sheet. Resident #1's representative stated they should have been the one to be contacted regarding the fall because they had a conference in April 2025 with the facility and it was determined that they would be the first to be contacted. 10 NYCRR 415.3(f)(2)(ii)(c)

Based on interview and record review during the recertification survey conducted on 2/10/25-2/14/25, the facility did not ensure each staff and was screened, offered the most recent COVID-19 vaccine and provided education regarding the benefits, risks and potential side effects associated with the vaccine for 10 of 10 staff reviewed for COVID vaccines. Specifically, there was no documented evidence Staff were offered, and education was provided for COVID vaccination for Dietary Aide #15, Housekeeping #16, Certified Nurse Aide #17, #18, #20, Licensed Practical Nurse #19, Registered Nurse #21, Social Worker #22, Dining Supervisor #23 and [NAME] #24. Findings include: The facility policy titled Management of COVID-19 and dated 11/30/24, documented the facility will offer consenting personnel the opportunity to receive any dose of the COVID-19 vaccine. Signage throughout the facility reminding personnel and residents that the facility offers COVID-19 vaccination will be posted. During an observation on 02/13/25 at 3:56 PM there were no visible signage promoting COVID-19 vaccination. During the recertification survey the facility was asked to provide documentation that COVID-19 vaccination was offered, education was provided, and staff had the opportunity to consent or decline the vaccine for Dietary Aide #15, Housekeeping #16, Certified Nurse Aide #17, #18, #20, Licensed Practical Nurse #19, Registered Nurse #21, Social Worker #22, Dining Supervisor #23 and Cook#24 but non was provided. During an interview on 02/13/25 at 1:34 PM with Licensed Practical Nurse #25 they stated they got their annual flu shot at the facility in the fall but was not offered and did not hear anything about the COVID-19 shot. They stated it was a good idea to get the COVID-19 vaccine to protect themselves and the residents and if it was offered at that time, they would have consented to it. During an interview on 02/13/25 at 3:44 PM the Assistant Director of Nursing stated they were responsible for the staff vaccines including COVID-19 boosters and did not think to offer COVID-19 vaccines because there had been a lack of interest amongst the staff. They stated they had done education with the staff but could provide any documentation and stated it was important for staff to be educated about vaccines because it was a way to protect staff and residents from getting COVID-19. During an interview, on 2/13/25 at 3:27 PM, the Director if Nursing stated they had not been keeping track closely on the vaccines and needed to work on obtaining vaccine status for residents and staff for offering, educating and obtaining declinations. They stated they did not know what happened to the signage throughout the facility reminding personnel and residents that the facility offered COVID-19 vaccination, and stated it should have been posted. 10NYCRR 415.19 (a)(1-3)

Based on record review and interview during the recertification and abbreviated surveys (NY00341482) conducted from 1/10/25 to 1/14/25, the facility did not ensure residents were free from significant medication errors for one of one residents (Resident #399) reviewed for Neglect and Medications. Specifically, staff administered a medication not physician prescribed to Resident #399 which resulted in Resident #399 being transferred to an acute care hospital for evaluation. The findings include: Resident #399 was admitted with diagnoses including but not limited to Chronic Hepatitis C, Diabetes Mellitus, and Liver Cirrhosis. The facility policy titled Administering Mediations dated 4/20/21 documented: medications are administered in a safe and timely manner, and as prescribed. The individual administering medications verifies the resident's identity before giving the resident their medications. Methods of identifying the resident include: a. checking identification band; checking photograph attached to medical record; and c. if necessary, verifying resident identification with other facility personnel. The individual administering the medication checks the label three (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. a. allergies to medications; and b. vital signs, if necessary. The Discharge Minimum Data Set (a resident assessment tool) dated 5/6/24 documented Resident #399's short-term memory was intact. The Care Plan titled Psychoactive Medications, dated 5/6/24, documented: resident on an anti-psychotic, anti-depressant, anti-anxiolytic, or hypnotic medication for disease process. Resident will have no negative side effects from the medication, administer medications as per orders. The Investigation Report findings documented: At 12:30 pm on 5/8/24, the registered nurse notified the charge nurse of a medication error, they administered another resident's methadone 150 milligrams by mouth. The charge nurse immediately went to interview the resident and inform them of the medication error, the resident girlfriend was at the bedside. Resident Identification band and photo identification were present. Vital signs obtained. No signs or symptoms of nausea, dizziness or respiratory distress noted. Charge nurse immediately informed the director of nursing and nurse practitioner. Orders received to send the resident to the local hospital for evaluation and observation. Resident sister and mother called and arrived at the facility where they met with social worker, charge nurse and registered nurse supervisor and were informed of the incident. Family in agreement with emergency room transfer. The incident/accident statement from Registered Nurse #9 documented residents medication was pulled. The alarm of a tube feed went off. Medications were placed in the cart and locked. When this registered nurse returned to the cart the alarm for the pump for another resident went off. Registered nurse went to turn off the alarm. Then the registered nurse refreshed the page on the electronic medical record and went to Resident #399. Resident #399 was with a visitor, but they gave permission for the registered nurse to enter. Registered nurse told the resident what the medication was, and the resident took the pills. Registered nurse took resident's blood pressure and left. Then the registered nurse went back to the cart and refreshed the electronic medical record page and realized the medication methadone was given to the wrong resident. The registered nurse went to the unit manager to report the error. The Investigative Conclusion documented registered nurse failed to follow policy and procedures for medication administration. The investigation revealed that this was a medication error on part of the registered nurse who failed to notice the resident's identification band, photo identification and confirm resident name prior to medication administration, along with resident name on the methadone that they administered to the resident. Resident's identification band present, room label on door present, photo identification and methadone was properly labeled with name of appropriate resident. The Plan to prevent reoccurrence/facility wide plan documented: resident sent to hospital. Nursing staff (registered nurse and licensed practical nurse) will be re-educated on medication administration policy and in-serviced on medication administration and resident medication rights. During an interview on 2/13/25 at 1:01 PM Licensed Practical Charge Nurse #8, stated Registered Nurse #9 presented to them at 12:30 pm on 5/8/24_to report they had incorrectly administered medication (Methadone 150 milligrams by mouth) to the wrong Resident (Resident #399). Licensed Practical Nurse #8 stated they immediately presented to Resident #399 upon receipt of the reported medication administration error. They stated Resident #399 was alert and oriented during interview and reported they had taken methadone in the past outside of the facility and did not feel unwell. They stated the nurse practitioner was contacted and provided orders to send Resident #399 to the local emergency room for evaluation. Resident #399 and family agreed with transfer to the emergency room . The director and assistant director of nursing were also made aware within 30 minutes of Registered Nurse #9 reporting the medication error. Licensed Practical Nurse #8 stated there was a photo of Resident #399 on the electronic medication record which should have been used to identify the resident and that Resident #399 also had an identification wristband on, and name on the door to the resident room. They stated the resident that the medication was prescribed for was in a separate room cluster halfway down the hall. They stated when Registered Nurse #9 reported the medication error to them, they stated they were being distracted by tube feeding alarms. Licensed Practical Nurse #8 stated that during the interview, Resident #399 stated they were informed by Registered Nurse #9 what medications were being administered and that Resident #399's girlfriend, who was present during medication administration and assessment, thought Registered Nurse #9 stated metformin (which resident was prescribed) and not methadone. They stated Resident #399 stated they were aware that Registered Nurse #9 stated methadone and did not question the medication administration. They stated Resident #399 did not return to the facility after presenting to the local emergency room for evaluation During an interview on 2/13/25 at 5:27 PM the Director of Nursing, stated Registered Nurse #9 immediately reported the medication administration error to the charge nurse on the unit. The resident was interviewed by the unit charge nurse, facility nurse practitioner and the director and assistant director of nursing were notified. They stated the nurse practitioner provided an order for Resident #399 to be sent to the local emergency room for evaluation due to the resident receiving a narcotic medication that was not ordered for them. The Director of Nursing stated they considered this occurrence a significant medication error. They stated they contacted the local emergency room and provided the information involved in the medication administration error. The Director of Nursing stated an immediate investigation was started including medication review, staff statements, checking Resident #399's identification wristband, photo identification on the electronic medical record, room door label, and that all medications involved were properly labeled. The Director of Nursing stated they contacted the local hospital 48 hours after the resident was transferred and was informed that Resident #399 was discharged to the community after evaluation. 10 NYCRR 415.12 (m)(2)

Based on observation and interview conducted during the recertification survey, the facility did not ensure that resident's dignity was maintained. Specifically,1) residents were being served milk and water in plastic storage cups with lids on 4 of 4 units (South 1, North 1, South 2 and North 2) and 2) and Certified Nurse Assistant #7 referred to Resident #26 as a feeder. In addition, a Resident progress note in the facility Electronic Medical Record also referred to Resident #26 as a feeder. The findings are: 1) Observations were made throughout survey from 2/10/25 to 2/14/25 on South 1, North 1, South 2 and North 2 units of residents being served milk and water out of plastic storage cups with lids. Observations were made on North 2 Unit on 2/10/25 at 12:24 PM and 2/11/25 at 12:21 PM, of residents being served milk and water out of plastic storage cups with lids. On 2/12/25 at 10:28 AM during the Resident Council Meeting 10 of 10 residents stated they were served milk and water in plastic storage cups and they preferred to use a hard plastic drinking cup. During interview on 02/12/25 at 2:24 PM the Food Service Director stated they pre-pour water and Lactaid milk to provide 4 oz of water or milk. The Lactaid milk only came in 8 oz containers and a portion size was 4 oz, so they poured the Lactaid milk into the storage cups with lids because the drinks needed to be covered. The Food Service Director stated they had hard plastic drinking cups in the main dining room and on the units in the small dining areas. The Food Service Director stated they stored the hard plastic drinking cups in the main dining room and on the units. The Food Service Director stated they were not aware that resident's should not use the storage cups with lids for drinking. During observation on 2/12/25 at 3:52 PM, 26 hard plastic drinking cups/non-disposable cups were on the tables in the main dining room. The South 1, North 1, South 2 and North 2 units only had disposable plastic storage cups with lids. During a follow up interview on 2/12/25 at 3:52 PM the Food Service Director stated the facility did not have hard plastic drinking cups on the units only had 31 hard plastic drinking cups in the main dining room. The Food Service Director further stated they now only had 26 hard plastic cups in the building. The Food Service Director stated if they left the hard plastic drinking cups on the units they would walk, or be taken. During interview on 2/13/25 at 9:24 AM the Food Service Director stated they last ordered hard plastic drinking cups a couple weeks ago but they had not been delivered. The Food Service Director stated they were not sure why they did not receive the hard plastic drinking cups. During interview on 2/13/25 at 12:06 PM, the Director of Rehabilitation stated they had seen the disposable storage cups being used by residents for drinking and had discussed this with the Director of Nursing. The Director of Rehabilitation stated residents should use hard plastic drinking cups especially since residents have a difficult time holding plastic storage cups. 50766 2) Resident #26 was admitted with diagnoses including Alzheimer's, Polyosteoarthritis, and Psychotic Disorder with Delusions. The Resident Care Plan (dated 1/14/2019) documented provide encouragement and set-up help. The Quarterly Minimum Date Set (a resident assessment tool), dated 12/10/24, documented Resident #26 had severe cognitive impairment and was dependent with eating. The Progress Note dated 12/17/24 documented resident is a feeder. During an observation and interview on 02/11/25 at 08:54 AM, Certified Nurse Assistant #7 presented to Resident #26's room with a breakfast tray. When asked by the surveyor regarding Resident #26's meal intake, Certified Nurse Assistant #7 referred to Resident #26 as a feeder. During an interview on 2/12/25 at 11:24 AM Certified Nurse Assistant #7, stated they referred to Resident #26 as a feeder on 02/11/25 at 08:54 AM during interview with the surveyor because the resident required assistance with meals. They stated they realized using the word feeder was inappropriate after the interview and knew they had used the wrong terminology for a resident who required assistance with meals. Certified Nurse Assistant #7 stated they had received in-service regarding dignity within the past year. During an interview on 02/13/25 at 10:10 AM the Director of Nursing stated Certified Nurse Assistants received dignity in-services annually. They stated that the use of the word of feeder is not an acceptable terminology in the facility and should not be used verbally or in resident clinical documentation. 10 NYCRR 415.5 (d) (1)(i)

Based on observation, record review and interview conducted during the recertification survey conducted 2/10/25 through 2/14/25, the facility did not ensure proper disposal of garbage and refuse. Specifically, the garbage compactor /dumpster was left open and there were large metal containers, old furniture, and debris on the ground around the dumpster. The findings are: The facility policy titled Food-Related Garbage and Rubbish Disposal dated 6/26/24 documented all garbage and rubbish containers should be provided with tight fitting lids or covers and must be kept covered when stored. Outside dumpsters provided by garbage pick-up services will be kept closed and free of surrounding litter. During an observation on 2/12/25 at 10:10 AM: -cardboard boxes in the dumpster and the dumpster was left open. -compactor was filled with old furniture and was left open -old furniture, large metal containers and debris were on the ground around the dumpster. During an interview on 2/14/25 at 9:31 AM, the Administrator stated the maintenance department were responsible for ensuring the dumpster was closed and that there was no garbage on the ground in the area. During an interview on 2/14/25 at 9:35 AM, the Director of Maintenance stated they had called the company to pick up the compactor, because it was full but were still waiting for the company to empty the compactor. The Director of Maintenance stated the large metal containers were donations and were awaiting pick up. The Director of Maintenance stated the old furniture was on the ground because the compactor was full, and they could not stop renovations. During a follow-up on 2/14/25 at 9:49 AM, the Director of Maintenance stated they had just called the company to come out and empty the compactor, but they would not be available until 2/25/25. They also stated they asked for a dumpster replacement lid but would not receive a lid until 2/25/25. During an interview at 9:55 AM, the Food Service Director stated they were not responsible for ensuring the dumpster was covered and were not responsible for ensuring garbage was not left in the area. They stated the Maintenance Director was responsible and concerns had been reported to them. 10 NYCRR 415.14(h)

Based on observation and interview conducted during the recertification survey from 2/10/25 through 2/14/25 the facility did not ensure food was stored in accordance with professional standards for food service safety. Specifically, beverages stored in nutrition and storage refrigerator/s were not labeled and were outdated, and a parcel of flour was left open not dated on the shelf. Findings include: The facility policy titled Food Receiving and Storage dated 6/26/2028 documented dry foods that are stored in bins will be removed from the original package, labeled and dated (use by date). Beverages must be dated when opened and discarded after 3 days. Other opened containers must be dated and sealed or covered during storage. An initial tour of the kitchen was conducted on 2/10/25 at 9:50 AM and the following were observed: - unlabeled 4 ounce cups were filled with white liquid dated 2/4, in the nutrition and storage refrigerator. - unlabeled 4 ounce cups were filled with brown liquid dated 2/4, in the nutrition and storage refrigerator. - unlabeled 4 ounce cups with thickened yellow liquid dated 2/10, on a tray. - an open parcel of all purpose flour that was open and not sealed. During an interview on 2/10/25 at 9:41 AM, [NAME] Supervisor #11 stated the white beverage in the 4 ounce cups were Lactaid milk, 4 ounce brown beverages were prune juice and the thickned yellow liquids were smoothies. [NAME] Supervisor #11 also stated the Lactaid milk and prune juices were outdated and should have been discarded after 3 days. [NAME] Supervisor #11 stated they were short staffed over the weekend and that was why the liquids were still in the refrigerator. During an interview on 2/11/25 at 9:55 AM, the Food Service Director stated the Lactaid milk and prune juice were supposed to stay in the refrigerator for 3 days, and usually they are labeled with L for Lactaid milk and A for apple juice.The Food Service Director stated the open parcel of flour that was observed on 2/10/25 was left open and should have been sealed. 10 NYCRR 415.14 (h)

Based on staff interview and record review during the recertification survey from 02/10/25 through 02/14/25, the facility did not ensure Certified Nurse Aide performance reviews were completed at least once every 12 months. Specifically, three of five Certified Nurse Aides (#2, #3, #4) did not have a performance review documented at least once every 12 months. Findings include: There was no documented evidence that performance reviews were completed in the last 12 months for Certified Nurse Aide #2 with a hire date of 2020, Certified Nurse Aide #3 with a hire date of 2018 and Certified Nurse Aide #4 with a hire date of 2017 During an interview on 2/13/25 at 10:42 AM the Human Resource Director stated unit supervisor/s were responsible for completion of Certified Nurse Aide performance reviews. The Human Resource Director stated Certified Nurse Aide performance reviews should be filed in employee folders, once completed. The Human Resource Director stated they did not realize Certified Nurse Aide performance reviews were not completed for Certified Nurse Aide #2, #3 and #4. During an interview on 2/13/25 at 10:44 AM the Assistant Administrator stated they were unsure why Certified Nurse Aide performance reviews were not completed for Certified Nurse Aide #2 ,#3, and #4. During an interview on 2/13/25 at 10:47 AM the Assistant Director of Nursing stated they helped with the completion of Certified Nurse Aide performance reviews in the past and thought they had been completed. 10NYCRR 415.26 (c) (2) (iii

Based on observations, interview, and record review during the recertification survey from 2/10/25-2/14/25, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive care plan for 1 of 1 (Resident # 15) residents reviewed for pain management. Specifically, there were multiple omissions on the medication and treatment administration records for medications and treatments related to pain management for Resident #15. The findings include: The policy titled Administering Medications dated 4/20/2021 documented medications are administered in accordance with prescriber orders, including any required time frame. The individual administering the medication will document that the medication was administered. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall document the refusal. Resident #15 was admitted to facility with diagnoses that included Coronary Artery Disease, Hypertension, and Peripheral Vascular Disease. The Comprehensive Care Plan titled Pain Management updated 1/2/25, documented potential pain and intermittent pain related to activity level, monitor for pain, administer medication as ordered, and monitor effectiveness of medications. The Physician Order dated 12/31/24 included Gabapentin oral capsule 300 mg 2 capsules by mouth every 8 hours, Lidocaine External Patch 4% 2 patches every day, Capsaicin External Cream 0.025% apply to leg twice daily, and pain monitoring every shift. The Admission Minimum Data Set, dated dated dated [DATE] documented pain of 9/10 almost constant, affecting sleep and therapy. The January 2025 Treatment Administration Record had omissions for Capsaicin Cream on 1/2, 1/6, 1/10, 1/13, 1/14, 1/15, 1/20, 1/26, and 1/27/25. There was no documented evidence that explained the reason for omissions. The January 2025 Medication Administration Record had omissions for Gabapentin on 1/2, 1/10, 1/13, 1/14, 1/20/25, Lidocaine Patch on 1/2, 1/13, 1/14, 1/20/25, and pain monitoring on 1/2, 1/13, 1/14, and 1/20/25. There was no documented evidence that explained the reason for omissions. The February 2025 Treatment Administration Record had omissions for Capsaicin Cream on 2/3, 2/6, 2/7, and 2/10/25. There was no documented evidence that explained the reason for omissions. During an interview and observation on 02/10/25 at 03:30 PM, Resident #15 verbalized pain and stated they had received some pain medication but were still in pain. Nurse was informed of resident reports of pain and observed discussing with resident. Gabapentin was documented as administered at PM as ordered and pain monitoring was documented for shift. During an interview on 02/13/25 at 11:37 AM, Resident #15 stated they felt their pain management was overall effective with the suboxone and Tylenol. Resident #15 stated they believe they were in so much pain a few days prior because they worked too hard in therapy. During an interview on 02/14/25 at 09:52 AM Registered Nurse Unit Manager #10, stated Resident #15's pain was managed with Suboxone and Tylenol. They acknowledged there were omissions for the Capsaicin Cream, Gabapentin, and Lidocaine in January and/or February 2025. They stated the medication nurse should have documented the reason for the medications not being administered. They stated they had requested that the medication nurses check their records for omissions prior to the end of their shift. During an interview on 02/14/25 at 10:52 AM, the Director of Nursing stated the expectation was no omissions on the medication or treatment administration records. The Director of Nursing stated if a medication was not administered, the medication nurse should document the reason why the medication was not administered in a progress note or on the medication or treatment administration record 10NYCRR 415.12

Based on observation, interview, and record review during the Recertification Survey from 2/10-2/14/25 the facility did not ensure comprehensive person centered care plans were developed for 1 of 3 residents (#37) reviewed for Limited Range of Motion. Specifically, Resident #37 did not have a care plan with goals and interventions specific to the use of a cervical collar. The findings include: The Facility Policy titled Comprehensive Care last reviewed 7/2/2024, documented the facility will develop and implement a comprehensive person centered care plan for each resident that includes measurable objectives and time frames to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. Resident #37 was admitted with diagnoses including but not limited to Alzheimer's Disease, Fracture, and Heart Failure. The Nursing Progress Note dated 1/4/25 documented Resident #37 was received at the facility at 4:30 PM, cervical collar in place. Cervical collar to be kept in place until follow up with neurosurgeon. The Nurse Practitioner Note dated 1/5/25 documented Resident #37 admitted status post fall with C2 fracture and right pelvic fracture. The Admission Minimum Data Set, dated dated dated [DATE] documented Resident #37 had severely impaired cognition, and required maximum assist/was dependant for activities of daily living. The Physician Order dated 1/29/25 documented keep cervical collar in place until neurosurgery follow up and evaluate skin integrity under cervical collar daily and as needed every shift. There was no evidence of a comprehensive care plan specific to fractures, positioning, cervical collar, or skin integrity monitoring related to cervical collar use. During observation on 2/10/25 at 1:12 PM and 2/12/25 at 11:49 AM, Resident #37 was sitting up in the wheelchair with a cervical collar in place. During observation on 2/13/25 at 8:52 AM, Resident #37 was in bed with a cervical collar in place. During an interview on 2/14/25 at 1:07 PM Registered Nurse Unit Manager #10 stated there should be a care plan with goals and interventions specific to the use of a cervical collar, but was not able to locate such care plan. They stated they were able to locate an assessment that documented the fractures under the evaluations section of the reactivated activities of daily living care plan dated 9/27/24, but no new goals or interventions were added since the most recent admission on 1/4/25. They stated they had obtained the order that was present in the electronic medical record to monitor the skin and keep the collar in place when they were working on the unit on 1/29/25, but they were not completing care plans for the unit at that time. 10NYCRR 415.11(c)(1)

Based on observation and interview conducted during the recertification survey, the facility did not ensure that a clean, comfortable, and homelike environment was provided. Specifically, North 2 unit rooms (S3, X1, X3, X6, V1, V3) had broken tiles, cracked walls, hanging curtains or damaged windows, the shower room had a damaged drain and the the hall window was open, resulting in the resident in room V3 offering complaints of feeling cold. The Findings include: During observation on 2/10/25 at 10:09 AM room X6 tiles under the bed were broken and chipped. During observation on 2/10/25 at 10:15 AM room X3 tiles under the closet were damaged. During observation on 2/10/25 at 10:16 AM room V1 had a cracked wall at the bottom right corner of window. During observation on 2/12/25 at 12:16 PM room V3, resident complained it was cold and the thermometer in the room registered 74 degrees. The hall window was open and blowing cold air into the room. During observation on 2/12/25 t 12:17 PM room S3 window curtain was hanging off the window. There was no documented evidence of a work order logbook with receipts from 8/20/24 and 10/10/24. During observation on 2/12/25 at 12:19 PM, of North 2-unit rooms (S3, X1, X3, X6, V1, V3) and shower room with the Maintenance Director, they stated they had been working on the renovations for some time and had not finished the second floor where these rooms were located. The Maintenance Director stated the shower drain was not secure and had last been fixed 8 weeks ago but the drain continued to break. The Maintenance Director stated it may be the weight of some residents that caused the drain to break. The Maintenance Director stated room V3 had central heating and the thermometer was at 74 degrees. They stated staff needed to close and keep the window in the hall closed. During observation on 2/13/25 at 11:05 AM and 2/14/25 at 1:58 PM, the unit North 2 hallway window was open near room V3. During interview on 2/14/25 at 1:59 PM, certified nurse aide #14 and Rehabilitation Aide #12, stated they were not aware of who opened the hallway window near room V3 and stated they did not open it. During interview on 2/14/25 at 2:01 PM, Registered Nurse #13 stated they were not aware of the window being opened and did not know who opened it. Registered Nurse #13 stated the window may have been opened for fresh air after providing care, but should have been closed. 10 NYCRR 415.5(h)(2)

Based on record review and interview during the recertification survey conducted 02/10/25-02/14/25, the facility did not ensure each resident was offered pneumococcal immunizations and received education regarding the benefits and potential side effects of the immunizations for 2 of 5 residents (Residents #9, #50) reviewed. Specifically, there was no documented evidence Resident #9, and Resident #50 were offered, declined, or educated about the pneumococcal immunization. Findings include: The facility policy for Pneumococcal Vaccination dated 10/01/2007 and last reviewed 1/4/2025 documented, in order to prevent the spread of infectious disease and to mitigate the risk of morbidity and mortality associated with pneumococcal pneumonia, the facility will offer pneumococcal vaccinations to all residents and staff. Resident #9 had diagnoses including Morbid Obesity, Type II Diabetes Mellitus and Major Depressive Disorder. The Minimum Data Set, an assessment tool, dated 12/2/24 documented the resident was cognitively impaired, ate with assistance and was dependent on staff for dressing and toileting. There was no documented evidence the resident/resident representative received education, was offered the vaccination, or declined the pneumococcal vaccine. Resident #50 had diagnoses including Chronic Obstructive Pulmonary Disease, dementia and Schizophrenia. The Minimum Data Set, dated dated dated [DATE] documented the resident had severe cognitive impairment and was dependent on staff for assistance with all activities of daily living. There was no documented evidence the resident/resident representative received education, was offered the vaccination, or declined the pneumococcal vaccine. During an interview on 2/13/25 at 3:27 PM, the Director of Nursing stated they were the Infection Preventionist and were responsible for the vaccine program and were supposed to document each resident's vaccine status when admitted to the facility. The Director of Nursing stated they had not been keeping a close eye on the pneumococcal vaccines for residents and had not been tracking the vaccine information. They stated they needed to get a better handle on it because the vaccines were important for protection against disease. 10NYCRR 415.19 (a) (1-3)

Based on observation, record review and interview, during a recertification and extended survey from 1/2/2024 to 1/11/2024, the facility failed to ensure the resident environment remained as free of accident hazards as possible. Specifically, a total of 26 residents on 2 of 2 resident floors were residing in 17 rooms where space heaters were in use (room M1, M2, R6, R2, R1, O1, O2, O3, O4, Q3, Q2, N1, N2 and N3 on the locked dementia unit with residents wandering in and out of the rooms, and rooms S1, S4, and X2). Additionally, facility staff reported that at times they had seen towels placed over the space heaters. Subsequently, residents were at risk for injury with the likelihood for harm or death that was Immediate Jeopardy (IJ) to the health and safety of the facility's 151 residents. The findings are: The facility Admission History documented the facility admitted 21 residents in the month of October 2023, 21 residents in November 2023 and 13 residents in December 2023. These residents were admitted to rooms with heat. The undated policy titled Maintaining Electrical Equipment documented portable space heaters would be placed in the facility only on a case-by-case basis. The heaters would be inspected on a weekly basis by the Director of Maintenance or designee. Results of the inspection would include vacuuming the unit, inspection of the cords and a touch test would be done by placing a hand on the unit. The log titled Weekly Check documented the following rooms were checked for space heaters: M1, M2, N1, N2, N3, O2, O3, O4, Q1, Q2, Q3, Q4 R1, R2, R6, E2, S4, X2 and L2 on the following dates: 10/5, 10/10, 10/17, 10/23, 11/2, 11/7, 11/15, 11/21, 11/27, 12/6, 12/13, 12/19 and 12/27/2023. There was no documented evidence resident room temperatures were checked. During an observation of the dementia unit on 1/2/2024 at 10:00 AM, space heaters were found in 11 out of 28 resident rooms (M1, M2, N1, N2, N3, O1, O2, O3, O4, R1, and R2). During this observation residents were noted wandering in and out of rooms. During an observation on 1/2/2024 at 1:20 PM, space heaters were in use on Unit S2 in rooms R6, Q2, Q3, X2, S1 and S4. During an interview on 1/2/2024 at 1:20 PM, Licensed Practical Nurse #1 stated the rooms had space heaters because the heat in those resident rooms did not work. During an interview on 1/2/2024 at 1:40 PM, the Maintenance Director stated that in October the lines in the P-Tac (Packaged Terminal Air Conditioner: ductless through the wall heating and cooling system) units did not work and the facility called in a vendor to replace the units. The Maintenance Director stated that they were aware space heaters were not permitted in resident rooms, but space heaters were provided to ensure the residents had heat. A radiant temperature check in room R6 on 1/2/2024 at 2:10 PM revealed the temperature of the space heater was 170 degrees Fahrenheit. During an interview on 1/2/2024 at 2:30 PM, Certified Nurse Aide #4 stated they started working at the facility last year and the heaters in the resident rooms were broken. Certified Nurse Aide #4 stated they did not receive education regarding the use of the space heaters. During an interview on 1/2/2024 at 3:00 PM, Registered Nurse Unit Manager #6 stated 28 of the 40 residents on the dementia unit were ambulatory and 11 of the 28 ambulatory residents were known wanderers. During an interview on 1/2/2024 at 3:00 PM, Certified Nurse Aide #3 stated they did not receive education regarding the management, observation or monitoring of the space heaters. During an interview on 1/2/2024 at 3:00 PM, Certified Nurse Aide #5 stated they checked the space heaters in the morning to determine that they were providing heat, but they did not receive education related to the use of space heaters and had not seen a policy regarding the space heaters. Certified Nurse Aide #5 stated that at times they had seen towels placed over the space heaters . During an interview on 1/2/2024 at 4:59 PM, the Maintenance Director stated that there was no documented evidence that staff were educated regarding the use of and/or monitoring of the space heaters. During an interview on 1/2/2024 at 5:00 PM, the Administrator stated there was no documented staff education regarding the use of and/or monitoring of space heaters. They were not aware that the use of space heaters was prohibited in resident rooms, and they thought some types of space heaters were allowed to be used in resident rooms. The Administrator stated the facility policy directed that space heaters were allowed on a case-by-case basis depending on weather temperatures. The Administrator stated they should have considered resident behaviors and diagnoses to determine individual room use. The Administrator also stated they were aware that space heaters had the potential to cause fires. The Administrator stated that although some resident rooms did not have heat, the facility continued to admit new residents into the rooms that had heat. The facility Admission History documented the facility admitted 21 residents in the month of October 2023, 21 residents in November 2023 and 13 residents in December 2023. These residents were admitted to rooms with heat . During an interview on 1/3/2024 at 1:50 PM Registered Nurse Manager #6 stated the dementia unit had residents who wandered in and out of resident rooms which could have resulted in the residents touching the space heaters and getting burned and/or electrocuted. Registered Nurse Manager #6 stated they did not report their concerns to anyone. Registered Nurse Manager #6 stated the space heaters had been in the resident rooms for approximately 1 month. During an interview on 1/3/2024 at 3:00 PM, Resident #135's family member stated they complained prior to the holidays that the heating unit in Resident #135's room was not working, and that it was cold in the room. The family member stated they spoke with Registered Nurse Unit Manager #6 and Social Worker #22 and the facility provided the resident with a space heater. The family member stated Resident #135 kept turning off the space heater and thought they had to pay for heat. During an interview on 1/3/2024 at 4:27 PM, the Medical Director stated they were unaware 26 residents were affected by the packaged terminal air conditioner (P-Tac) units being broken. The Medical Director stated they were not aware the facility was using space heaters. The Medical Director stated they were concerned that a resident could touch the heater or put items on the space heater. The Medical Director stated the lack of heat in the building was not discussed with them or the medical team. The Medical Director stated they were part of the QAPI (Quality Assurance Performance Improvement) team, and it was not brought up in any of their meetings. The Medical Director stated they were also part of the Emergency Preparedness team and if the facility could not accommodate the residents with heated rooms, they could have moved the residents to a sister facility. The Administrator was informed of the Immediate Jeopardy and provided the Immediate Jeopardy Template on 1/3/2024 and signed it at 7:57 PM. Based on surveyor observations and evidence provided by the facility, the immediacy was removed on 1/5/2024 at 5:30 PM. The following was completed to remove the immediacy: On 1/3/2024: - All space heaters were removed from resident rooms. - The heating repair company arrived to retro fit for new PTAC (Packaged Terminal Air Conditioner) units. - The affected residents were moved to common areas with effective heating. - Team meeting to discuss bed management for affected residents to be relocated to adequately heated areas. - Bed management and relocation of residents performed all residents were moved to adequately heated areas. In person hand off report was given to staff on unit for all residents relocated and care plan were reviewed and updated. - Social work called residents' primary contacts to update on heating issue and room changes. - Education started with Department Directors, Maintenance staff, Housekeeping, Nursing, Receptionist, Social Work, Therapy, Admissions and Dietary. In-services included Resident safety related to non-use of space heaters, monitoring room temperature, and emergency preparedness for lack of heat. Daily rounds in progress until all education completed. On 1/4/2024: - Education to families via letter and notification at front desk to inform that space heaters were prohibited in Nursing Home was completed. - A corporate consultant educated the Administrator, Director of Nursing and Director of Maintenance of prohibited use of space heaters. - Electrical Safety policy was revised to add language that space heaters were prohibited in nursing homes. - A QAPI meeting was scheduled to discuss Immediate Jeopardy findings and the Plan of Correction. On 1/5/2024: -Staff education was 95% completed. -Heating units arrived at facility. 10 NYCRR 415.12 (h) (1)

Based on observation, record review, and interviews conducted during the recertification survey (1/2/2024-1/11/2024), it was determined the governing body did not establish and implement policies regarding the management and operation of the facility. The governing body did not maintain consistent communication with the Administrator who was responsible for the management of the facility to ensure regulatory compliance. Specifically, multiple deficiencies were identified on the recertification survey including in the areas of accidents and hazards (F689), and space heaters not permitted (K781). Findings include: The policy titled Administrative Management (governing board) dated 2/17/2021: documented the governing board shall be responsible for the management and operation of the facility. Review of the undated policy titled Electrical Safety for Residents documented portable space heaters are placed in the facility only on a case-by-case basis. The heaters would be inspected on a weekly basis by the Director of Maintenance or designee. Results of inspection will include vacuuming the unit, inspection of cords and touch test of placing hand unit. During an observation on 1/2/2024 at 9:00 AM a space heater was observed in a resident's room plugged into the wall. During an observation on 1/2/2024 at 1:00 PM space heaters were in use in rooms M1, M2, R6, R2, R1, O1, O2, O3, O4, Q3, Q2, N1, N2 and N3, S1, S4, and X2. During an interview on 01/10/24 at 02:05 PM the Administrator stated the governing body representatives were aware that the heat was not working in rooms on N1. The Administrator stated that they put free standing heaters in the rooms, The Administrator stated they were unaware that space heaters were not allowed. The Administrator stated that they had notified corporate in October when they became aware the heat was not working. The Administrator stated that replacing the portable thru the wall air conditioning units would be a capital project and would need approval from corporate purchasing. The Administrator stated they were trying to get the heat fixed, but had delays related to securing the units and having the contractor install them. The Administrator stated that the Corporate Administration had resigned and a new one will be starting soon. During an interview on 01/10/24 at 03:54 PM the Governing Body Representative stated they were made aware of the issues with the heat and the use of space heaters after the survey team came in. The Governing Body Representative stated they did not recall being told the heat was not working in any of the resident rooms. The Governing Body Representative stated they were aware that they were looking to upgrade the heating systems in some of the rooms and should have been made aware that the heat was not working. The Governing Body Representative stated that capital projects were approved by corporate, and the expenditures had been approved a while ago, The Governing Body Representative stated that they were surprised to hear the survey team found the heat was not working in certain rooms. They stated they do visit the building and have been to the building since October. The Governing Body Representative stated the administrator reported informally, not a written report at least quarterly to the governing body. The Governing Body Representative stated they hold the administrator accountable through meetings with the corporate administrator and they relay important information to the governing body. The Governing Body Body Representative stated they were not involved in developing the facility assessment and believed the regional administrator was involved in developing and updating the facility assessment. During an interview on 1/11/24 at 9:34 AM the Director of Nursing stated they were more clinical and that corporate was the facility governing body. The Director of Nursing stated that the administrator had the direct line to them and would have communicated any issues with maintenance. 10NYCRR 415.26(b)(3)(1)

Based on Observation, record review and interview conducted during the recertification survey (1/2/24-1/11/24) the facility did not ensure that operative oversight for an effective system was in place to maintain health, safety, and the highest practicable well-being of residents reviewed for accidents. Specifically, space heaters were in use for 26 residents in 17 rooms (M1, M2, N1, N2, N3, R1, R2, R6, O1, O2, O3, O4, Q2, and Q3 on the locked dementia unit with residents wandering in and out of the rooms) and rooms S1, S4, X2. The findings are: Review of the undated policy titled Electrical Safety for Residents documented portable space heaters are placed in the facility only on a case-by-case basis. The heaters would be inspected on a weekly basis by the Director of Maintenance or designee. Results of inspection will include vacuuming the unit, inspection of cords and touch test of placing hand unit. During an observation on 1/2/24 at 10:00 AM of the locked dementia unit, which houses residents diagnosed with dementia space heaters were found in 11 out of 28 residents' rooms M1, M2. N1, N2, N3, R1, R2, O1, O2, O3, O4, Q2, and Q3. During this observation residents were noted wandering in and out of rooms. During an observation on 1/2/24 at 1:20 PM, there were space heaters in use in rooms M1, M2, N1, N2, N3, R1, R2, R6,.O1, O2, O3, O4, Q2, and Q3 During an Observation on 1/2/24 at 1:30 PM there were space heaters in room S1, S4 and X2 During an interview on 1/2/24 at 1:40 PM the Maintenance Director stated in October the lines in the P-Tac (Packaged Terminal Air Conditioner: ductless through the wall heating and cooling system) units did not work and the facility called in a vendor to replace the units. The Maintenance Director stated the facility was waiting for the parts. The Maintenance Director stated they were aware that space heaters were not permitted in resident rooms, but space heaters were provided to ensure residents had heat. During an interview on 1/2/24 at 5:00 PM the Administrator stated they became aware that the heat was not working a few months ago. The Administrator stated that they thought some types of space heaters were allowed in resident rooms and that they were aware that space heaters had the potential to cause fires. The Administrator stated the facility policy directed that space heaters were allowed on a case-by-case basis and that the facility based that decision on weather. The Administrator stated they should have considered resident behaviors and diagnoses to determine individual room use. The Administrator stated that they were not aware that the use of space heaters was prohibited in resident rooms The Administrator stated that they met with the contractors in December 2023, but had not moved forward with the repairs. The Administrator stated they had a safety committee, but the issue was not discussed as they already had a plan to repair the P-Tac (packaged terminal air conditioner) units. The Administrator stated the plan to restore the heat consisted of ensuring both the packaged terminal air conditioner units and the contractor were available at the same time to install them. The Administrator stated that although the contractors were now available, the facility had not been able to secure all the required heating units for the completion of the work. The Administrator stated that the facility continued to admit residents to the facility. 10 NY CRR 415.26

Based on record review and interview conducted during the recertification and abbreviated surveys (# NY00320640) from 1/2/2023 to 1/11/2024, the facility did not ensure all injuries of unknown origin were thoroughly investigated for 1 of 2 residents reviewed for abuse. Specifically, Resident #54 had an injury of unknown origin was not thoroughly investigated to rule out abuse. The investigation did not include interviews or statements from staff working with the resident. Findings include: Resident # 54 was admitted with diagnoses including Dementia, Coronary Artery Disease, and anemia. A review of the Policy and Procedure Prevention/Prohibition of Abuse, Neglect, Mistreatment, Exploitation, injury of unknown source and Misappropriation of Property dated 12/1/2017 and revised on 11/1/2019, documented the facility shall conduct a thorough investigation of all alleged violation/sexual abuse involving mistreatment, neglect or abuse including injuries of unknown origin. A Quarterly Minimum Data Set (MDS) documented Resident #54 had severely impaired cognition and required supervision with eating and substantial to maximum assistance for all other activities of daily living. A review of a progress note dated 7/4/2023 documented the resident was seen for a bruise to the left calf and the x-rays were negative for fracture. A review of an Accident & Incident report dated 7/4/2023 documented a bruised left upper calf measuring 9 inches by 5 inches, unknown when it occurred, and it was discovered during a shower. The resident's statement was that the bruise was there for 5 years. A root cause analysis documented the bruise was related to anticoagulant therapy and fragile skin. The report was completed on 7/5/2023 at 1:58PM. The report did not include any interviews from the staff on the shift or on prior shifts. A review of Accident and Incident report dated 7/16/2023 documented the resident was sent to the emergency room per daughter's request for left hip pain and swelling. The report documented the resident noted to attempt self-transfers from bed to wheelchair and wheelchair to bed and it was likely that the resident miscalculated the distance resulting in the left hip hitting the wheelchair arm. The report did not include interviews or statements from staff on the shift or prior shifts. The report documented the Nurse Practitioner was notified at 6:30 PM. A progress note dated 7/16/2023 documented the emergency room physician called at 8:50 PM inquiring about hematoma to left leg and informed the facility the resident would have an X-ray and ultra sound to rule out fracture or abscess. An acute progress note created on 1/8/2024 (almost 6 months after incident) as a late entry for 7/16/2023 at 8:00 PM, documented a telehealth called to evaluate patient due to complaint of hip pain, noted with mild swelling and discoloration. The assessment/plan was osteoarthritis versus hip pain, bruising likely due to patient self-transferring to wheelchair without assist and likely hit left hip on arm of wheelchair; the resident was interviewed by the Registered Nurse and denied fall. During an interview on 01/08/24 at 11:50 AM, the Director of Nursing stated to investigate an injury of unknown origin, they would speak to the resident and ask what happened. They stated Resident #54 was sometimes lucid and sometimes confused. They stated the physician and family were notified. For both incidents, abuse/neglect or mistreatment was ruled out based on the resident statement and behavior related to self-propelling wheelchair. The resident was on anticoagulation and had a history of bruising. The Director of Nursing stated it was not necessary to interview staff as they were able to rule out abuse, neglect or mistreatment base on the resident's history and physician input. During an interview on 01/08/24 at 12:20 PM, the Administrator stated for an injury of unknown origin, they would do an investigation to rule out abuse. The investigation included a review of the chart taking into consideration the resident's statement, the medical history, any behaviors, and staff statements. During an interview on 01/08/24 at 02:42 PM, the Nurse Practitioner stated they did a tele-visit with a picture the facility sent and was able to rule out abuse, neglect, or mistreatment. The resident was on anticoagulation and bruised easily. 10NYCRR 415.4

Based on observation, interview and record review conducted during a recertification survey from 1/2/24 to 1/11/24, the facility did not ensure residents received the necessary assistance for bathing to maintain personal hygiene for 2 of 4 residents (Residents #12 and #88), reviewed for activities of daily living (ADLs). Specifically, Resident #12 and #88 did not receive twice weekly showers as scheduled. Findings include: The facility policy dated 3/1/2017 for Bathing /Showering documented showering and bathing were to promote cleanliness, provide comfort to the resident and to observe the condition of the skin. 1) Resident # 12 was admitted to the facility on [DATE] with diagnoses including Hypertension, Diabetes and Bipolar Disorder. The residents Minimum Data Set (an assessment tool) dated 12/12/23, documented the resident was cognitively intact, had moderately impaired vision, and a shower/bath was very important to them. The assessment documented the resident needed partial/moderate assistance with bathing. Rejection of care was not identified on the assessment. During an interview on 01/03/24 at 11:39 AM, Resident #12 stated that they received only one shower a week and sometimes none at all. The resident stated they asked for a second shower last week and was told it could not be done because there were only two Certified Nurse Aides on duty. The Activities of Daily Living Care Plan initiated 4/16/2019, and updated 12/14/23, documented the resident required moderate assistance with bathing. Goals included the resident would maintain optimal level of self-care and will bathe at optimal level. Interventions included assisting the resident with washing body parts they could not reach and encouraging performance of self-care tasks to maximum independence for bathing. Further review of the Comprehensive Care Plan revealed no evidence the resident refused showers. The S1 Unit Shower Schedule revealed the resident was scheduled for showers on Tuesdays and Fridays on the day shift. Review of the Resident Certified Nurse Aide (CNA) Documentation History Detail from 10/21/23-1/5/24, revealed: - no shower documentation was available for 10/1/23-10/21/23 and the Unit Manager was not able to find when requested. - no showers were documented the weeks of 10/22/23-10/28/23, 10/29/23-11/4/23, 11/12/23-11/18/23, 11/26/23-12/2/23, 12/3/23-12/9/23, 12/10/23-12/16/23. - one shower was documented each week for the weeks of 11/5/23-11/11/23, 12/17-12/23/23, 12/24/23-12/30/23, and 12/31/23-1/5/24. - two showers were documented for the week of 11/19/23-11/25/23. - there was no documented evidence the resident refused any shower. The electronic medical record for shower documentation was reviewed and certified nurse aides documented the level of care the resident needed with a number and their initial. It could not be determined if the certified nurse aide provided a shower or bath. During an interview with Staff #18, Certified Nurse Aide on 01/05/24 at 11:38 AM they stated showers were supposed to be given twice a week but it did not always happen because of staffing. The Certified Nurse Aide documented the date of the shower and their initials on the Shower sheet. During an interview with Staff #20, Licensed Practical Nurse on 1/9/24 at 12:48 PM they stated sometimes showers were not done because they were short staffed and tried to give a good bed bath but it was not optimal. During an interview with Staff #16, Licensed Practical Nurse Unit Manager, on 1/11/24 09:10 AM they stated they could not find and shower log for the first three weeks of October and knew the shower logs through January did not look good. Staff #16 stated there were many missing dates for all of the residents which meant they were not getting their showers as scheduled. 2) Resident #88 was admitted with diagnoses including but not limited to vascular dementia, hypothyroidism, and muscle weakness. Review of the Comprehensive Minimum Data Set, dated dated dated [DATE], documented Resident #88 had moderately impaired cognition, and required extensive assist with toileting, transfers, and bathing. The Activities of Daily Living (ADL) care plan notes changes to resident participation in bathing activities. On 6/8/23 Resident #88 was noted to need physical help in part of bathing activity with a 1 person assist. On 8/18/23 care plan update it is noted Resident #88 required physical help in part of bathing activity with a 2 person assist. During an interview conducted on 01/10/24 at 03:31 PM with Resident #88's family member, they stated that the family had visited resident and the resident was not clean. The stated the resident smelled and was clearly not bathed. During review of records conducted on 01/11/24 review of bathing records from 7/1/23 through 10/31/23 show that resident was bathed or showered inconsistently. There were many dates bathing was not documented. The following dates were not documented for bathing: 7/12/23 through 7/24/23, 8/4/23 through 8/7/23, 8/10/23 through 8/15/23, 8/19/23 through 8/24/23, 8/31/23 through 9/13/23, 9/16/23 through 9/17/23, 9/24/23 through 9/25/23, 9/27/23 through 9/28/23. During an interview conducted on 01/11/24 at 11:05 AM with Staff #6 stated that documentation for bathing and personal hygiene was in the computer for each shift. They also stated staff documented bathing or personal hygiene activities on another sheet that was stored in administration when completed. During an interview conducted on 01/11/24 at 12:53 PM, Staff #25 and Staff #27 stated that certified nurse aides were to document in the computer. Stated that the computer system has been in place over a year. Stated that if a task was not done or a resident refused, they were to mark refusal of care in the computer. The stated that if a task was not completed, the Certified Nurse Aide was to notify the nurse, and the nurse would try to talk with the resident. The nurse would then document about refusal of care in their notes. Review of additional documentation provided on 1/11/24 did not provide evidence the resident was bathed or assisted with bathing on the dates listed above. 415.12(a)(3) 48822

Based on observations, interviews, and record review during a recertification survey 1/02/2024-1/11/2024, the facility did not ensure residents had the right to a dignified existence for 6 residents (#38, #69. #80, #139 #82 and #98) observed during dining observation. Specifically, Residents #38, #69 and #80, were observed being fed by staff while staff were standing over the residents, Resident # 139 was heard being called a feeder by staff and Residents #82 and #98 had blood drawn in the common diningroom/dayroom while in the presence of other residents. The findings are: The facility policy for Assistance with Meals dated 2/1/17 documented residents who cannot feed themselves will be fed with attention to safety comfort and dignity, for example, not standing over residents while assisting them with meals. The facility's policy titled residents rights dated 2//5/21 documented residents have a right to a dignified experience and be treated with respect, kindness, and dignity. 1. Resident #38 had diagnoses including but not limited to Alzheimer's Disease, Hypertension, and Dementia. The 10/23/23 Minimum Data Set (MDS, an assessment tool) documented the resident was severely impaired and totally dependent on staff for eating. The 7/6/21 nursing care plan titled Activities of Daily Living documented the resident required total assist for meals and was to be fed by staff. During an observation on 1/8/24 at 8:32 AM Staff #17 (Licensed Practical Nurse) was observed standing over Resident #38 feeding them cereal. Staff #17 did not make eye contact or speak to the resident but instead watched television. During an interview on 1/8/24 at 08:32 AM Staff #17 stated they usually sit while feeding residents but didn't today and remarked it was better to feed the resident while standing because they could see the resident better. During an interview on 1/8/24 at 12:12PM the Director of Nursing stated staff must sit while feeding residents and should also maintain good eye contact. 2. Resident #139 was admitted with diagnoses including but not limited to Hypertension, Iron Deficiency Anemia, and Type 2 Diabetes. The 10/31/2023 Minimum Data Set (MDS) assessment documented the resident's cognition was severely impaired. During an observation on 01/02/24 at 12:15 PM, Staff #7 was observed feeding Resident #139 and was heard multiple times addressing Resident #139 as a feeder. Staff #7 stated that all residents that need assistance with meals were called feeders. During an interview on 01/09/24 at 10:30 AM, the Director of Nursing stated that residents should never be addressed as feeders and that staff are trained and in serviced on the dignity of the residents. 3. Resident # 82 was admitted with Unspecified Dementia, Major Depressive Disorder, and Adult Failure to Thrive. The Minimum Data Set (MDS-an assessment tool) dated 8/7/23 documented the resident was cognitively intact. During an observation on 01/02/24 at 12:13 PM Consultant #2 (Phlebotomist) entered the dining room, identified Resident #82 by calling out their name. Resident #82 who was eating their lunch, responded, put their fork down and stopped eating. Consultant #2 then proceeded to apply a tourniquet to the residents left lower arm, and drew the residents blood at the table. During the observation multiple other residents were present in the dining room at surrounding tables. During an interview on 01/03/24 at 01:50 PM the Director of Nursing, stated that Consultant #2 was contracted through an outside laboratory and privacy should be utilized for lab draws. The Director of Nursing stated lab draws should not be done in front of other residents. During an interview on 01/11/24 at 09:00 AM Staff #28 (Registered Nurse Unit Manager) stated it was expected that staff would redirect the consultant if this were observed. The consultant would be told not to draw the resident's blood while they were eating, and that to provide privacy, they were to take the resident to their room to draw their blood. NYCRR 415.3 (d)(1)(i) 48847 49372

F657 Based on record review and interview conducted during the recertification survey, from 1/2/24 through 1/11/24, the facility did not ensure that the comprehensive care plan was reviewed and revised in timely manner for 1 of 3 residents (Resident #69), reviewed for care planning revision. Specifically, Resident #69's care plan was not updated as planned to reflect the need of a 2 person assist for personal cares after a fall. Findings include: Resident #69 was admitted to the facility with diagnoses and conditions including but not limited to Unspecified Dementia, Cerebral infarction and Osteoarthritis. Review of the care plan Activities of Daily Living (ADL) dated 11/21/23 documented bathing provide 1 person assist with personal hygiene/bathing to complete tasks. Review of Accident/Incident report dated 10/9/23 documented, resident rolled off the bed when while receiving personal care, being assisted by 1 staff. The recommendation was for the resident to be assisted by 2 staff, for personal cares, for safety intervention. Review of the progress note dated 10/10/23 documented to continue assistance by 2 staff members for personal care. Further review of the care plan revealed it was not updated to refect the change to a 2 person assist. During an interview on 01/11/24 at 09:00 AM Staff #28 (Registered Nurse Unit Manager) stated at that time of the incident (10/9/23), the resident was a 1 person assist for personal cares and the did not update the care plan. 415.11 (c)(2)(i-iii)

Based on observations, interviews and and record reviews conducted during an abbreviated survey, the facility failed to ensure that there were systems in place to adequately monitor and supervise residents who were identified as being at-risk for elopement. The facility failed to ensure that staff responded to door alarams and that staff were aware of interventions to prevent elopment, such as knowing the whereabouts of at-risk residents at all times. This was evident for 6 of 6 residents that were identifed as at-risk for elopment. Specifically, a resident (Resident #1) was able to exit the facility undetected and was found by the police near a four-lane highway. The facility was not aware the resident was missing until notified by the police. This resulted in the potential for serious harm to resident health and safety that is Immediate Jeopardy and Substandard Quality of Care for all 6 residents at-risk for elopment. Complaint ID Number: NY 777 The findings are: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident resided on an unlocked, unalarmed unit where she was independently mobile in ambulation without safety awareness or direction throughout the 2nd floor unit. According to the Minimum Data Set (a resident assessment tool) dated 08/31/2010, the resident was assessed as having short term memory loss and modified independence in cognitive skills for daily decision-making. A review was conducted of Resident #1's care plan for elopement. Included among the interventions are: (1) photo at front desk; (2) staff will be aware of resident whereabouts at all times; and (3) if resident is noted at an exit door, assist resident to a supervised area. None of these interventions were reflected in the care guide sheets provided to the nursing staff. An interview was conducted with the Unit Manager (UM) on 01/03/2011 at 1:40 PM. She stated that the resident scored a 22 on her mini mental (a test designed to assess cognitive function in the elderly). According to the results of that assessment, the UM stated that the resident lacked impulse control; was very confused at times; was always walking in the hallways and in and out of resident rooms; and that the resident often stated she wanted to go home or outside.A social history report, dated 08/31/2010 and signed by a social worker, documented that the resident is a wanderer and has a history of wandering. It further documents the resident's desire to go home and indicates that the resident is at risk for elopement because she is ambulatory and able to walk unassisted. A review of the nurse's note dated 11/20/2010 revealed that the resident was seen by a Certified Nurse Aide (CNA) walking outside the facility at 4:30 PM. The CNA responded to the resident and returned her to the facility. Resident condition was stable. An Accident/Incident Report for the elopement of 11/20/2010 was reviewed on 01/03/2011. It indicates that the resident was last seen by a nurse's aide at 3:55 PM. The resident was found outside at 4:30 PM. The Unit Manager (UM) was interviewed on 01/04/2011 at 11:45 AM. The UM signed the incident report that was completed for the elopement on 11/20/2010. She stated she never formally submitted the report to the facility's administration because it got buried under other papers on the unit and she forgot about it. She further stated that she did not consider the incident on 11/20/2010 an elopement because a CNA found the resident outside and brought her back into the facility unharmed. She stated that "most likely" facility staff discussed this incident during the morning report. The Unit Manager also said she did not recall making any changes to the resident's care plan after that incident. A review of Resident #1's care plan revealed that no new interventions were developed or implemented following the resident's multiple verbalizations of intent to leave the facility or her elopement from the facility on 11/20/2010. A review of the comprehensive care plan (CCP) initiated on 08/31/2010 revealed a social worker note dated 12/01/2010, documenting, "no attempts to elope this quarter, resident continues to ambulate independently and will remain an elopement risk." On 12/14/2010 the CCP states, "resident presented as wandering on the unit, social worker provided 1:1 with resident." An interview was conducted with the social worker on 01/04/2011 at 11:45 AM. The social worker stated that she did not recall the elopement of 11/20/2010. She stated that she must have forgotten about it and made an error when documenting the CCP on 12/01/2010 that there "were no attempts to elope this quarter..." A review of the facility investigation dated 12/31/2010 revealed that on 12/30/2010 at approximately 8:45 PM the facility was notified by the Fishkill Police Department that Resident #1 was found a short distance from the facility and was being treated by emergency medical staff. The investigation further reveals that Resident #1 was returned to the facility by ambulance at approximately 9:45 PM with facial bruising and abrasions. The facility investigation concluded that Resident #1 exited through the front entrance of the facility. This conclusion was based largely on the statement of a Certified Nurse Aide (CNA #2), who said she thought she saw the resident exit through the front door because she recognized the coat the resident was wearing when the police returned her to the facility. A review of a Police Report dated 12/30/2010 revealed that the Police Department received a 911 call at 8:26 PM that a person was down on the side of the road. Police arrived at 8:46 PM and observed the resident sitting in the snow on the shoulder of a four-lane highway approximately one-quarter mile from the facility. During an interview with CNA #2 on 01/03/2011 at 3:00 PM, she stated that at 8:30 PM on 12/30/2010 she observed a woman going out the front door. She stated that she was sure of the time because her break was over at 8:30 PM. She further stated, "I can't be 100% sure who it was leaving because I never saw her face and I don't know the resident." She then stated, "I thought it was her because when the ambulance brought the resident back I noticed the coat she had on looked like the one I noticed earlier." The CNA also stated that, prior to this incident, she did not know how to identify residents who are at risk for elopement and believed that all wandering residents were on the facility's locked unit. A review was conducted of the facility's policy and procedure for "Missing Resident" and the policy and procedure for "Resident Head Count." These policies and procedures document that outside exit doors are to be secured and closed at all times. They further state that any facility staff person who interferes with the security of these doors places residents at "dangerous risk." The policies and procedures do not identify who is responsible for responding to alarms at egress doors and do not give any guidance as to what to do or where to look when an alarm is sounding. The policies and procedures also do not address the key pad code that is found on egress doors, the frequency with which these codes are changed and how the code is communicated to staff and family members. A surveyor observed doors with key pad locks and found that family members of three (3) different residents, as well as numerous facilty staff, were using these key pads to gain access to stairwells. A family member was interviewed on 01/04/2011 at 2:00 PM. The family member stated that the key pad code has always been the same: the last four (4) digits of the facility's telephone number. When the family member revealed the key pad code to the surveyor, he never asked who the surveyor was or why the surveyor needed the code. He simply provided the code to the surveyor without hesitation. An interview was conducted with the Director of Nursing (DON) at 12:30 PM on 01/03/2011. The DON stated that the key pad lock located at the facility's main entrance was not activated on 12/30/2010 and the door was not locked after the receptionist left her post at approximately 7:30 PM. She further stated that there is no staff that monitors the front entrance after the receptionist leaves the facility each evening. The DON stated that the resident was last seen by the assigned CNA at approximately 7:50 PM and was observed by CNA #2 (from another unit) at approximately 8:30 PM, who mistook the resident for a visitor. The DON further stated that the social worker is responsible for completing the elopement/wandering risk assessment and elopement care plan for all residents upon their admission to the facility, on a quarterly basis and/or as needed. The DON stated that she was not aware that the resident had made a previous attempt to elope from the facility on 11/20/2010 and had been found outside by a CNA. Another interview was conducted with the Director of Nursing (DON) on 01/03/2011 at 4:20 PM. The DON stated that most residents who are at risk for elopement reside in the facility's locked dementia unit. The DON stated that Resident #1 was not placed in the locked unit because she was high functioning and alert and oriented at all times. She further stated that the resident is independent in ambulation and the staff felt the resident would not be a good fit on the locked unit. During a brief interview on 01/04/2011, the DON added that she never saw the incident report for the 11/20/2010 elopement because it was buried under other paperwork on the unit and was never sent to her. An interview was conducted with the receptionist on 01/04/2011 at 9:00 AM. She stated that it was not the facility's policy to lock the front door when the reception area was closed because family and staff are always going in and out of the front entrance. She stated that the policy has now changed since the incident with Resident #1 and she has been instructed to lock the door at the end of her shift. A tour of the facility was conducted on 01/03/2011 at 3:30 PM with the Administrator, the DON and the Maintenance Supervisor. During the tour it was observed that on three (3) occasions, at three (3) different locations in the facility, direct care staff failed to respond to door alarms when the doors were held opened and the alarm was sounding for up to five (5) minutes each time. On 01/04/2011 at approximately 9:30 AM an observation was made on the first floor of the facility in the center of the building. The facility has an unalarmed elevator that is accessible to all residents that are not in the facility's locked dementia unit, including those residents at risk for elopement. Approximately ten (10) feet from the elevator is an unlocked door. This unlocked door leads to a basement stairwell. At the foot of the stairwell is an alarmed egress door to an outside area of the facility. This alarmed door in the basement was held open for approximately five (5) minutes with no response from staff. The alarm was not sounding because it had been disarmed. On the 1st floor South unit, a panel light was blinking, indicating that a door was open. The Maintenance Supervisor was interviewed on 01/04/2011 shortly after this observation. He stated that the door in the basement was disarmed because staff go in and out the door all day. The Maintenance Supervisor also stated that he was aware that staff were not responding to door alarms when they sounded. After the alarm was reactivated for this door, a Licensed Practical Nurse (LPN #1) stated, "I don't know who is responsible for that alarm, I don't even know which door that is," referring to the light on the electronic panel for the 1st floor South unit. The nurse explained that the light on the panel does not correspond to any specific door. Eight (8) CNAs were interviewed on 01/03/2011 and 01/04/2011. They were unable to identify residents who are at risk for elopement. They stated that they were not aware that they were required to know the whereabouts of all residents at risk for elopement, at all times. They further stated they would not know what to do if they heard an alarm ringing and added that if the alarms rang for prolonged periods of time they would ask the nurse about it. All eight CNAs stated that they could not determine which facility door was open by looking at the electronic panel on the unit. Four (4) of four (4) Licensed Practical Nurses (LPNs) were interviewed. LPN #1 was interviewed on 01/03/2011 at 1:15 PM; LPN #2 was interviewed on 01/03/2011 at 1:30 PM; LPN #3 was interviewed on 01/03/2011 at 3:30 PM; and LPN #4 was interviewed on 01/03/2011 at 3:50 PM and again on 01/04/2011 at 11:10 AM. All four nurses stated they would probably do nothing if an alarm was sounding because facility staff go in and out of the alarmed doors all day and trigger the alarms all the time. They further stated that they could not identify which door was alarming by looking at the electronic panel on the unit. Two of the four LPNs stated they are only responsible for four doors on their unit. Two (2) Registered Nurses (RNs) were interviewed. RN #1 was interviewed on 01/03/2011 at 1:40 PM and again on 01/04/2011 at 10:00 AM and RN #2 was interviewed on 01/03/2011 at 2:45 PM. They both stated that they did not know how to read the lights on the panel to determine which alarms were ringing. They stated they would not respond to the alarms because they could not identify which door was opening by looking at the light panel. Both RNs stated that they are responsible for the two (2) day room egress doors and the egress doors at the end of the halls. During an observation on 01/04/2011 two (2) surveyors exited an unalarmed, unlocked 1st floor door in the center of building which leads to the basement. They went through another unlocked, unalarmed door which leads to an alarmed egress door. The surveyors kept this egress door open for five (5) minutes. The alarm rang the entire time the door was held open. No one from the facility's staff responded to the alarming door. LPN #1 was interviewed shortly thereafter and she stated that she thought that the alarm was sounding because maintenance staff were repairing the door. An interview was conducted with the facility's Administrator on 01/04/2011 at approximately 4:00 PM. The Administrator stated that he was not aware, prior to the most recent elopement of Resident #1, that alarmed egress doors were not being monitored and that staff were not responding to door alarms. 415.12(h)(1)(2)

A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Based on observations, interviews and and record reviews conducted during an abbreviated survey, the Admministrator failed to ensure that there were systems in place to adequately monitor and supervise residents who were identified as being at-risk for elopement. The Administrator failed to ensure that staff responded to door alarams and that staff were aware of interventions to prevent elopment, such as knowing the whereabouts of at-risk residents at all times. This was evident for 6 of 6 residents that were identifed as at-risk for elopment. Specifically, a resident (Resident #1) was able to exit the facility undetected and was found by the police near a four-lane highway. The facility was not aware the resident was missing until notified by the police. This resulted in the potential for serious harm to resident health and safety that is Immediate Jeopardy for residents at-risk for elopment who are not on the locked dementia unit. Refer, also, to F 323 (Accidents and Supervision). Complaint ID Number: NY 777 The findings are: A review of a facility investigation dated 12/31/2010 revealed that on 12/30/2010 at approximately 8:45 PM the facility was notified by the Fishkill Police Department that they found Resident #1 a quarter-mile away from the facility in response to a 911 call. The resident was found in the snow on the shoulder of a four-lane highway. The resident was returned to the facility by ambulance at approximately 9:45 PM with facial bruising and abrasions. The facility investigation concluded that Resident #1 exited through the front entrance of the facility. The facility was unaware the resident was missing until notified by the police. A review was conducted of Resident #1's care plan for elopement. Included among the interventions are: (1) photo at front desk; (2) staff will be aware of resident whereabouts at all times; and (3) if resident is noted at an exit door, assist resident to a supervised area. None of these interventions were reflected in the care guide sheets provided to the nursing staff. No new interventions were developed or implemented following the resident's multiple verbalizations of intent to leave the facility or after a prior elopement from the facility on 11/20/2010. During the survey it was determined that the facility has no system in place to monitor residents at risk for elopement who did not reside on the locked dementia unit. Interviews of facility staff revealed they did not know how to identify residents who are at risk for elopement and did not know what to do if they heard a door alarm sounding. Direct care staff did not know that they had to monitor residents who were at risk for elopement. They also could not identify which doors were alarming by looking at an electronic panel that activates a light when a door is opened. Observations also revealed that facility staff consistently failed to respond to door alarms. This was demonstrated on several occasions when surveyors held the doors open and the alarms sounded for five (5) minutes with no response from the staff. Some of these observations were conducted in the presence of the Administrator, the Director of Nursing and the Maintenance Supervisor. Follow-up interviews with licensed nursing staff revealed that they did not respond to the alarms because staff and family members were always using the alarmed doors to enter and exit the facility and the alarms were always sounding. An interview was conducted with the facility's Administrator on 01/04/2011 at approximately 4:00 PM. The Administrator stated that he was not aware, prior to the most recent elopement of Resident #1, that alarmed egress doors were not being monitored and that staff were not responding to door alarms. 415.26