Every finding on record at Gold Crest Care Center

Based on observation, record review, and interviews the facility failed to maintain a resident's right to a safe, clean, comfortable and homelike environment. This was evident for one (1) (Unit 1) of four (4) units observed. Specifically, residents' rooms in Unit 1 were noted with worn furniture, rusted bed frames, holes in the walls, windows in disrepair, peeled wallpaper, mismatched paint, and electrical outlets that were not secured to the wall.The findings include but are not limited to:The facility's environmental policy with a reviewed date of 07/2021 stated that the facility maintains resident rooms, common areas, furnishings, fixtures, and equipment in clean, safe, and operable condition through routine housekeeping, maintenance practices, and ongoing staff awareness during daily operations.During observation from 01/28/2026 to 02/05/2026, the following were observed in Unit 1:1. In room [ROOM NUMBER], windows have black substance around them, wood around the window was in disrepair, and the electrical outlet located under the window was hanging off the wall.2. Two (2) holes were observed on the wall, in the unit hallway, located next to room [ROOM NUMBER].3. room [ROOM NUMBER] had a light fixture with a red colored piece of clothing hanging over it. The bed head and foot board were chipped, the metal bed frame had brown stains, and the wallpaper was peeling off the wall.4. room [ROOM NUMBER] had two (2) holes in the wall above the television. The room had mismatched paint, and the wood around the window was in disrepair.5. The unit dayroom had four (4) windows in disrepair, including missing shades, chipped wood, boarder around the window is missing and disrepair.6. room [ROOM NUMBER] had black and clear tape surrounding the air conditioning unit.7. The dayroom located by the entrance door had exposed grey colored wire coming out of the ceiling.8. room [ROOM NUMBER]'s bedside table was dirty and had mismatched white and grey colors.9. room [ROOM NUMBER] had a broken headboard, worn furniture.10. room [ROOM NUMBER]'s window blinds were broken, the closet door was off the hinge, furniture worn, and the bedside table had rust.On 02/05/2026 at 10:00 AM, Resident #52 stated the window was covered with tape to keep the air out.On 02/05/2026 at 10:20 AM, Housekeeper #1 was interviewed and stated their job is to make sure that the unit is clean. They stated that they report to the Maintenance Department if repairs are needed in the unit and also documents the repairs needed in the maintenance logbook.On 02/05/2026 at 10:28 AM, the Housekeeping Supervisor was interviewed and stated they oversee the housekeepers and the cleanliness of the unit. They stated that the nurses are responsible for letting the maintenance director know of repairs needed in the unit by writing them in the maintenance logbook. They stated it is not their job to report or say anything about the environment. On 02/05/2026 at 10:45 AM, the Director of Maintenance was interviewed and stated they check the maintenance logbook every morning to see if there are any issues that need to be addressed, and they do monthly rounds to see if there are any needed repairs. As for the observations made, they stated a contractor is needed to fix the windows and that the Administrator was aware of it. They stated the air conditioning unit had a tape around it to keep the cold air out. They stated that the administration is aware of the needed repairs in the building.On 02/05/2026 at 12:21 PM, the Administrator was interviewed and stated they have a plan to renovate Unit 1. They stated they were not aware of the windows in the dayroom that needed repair.10 NYCRR 415.5(h)(2)

Based on observation, record review, and interviews, the facility failed to ensure that each resident's right to privacy and confidentiality of their personal and medical records was maintained for one (1) (Resident #48) of two (2) residents investigated for Privacy, out of 35 total sample residents. Specifically, the names, room numbers, and dietary orders of Resident #48 and 12 other residents were posted on the 3rd floor bulletin board in an area that was visible to other residents and visitors on the unit.The findings include but are not limited to:The facility policy titled Dignity and Privacy last reviewed 10/2025 documented that staff shall maintain an environment in which confidential clinical information is protected.On 01/28/2026 at 11:26 AM and 01/29/2026 at 10:35 AM, observations were made of the 3rd floor bulletin board located in the hallway outside of the dining room. The bulletin board contained a poster titled Aspiration Precaution List Updated 12/15/2025 which documented Resident #48's first and last name, room number, and that they required a Ground/Nectar Liquids diet. The Aspiration Precaution list also contained the name, room number, and diet of 12 other residents. None of these residents, including Resident #48, resided on the 3rd floor. The bulletin board also contained posters for the Ombudsman's contact information in English and Spanish, the weekly meal menu, a list of meal times per floor, the recreation activity calendar, and a poster titled Notice to Residents related to state survey results.Resident #48 had diagnoses including Cerebral Infarction, Hemiplegia and Hemiparesis, and Malnutrition.The Minimum Data Set assessment dated [DATE] documented that Resident #48 had intact cognition and was on a mechanically altered and therapeutic diet.On 01/29/2026 at 10:40 AM, Registered Nurse #2 was interviewed and stated that the Aspiration Precaution List is always posted on the bulletin board and is there so that staff know who is at risk of aspirating during meals. Registered Nurse #2 stated that they did not know if publicly posting the resident's name, room number, and dietary order was a privacy concern.On 02/02/2026 at 11:38 AM, Registered Nurse #1 was interviewed and stated that they are the Nurse Manager for the 3rd floor. They stated that the Aspiration Precaution List is posted on that bulletin board to ensure that staff know which residents are at risk for aspiration. Registered Nurse #1 stated that the list was hung on the bulletin board by the Speech Language Pathologist and that they did not believe that posting the information on the publicly facing bulletin board was a privacy concern.On 02/05/2026 at 12:00 PM, the Speech Language Pathologist was interviewed and stated that they are responsible for creating the Aspiration Precaution List, which is created to ensure that anyone who works with the residents identified as being at risk for aspiration were aware of their status. The Speech Language Pathologist stated that whenever they update the list, they physically hand it to each floor's nurse manager or leave it in the floor manager's mailbox. The Speech Language Pathologist stated that they do not personally post the lists on the unit or decide where the lists are posted.On 02/04/2026 at 11:36 AM, the Director of Nursing was interviewed and stated that the Aspiration Precaution List should have been posted behind the nurse's station to respect resident privacy while also ensuring that staff were aware of which residents were at risk of aspirating during meals. The Director of Nursing stated that the list should not have been posted on the 3rd floor bulletin board.10 NYCRR 413.3(e)(1)(ii)

Based on record review and interviews, the facility failed to ensure that resident or resident representatives were included in all aspect of care planning. This was evident in one (1) (Resident #70) of three (3) residents reviewed for care planning out of 35 total sampled residents. Specifically, there was no evidence that Resident #70 or their representative was invited to care plan meetings. The findings are:The facility's policy and procedure titled Care Plan with a reviewed date of 02/2025 documented that the interdisciplinary team will initiate, implement and update the resident's plan of care on admission, quarterly, and as needed to meet the individual needs of each resident. It also documented the resident and family/designated representative will be involved in the care planning process.Resident #70 was admitted to the facility with diagnoses of Hypertensive heart disease with heart failure, Disease of upper respiratory tract, and Chronic pain syndrome.The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #70 was cognitively intact. The Quarterly Minimum Data Set assessment also documented Resident #70, and their designated representative participated in the assessment. On 01/28/2026 at 11:03 AM, Resident #70 was interviewed and stated they made decisions for themselves. Resident #70 also stated they could not recall when was last time they attended a care plan meeting; and they cannot recall when they were last invited to attend a care plan meeting. The Care Plan Meeting schedule for 2025 documented Resident #70 had an annual care plan meeting on 04/09/2025, significant change care plan meeting on 06/18/2025, and quarterly care plan meetings on 01/22/2025, 09/17/2025 and 11/19/2025.The Care Conference Report documented Resident #70 declined to participate in the annual care plan meeting. However, there was no documented evidence in the medical record that Resident #70 and/or their designated representative were invited to participate or attend the care plan meetings. On 02/02/2026 at 12:55 PM, the Director of Social Services was interviewed and stated that the social worker is responsible for inviting residents and/or their representatives to care plan meetings. The Director of Social Services reviewed Resident #70's medical records and had no explanation why Resident #70 was not consistently invited to care plan meetings in 2025. On 02/04/2026 at 1:55 PM, the Administrator was interviewed and stated that residents and/or their representatives should be invited to all care plan meetings including admission, significant change, annual, quarterly, and as needed. The Administrator also stated they were not aware residents and/or their representative were not consistently invited to care plan meetings. 10 NYCRR 415.11(c)(2)(i-iii)

Based on observation, record review, and interviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. Specifically, the staff bathroom on the first floor in the dayroom had discolored tiles and cracked ceiling. The findings are:The facility's environmental policy with a reviewed date of 07/2021 stated that the facility maintains resident rooms, common areas, furnishings, fixtures, and equipment in clean, safe, and operable condition through routine housekeeping, maintenance practices, and ongoing staff awareness during daily operations. During observation conducted from 01/28/2026 to 02/05/2026, the staff bathroom on the first floor in the day room had minimal lighting, there was a cracked ceiling tile, ceiling tiles had brown discoloration, and a tile that seems it's about to fall off. On 02/05/2026 at 10:45 AM, the Director of Maintenance was interviewed and stated they do monthly rounds to see if there are any needed repairs. They stated that the administration is aware of the needed repairs in the building. 10 NYCRR 415.29

Based on observation, record review, and interviews, the facility failed to ensure that the binding arbitration agreement provides for the selection of a venue that is convenient to both parties. This was evident for three (3) (Residents #3, #83, and #174) of three (3) residents reviewed for arbitration. The findings are:The facility's policy titled Arbitration Agreement dated June 2019 documented the facility offered a voluntary arbitration agreement in accordance with federal regulations.The Voluntary Agreement for Arbitration signed by Residents #3, #83, and #174 were reviewed. The Binding Arbitration Agreement documented that an arbitration hearing arising under the Arbitration Agreement shall be held in the county where the facility is located.On 02/04/2026 at 3:42 PM, Social Worker #1 was interviewed and stated arbitration agreement was part of admission package and that they are responsible for explaining the content of the voluntary arbitration agreement to residents and/or their representatives. Social Worker #1 stated they informed the residents and/or their representatives that arbitration hearing had to be held in the Bronx, which is the county where the facility is located, as stated in the arbitration agreement. On 02/04/2026 at 3:48 PM, the Director of Social Services was interviewed and confirmed the arbitration hearing had to take place in Bronx County where the facility was located according to the arbitration agreement. The Director of Social Services also stated the arbitration agreement was provided to them by the facility's corporation. The Director of Social Services further stated they were not aware the regulation required the binding arbitration agreement to provide for the selection of a venue that is convenient to both parties.On 02/04/2026 at 4:21 PM, the Administrator was interviewed and stated the arbitration agreement was drafted by the lawyer of the facility. The Administrator also stated they were not aware the arbitration agreement was not compliant with the regulation. 10 NYCRR 415.30

Based on record review and interview conducted during the Recertification Survey from 09/26/2024 to 10/03/2024, the facility did not ensure that a comprehensive care plan was developed and implemented to meet each resident's needs. This was evident in 2 (Resident #228 and #17) out of 36 sampled residents. Specifically, 1.) Resident #228, who had a diagnosis of osteomyelitis, had no comprehensive care plan developed to address the presence of infection. 2.) Resident #17, who had a diagnosis of osteomyelitis, had no comprehensive care plan developed to address the presence of infection. The findings are: The facility policy titled Care Plans - Comprehensive with a last revision date of July 2024 documented that an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Each resident's comprehensive care plan is designed to incorporate identified problem areas , reflect treatment goals, and reflect currently recognized standards of practice for problem areas and condition. 1.) Resident #228 was admitted to the facility with diagnoses that include Acute Osteomyelitis of Left Ankle and Foot and Diabetes Mellitus with Diabetic Chronic Kidney Disease. The Admission Minimum Data Set assessment dated [DATE] documented that Resident #228's cognition was intact. The admission nurse's progress notes dated 09/10/2024 at 9:03 PM documented that Resident #228 was admitted from the hospital. The Resident had a peripherally inserted central catheter and continues with intravenous antibiotic until 10/13/2024 due to Osteomyelitis to lower extremity. A review of Resident #228's physician's order dated 09/11/2024 documented to administer Ceftriaxone intravenous piggyback 2 grams / 50 milliliters daily at 10:00 AM and Doxycycline 100 milligram capsule, 1 capsule by mouth every twelve hours for Osteomyelitis. A nurse's progress note dated 09/25/2024 at 8:27 PM documented that Resident #228 continues on intravenous antibiotic Ceftriaxone and oral antibiotic Doxycycline for osteomyelitis. A review of Resident #228's comprehensive care plan revealed that a care plan was not developed to address the Resident's diagnosis of osteomyelitis. On 10/02/2024 at 11:49 AM, Registered Nurse #1, who was the Nurse Manager, was interviewed and stated that the admission nurse was responsible for initiating the comprehensive care plan and might have missed the care plan for osteomyelitis. Registered Nurse #1 stated they should have checked the comprehensive care plans to make sure that it was initiated and implemented. On 10/02/2024 at 3:35 PM, Registered Nurse #2, who was the Nursing Supervisor, was interviewed and stated that they admitted Resident #228 and developed the initial care plans. They stated that Resident #228 was admitted with osteomyelitis and was receiving antibiotic through the peripherally inserted catheter. They stated they assumed that the Nurse Manager would go over the care plans to ensure that none was missed. Registered Nurse #2 stated it was an oversight. On 10/03/2024 at 10:44 AM, the Director of Nursing was interviewed and stated that they do not know why the care plans for use of antibiotics and diagnosis of osteomyelitis were missed. The Director of Nursing stated it is the nurse manager's responsibility for ensuring that comprehensive care plans are in place. 48876 2.) Resident #17 was admitted to the facility with diagnoses that include Osteomyelitis of the Vertebra and Polyarthritis. The Admission Minimum Data Set assessment dated [DATE] documented that Resident #17's cognition was intact. A nurse's progress notes dated 09/25/2024 at 1:14 PM documented that Resident #17 continues on Meropenem until 09/29/2024 due to osteomyelitis to lumbar spine. A review of Resident #17's comprehensive care plan revealed that a care plan was not developed to address the Resident's diagnosis of osteomyelitis. On 09/30/2024 at 4:11 PM, the Assistant Director of Nursing was interviewed and stated that Resident #17's care plan on infection was overlooked. On 10/03/2024 at 2:15 PM, the Director of Nursing was interviewed and stated that it is the Registered Nurse Supervisor's responsibility to develop the care plans. They stated that it was an oversight that the care plan for infection was not developed for Resident #17. 10 NYCRR 415.11(c)(1)

Based on observation, interview, and record review conducted during the Recertification Survey from 09/26/2024 to 10/03/2024, the facility did not ensure that a resident was free from physical restraints for purposes of discipline or convenience and that are not required to treat the resident's medical symptom. This was evident in 1 (Resident #60) of 1 resident reviewed for physical restraints out of 36 total sampled residents. Specifically, Resident #60 was observed, on multiple occasions, in bed with upper quarter bed side rails raised on both sides. The findings are: The facility policy titled Physical Restraints with a revision date of 04/2024 documented physical restraint is defined as any manual method, physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, and which restricts the freedom of movement or normal access to one's body. The policy documented that bed rails are considered physical restraints and that the use of restraint must be documented in the medical records, including reason for each continued use or discontinuance. Resident #60 had diagnoses of Non-Alzheimer's Dementia, Hemiplegia and Hemiparesis following Non-Traumatic Intra-cerebral Hemorrhage affecting the right dominant side. The Quarterly Minimum Data Set, dated dated dated [DATE] documented Resident #60 was severely cognitively impaired, dependent with transfers, and required maximal assistance to roll left and right. The Minimum Data Set documented that physical restraints were not used. On 09/26/2024 at 12:09 PM, 09/30/2024 at 12:24 PM, and on 10/02/2024 at 10:12 AM, Resident #60 was observed resting in bed with upper quarter bed side rails raised on both sides. A Siderail Assessment Tool completed by the Occupational Therapist dated 07/23/2024 documented that Resident #60 was unable to get out of bed independently, was unable to use the side rail safely, there was no history of falling out of bed, was restless and disoriented at times, and was at risk of becoming entrapped if side rails were used. The assessment documented that side rails were not recommended. A Comprehensive Care Plan related to activities of daily living dated 10/26/2023 and was revised on 08/01/2024 documented that Resident #60 required total assistance with all areas of activities of daily living and was dependent with bed mobility. Further review of Resident #60's comprehensive care plan did not include use of bed side rails. A review of Resident #60's medical record revealed no documented evidence that a physician's order was obtained with instruction and clinical rationale for use of bed side rails. There was no documented evidence of family consent and / or that direct monitoring was provided during the use of bed side rails. On 10/02/2024 at 2:47 PM, Certified Nursing Assistant #1 was interviewed and stated that Resident #60 was in their assignment. They stated that Resident #60 is dependent with bed mobility and that they raise the side rails in Resident #60's bed during care although it was not listed on the Certified Nursing Assistant instructions. The Certified Nursing Assistant stated that they put the bed side rails down when they finish providing personal care to the Resident. Certified Nursing Assistant #1 was not able to explain why the bed side rails for Resident #60 was left raised. On 10/03/2024 at 9:43 AM, Certified Nursing Assistant #3 was interviewed and stated that Resident #60 was on their assignment on 09/30/2024. The Certified Nursing Assistant stated they left the bed side rails raised as a safety precaution because Resident #60 moves around in bed. They stated that Resident #60 is confused, does not talk, and is unable to release the side rails. Certified Nursing Assistant #3 stated they raise the side rails during care and forgot to put them down when they were finished. On 10/03/2024 at 10:18 AM, Registered Nurse #4, who was the Unit Manager, was interviewed and stated that the bed side rails should only be used for Resident #60 when personal care is being provided and should be lowered when not in use. Registered Nurse #4 stated side rails are considered a restraint if the resident cannot bring the side rail down on their own. Registered Nurse #4 further stated that there is no physician's order for use of side rails and that side rails were not recommended by the rehabilitation department either. On 10/30/2024 at 12:59 PM, the Occupational Therapist was interviewed and stated they completed a side rail assessment for Resident #60 and that side rails were not recommended. The Occupational Therapist stated that Resident #60 is fidgety in bed and could be trapped if side rails are used. They also stated that Resident #60 does not use their hands purposely and cannot follow instructions. On 10/03/2024 at 2:29 PM, the Director of Nursing was interviewed and stated that some beds in the facility came with side rails attached and cannot be removed from the bed. They stated that Certified Nursing Assistants raise the side rails when performing resident care. They stated that the Certified Nursing Assistants were instructed to place the side rails down after care is completed. The Director if Nursing stated that bed side rails are considered a restraint when a resident cannot put the side rails up or down independently, which Resident #60 is unable to do. 10 NYCRR 415.4(a)(2-7)

Based on observation, interview, and record review conducted during the Recertification Survey from 09/26/2024 to 10/03/2024, the facility did not ensure that a resident was assessed for risk of entrapment from bed rails prior to use. Additionally, the facility did not ensure that the risk and benefits of bed rails were discussed with the resident, or their representative, and that informed consent was obtained prior to bed rail use. This was evident in 1 (Resident #60) of 1 resident reviewed for physical restraints out of 36 total sampled residents. Specifically, Resident #60 was observed, on multiple occasions, in bed with upper quarter bed side rails raised on both sides. The facility had no documented evidence of assessment for risk of entrapment and informed consent prior to bed rail use. There was also no documented evidence that preventive maintenance of bed rails was conducted. The findings are: The facility policy titled Physical Restraints with a revision date of 04/2024 documented physical restraint is defined as any manual method, physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, and which restricts the freedom of movement or normal access to one's body. The policy documented that bed rails are considered physical restraints and that the use of restraint must be documented in the medical records, including reason for each continued use or discontinuance. The facility was not able to provide a policy related to siderail safety and entrapment risk. Resident #60 had diagnoses of Non-Alzheimer's Dementia, Hemiplegia and Hemiparesis following Non-Traumatic Intra-cerebral Hemorrhage affecting the right dominant side. The Quarterly Minimum Data Set, dated dated dated [DATE] documented Resident #60 was severely cognitively impaired, dependent with transfers, required maximal assistance to roll left and right. The Minimum Data Set documented that physical restraints were not used. On 09/26/2024 at 12:09 PM, 09/30/2024 at 12:24 PM, and on 10/02/2024 at 10:12 AM, Resident #60 was observed resting in bed with upper quarter bed side rails raised on both sides. A review of Resident #60's medical record revealed no documented evidence that a physician's order was obtained with instruction and clinical rationale for use of bed side rails. There was no documented evidence of family consent and / or that direct monitoring was provided during the use of bed side rails. The facility was not able to provide documented evidence that Resident #60 was assessed for risk of entrapment prior to bed side rail use. There was also no documented evidence that preventive maintenance of bed rails was conducted. On 10/02/2024 at 2:47 PM, Certified Nursing Assistant #1 was interviewed and stated that Resident #60 was in their assignment. They stated that they raise the bed side rails in Resident #60's bed during care and that they put the bed side rails down when they finish providing personal care to the Resident. Certified Nursing Assistant #1 was not able to explain why the bed side rails for Resident #60 was left raised. On 10/03/2024 at 9:43 AM, Certified Nursing Assistant #3 was interviewed and stated that Resident #60 was on their assignment on 09/30/2024. The Certified Nursing Assistant stated they left the bed side rails raised as a safety precaution because Resident #60 moves around in bed. Certified Nursing Assistant #3 stated they raise the side rails during care and forgot to put them down when they were finished. On 10/03/2024 at 10:18 AM, Registered Nurse #4, who was the Unit Manager, was interviewed and stated that the bed side rails should only be used for Resident #60 when personal care is being provided and should be lowered when not in use. On 10/03/2024 at 11:45 AM, The Director of Maintenance was interviewed and stated they had not checked residents for risk of entrapment related to the use of bed side rails because they were informed over 2 years ago that the facility discontinued bed side rail use. They stated that since the bed rails were attached to the beds and cannot be removed, they tied down the side rails and conducts continuous checks to make sure that all side rails were tied down. The Director of Maintenance stated that sometimes the Certified Nursing Assistants cut the ties and use the side rails. On 10/30/2024 at 12:59 PM, the Occupational Therapist was interviewed and stated that side rails were not recommended for Resident #60. The Occupational Therapist stated that Resident #60 is fidgety in bed and could be trapped if side rails are used. They also stated that Resident #60 does not use their hands purposely and cannot follow instructions. On 10/03/2024 at 2:29 PM, the Director of Nursing was interviewed and stated that some beds in the facility came with side rails attached and cannot be removed from the bed. They stated that Certified Nursing Assistants raise the side rails when performing resident care. They stated that the Certified Nursing Assistants were instructed to place the side rails down when care has been completed. 10 NYCRR 415.12(h)(1)

Based on observation, record review, and interview conducted during the Recertification Survey from 09/26/2024 to 10/03/2024, the facility did not ensure that infection control prevention practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. This was evident in 2 (Residents #14 and #60) of 4 residents observed for medication administration. Specifically, Enhanced Barrier Precautions were not maintained during medication administration for residents with gastrostomy tube. The findings are: The Centers for Medicare and Medicaid Services, Center for Clinical Standards and Quality/Quality, Safety & Oversight Group memorandum titled Enhanced Barrier Precautions in Nursing Homes, Ref: QSO-24-08-NH dated 03/20/2024 documented that effective 04/01/2024, Centers for Medicare and Medicaid Services is issuing a new guidance for long term care facilities on the use of enhanced barrier precautions to align with nationally accepted standards. Enhanced Barrier Precautions recommendations now include use of enhanced barrier precautions for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status. The new guidance related to enhanced barrier precautions is being incorporated into F880 Infection prevention and Control. The facility policy and procedure titled Enhanced Barrier Precautions with a revised date of 03/21/2024 documented that the facility will implement enhanced barrier precautions during high contact resident care activities for any resident with an indwelling medical device, including feeding tubes, regardless of Multi Drug Resistant Organism colonization or infection status. Staff will perform hand hygiene before entering a resident's room, don gown and gloves when providing high contact care activities. Staff will remove personal protective equipment and perform hand hygiene before exiting resident's room. 1.) Resident #14 was admitted to the facility with diagnoses that include Non-Alzheimer's Dementia and Dysphagia. The Minimum Data Set assessment dated [DATE] documented that Resident #14 had severely impaired cognitive skills for daily decision making and had a gastrostomy tube. A physician's order dated 04/15/2024, documented enhanced barrier precautions due to presence of feeding tube. 2.) Resident #60 was admitted to the facility with diagnoses that include Non-Alzheimer's Dementia and Dysphagia. The Minimum Data Set assessment dated [DATE] documented that Resident #60 had severely impaired cognitive skills for daily decision making and had a gastrostomy tube. A physician's order dated 04/15/2024 documented enhanced barrier precautions due to presence of feeding tube. During medication administration observation on 10/01/2024 at 09:07 AM, Licensed Practical Nurse #3 was observed performing medication administration via gastrostomy tube for Resident #14 without wearing a gown. At 9:20 AM, same Licensed Practical Nurse was observed performing medication administration via gastrostomy tube for Resident #60. Licensed Practical Nurse #3 entered Resident #60's room and donned a gown prior to administering the Resident's medication. Licensed Practical Nurse #3 then exited Resident's room without removing the gown and immediately went to the medication cart in the hallway. On 10/01/2024 at 09:40 AM, Licensed Practical Nurse #3 was interviewed and stated that Resident #14 has a gastrostomy tube and that they should have worn a gown before administering the Resident's medications. They stated that they wore a gown when they administered Resident #60's medication but did not remove the gown before exiting the room. On 10/01/2024 at 10:00AM, Registered Nurse #3, who was the Unit Manager, was interviewed and stated enhanced barrier precautions starts when the nurse enters the room of the resident with a gastrostomy tube. Gown and gloves should be worn for any close contact care or treatment and must be removed while inside the resident's room when treatment has been completed and placed in a red bin. On 10/03/2024 at 08:29 AM, the Director of Nursing, who was also the Infection Preventionist, was interviewed and stated that enhanced barrier precautions are required when administering medications to residents with gastrostomy tube. 10 NYCRR 415.19 (a)(1-3)

Based on record review and interviews conducted during an abbreviated survey (Case # NY00348463) on 07/22/2024-07/23/2024, the facility failed to notify Justice Involved Residents of their transfer or discharge and the reason for the move in writing. Additionally, the facility did not send a copy of the transfer or discharge notice to the Office of New York State Long Term Care Ombudsman. This was evident for 4 out of 5 Justice Involved Residents (Justice Involved Resident #1, Justice Involved Resident #2, Justice Involved Resident #3, and Justice Involved Resident #5). Specifically, Justice Involved Resident #1, #2, #3, and #5 were discharged from the facility, there was no documented evidence that a discharge or transfer notice was provided to them. The facility did not notify the New York State Long Term Care Ombudsman office that Justice Involved Residents #1, #2, #3, and #5 were discharged from the facility. The Findings are: The Facility's Policy and Procedures, entitled Change in Condition, revised date 04/2024, documented that the facility must immediately inform the resident, consult with the resident's physician, and, if known, notify the resident's legal representative or an interested family member when a decision is made to transfer or discharge the resident from the facility. The Facility's Policy and Procedures Discharge Process, revised date 04/2024, documented the purpose to implement an effective discharge planning process that focuses on the resident's discharge goals, preparing the resident to be active partners and effectively transitioning them to post-discharge care, and reducing factors to prevent readmissions. Justice Involved Resident #1 was admitted on [DATE], to the facility with a diagnosis of Cord Compression (Spine Problem), Hemiplegia (left side weakness), and Cerebral infarction. The Minimum Data Set 3.0 assessment (an assessment tool) dated 11/14/2022, documented that Justice Involved Resident #1 had intact cognition. A Care Plan for Return to Community Referral initiated on 05/31/2022, target date 02/01/2023, documented that Justice Involved Resident #1 to be discharged from the facility. The interventions include arranging for a discharge planning conference. A Physician's order dated 02/02/2023, documented a discharge order to the custody of Bureau of Prisons guards and the medical transport team. A Physician's Discharge Summary dated 02/02/2023, documented Justice Involved Resident #1 with a Seizure (uncontrolled body movements), and Psychosis was stabilized and transferred to another state facility. A Review of Justice Involved Resident #1's medical record revealed no documented evidence that a Discharge or Transfer Notice was given in writing to Justice Involved Resident #1 or their legal representative. The Office of the New York State Long Term Care Ombudsman was not notified that Justice Involved Resident #1's was discharged . Justice Involved Resident #2 was admitted to the facility on [DATE], with diagnoses of Type 2 Diabetes Mellitus (high blood sugar), End Stage Renal Disease (urine problem), and Atherosclerotic Heart Disease (heart problems). The Minimum Data Set 3.0 Assessment (an assessment tool) dated 05/08/2023, documented that Justice Involved Resident #2 had intact cognition. A Care Plan for Return to Community initiated on 03/01/2022, documented return to the community with interventions that included considering the resident's and family's preferences for care. A Physician Discharge Summary dated 06/08/2023, documented Justice Involved Resident #2 with End Stage Renal Disease was stabilized and transferred to a federal facility. A Physician order dated 06/09/2023, documented an order to discharge Justice Involved Resident #2 to federal custody. A Review of Justice Involved Resident #2's medical record revealed no documented evidence that a Discharge or Transfer Notice was given to Justice Involved Resident #2 or to their legal representative. The New York State Long Term Care Ombudsman office was not notified that Justice Involved Resident #2's was discharged . Justice Involved Resident #3 was admitted to the facility on [DATE], with diagnoses of Peripheral Vascular Disease, Venous insufficiency (circulation problems), and Chronic Cellulitis to the left foot. The Minimum Data Set 3.0 assessment (an assessment tool) dated 09/28/2023, documented that Resident #3 had intact cognition. A Care Plan Return to Community Referral initiated on 03/10/2020 and updated on 11/19/2023, documented Justice Involved Resident #3 will be discharged to a federal correctional facility. The interventions included providing education to maintain safety. A Physician's Order dated 11/22/2023, documented Justice Involved Resident #3 was transferred by United States Marshall to another Nursing Home. A Physician Discharge Summary dated 11/25/2023, documented Justice Involved Resident #3 was in the facility for chronic medical issues, including Obesity, and was transferred to another Skilled Nursing Facility for further care. A Review of Justice Involved Resident #3's medical record reveals no documented evidence that a Discharge or Transfer Notice was given to Justice Involved Resident #3 or their legal representative. The New York State Long Term Care Ombudsman office was not notified that Justice Involved Resident #3 was discharged from the facility. Justice Involved Resident #5 was admitted to the facility on [DATE], with diagnoses of Right Above Knee Amputation( leg removed), Infection of Amputation Stump, and Atrial Fibrillation (heart problems). A Care Plan Return to Community Referral was initiated on 07/28/2023, and updated on 01/16/2024. Resident #5 was scheduled to be discharged from the facility. The interventions included arranging a discharge planning conference. A Physician's Order dated 03/20/2024, documented an order to transfer Resident #5 to a skilled nursing facility (name redacted) under the custody of the United States Marshall. A Physician Discharge Summary dated 03/25/2024, documented Resident #5 with Above- Knee Amputation, Atrial Fibrillation was treated, and the Gait (balance) was stabilized. Justice Involved Resident #5 was stable to be transferred to another skilled nursing facility. A Review of Resident #5's medical record revealed no documented evidence that a Discharge or Transfer Notice was given to Resident #5 or their legal representative. The Office of the New York State Long Term Care Ombudsman was not notified of Resident #5's discharge. During an interview on 07/22/2024 at 4:20 PM, the Director of Social Service stated when a resident is going to the hospital, the admission department provides them a written Notice of Transfer/Discharge with a bed hold policy. The Director of Social Service stated if the resident goes to another facility, the Social Worker provides a notice of Transfer/Discharge before they leave. The Director of Social Service stated that they did not give a Notice of Discharge/Transfer to Justice-Involved Residents when they were transferred to other facilities or hospitals or if they went back to custody. The Director of Social Service stated that most of the time it last- minute discharge that is initiated by the doctor from the Bureau of Prison, and facility staff was not allowed to tell Justice-Involved Residents where and when they are discharged . The Director of Social Service further stated they did not notify the Ombudsman when Justice-Involved Residents were discharged from the facility. The Director of Social Service also stated that they do not notify the Ombudsman's office of discharge or transfers unless 30 days' notice is given. During an interview on 07/23/2024 at 12:11 PM, the Admission Director stated they notify the Ombudsman's office only when residents go to the hospital because of the bed hold policy. The Admission Director stated they do not notify the Ombudsman when residents are discharged to the community or to other facilities. During an interview on 07/23/2024 at 2:47 PM, the Administrator stated Social Workers are responsible for providing Notices of Discharge or Transfer to all residents. The Administrator stated that a Notice of Discharge or Transfer was not provided to Justice Involved Residents #1, #2, #3, and #5, due to security reasons and short notice from the Security Guards. The Administrator stated the Ombudsman's office is notified when residents are transferred to the hospital or if there are issues with the 30 days' notice. 10 NYCRR 415.3(h)(1)(iii)(a-c)

Based on record review and interviews conducted during an abbreviated survey (Case # NY00314017) the facility did not ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, to the New York State Department of Health. This was evident for 1 out of 7 residents (Resident #6) sampled for abuse. Specifically, on 03/28/2023, Resident #6's adult child called Licensed Practical Nurse #2 and stated that Certified Nursing Assistant #1 was rough when providing personal care. The allegation of rough handling of Resident #6 was not reported to the New York State Department of Health. The Findings are: The facility's Policy and Procedure titled Abuse Prohibition: Reporting and Prevention reviewed/revised on 04/2024, documented all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. Resident #6 was admitted to the facility with diagnoses including Liver Cirrhosis/Ascites (Liver problems), Thrombocytopenia (bleeding problems), and Dementia (memory loss). A Minimum Data Set (a resident assessment tool) dated 01/17/2023, documented Resident #6 had moderately impaired cognition. A Facility Internal Investigation dated 03/28/2023, documented that on 03/28/2023 at around 6:25 PM, Resident #6's adult child called Licensed Practical Nurse #2 and stated that their parent called them and complained that the Certified Nursing Assistant #1 was rough during personal care. Licensed Practical Nurse #1 notified the Director of Nursing and Administrator. The facility investigated the incident and concluded that abuse did not occur. There was no documented evidence the facility reported an allegation of rough handling during care to the New York State Department of Health. During an interview on 07/26/2024 at 1:28 pm, the Director of Nursing stated they and the Administrator were responsible for investigating the incidents, reporting to the New York State Department of Health and to local law enforcement. The Director of Nursing stated they did not report Resident #6's allegation of rough handling during care to the New York State Department of Health because they felt Resident #6 misunderstood Certified Nurse Assistant #1 action when they attempted to prevent Resident #6 from falling on 03/23/2023. During an interview on 07/23/24 at 3:24, the Administrator stated that the Director of Nursing is responsible for the investigation of the incidents, and the Director of Nursing or Administrator is responsible for reporting to the Department of Health or other authorities. The Administrator stated that the allegation of rough handling constitutes abuse, but the case was not reported to the Department of Health because they were able to rule out abuse within 2 hours, and it was unsubstantiated. 10 NYCRR 415.4(b)(2)

Based on interviews and record review conducted during the Recertification and Complaint survey (NY 582, NY 771, and NY 425) from 7/11/2022 to 7/18/2022, the facility did not ensure all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegations were made, to the State Survey Agency. Specifically, the facility did not report (1) Resident # 97 alleged being hit by a staff member, (2) Resident # 362 alleged being struck at frontal head by Resident # 120, and (3) Resident # 160 alleged being struck by a shoe on the face by Resident # 361 to the New York State Department of Health (NYSDOH) within 2 hours. This was evident for 5 of 5 residents reviewed for Abuse out of a sample of 35 residents. (Resident # 97, 120, #160, #361, and # 362). The findings are: The facility policy titled Abuse Prohibition: Reporting & Prevention effective December 2016 and last reviewed December 2021 documented under Definitions section that Abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain, or mental anguish and inappropriate physical contact with a resident of a residential health care facility, which harms or is likely to harm the resident. Inappropriate physical contact includes, but is not limited to, striking, pinching, kicking, shoving, bumping and sexual molestation. It also documented that Physical Abuse includes hitting, slapping, pinching, and kicking. The policy also documented under Reporting that Federal and state regulations require the reporting of alleged violations of abuse, mistreatment and neglect, including injuries of unknown origin and misappropriation of resident property, immediately to facility administrator and in accordance with the state law, to the Department of Health upon having reasonable cause to believe that abuse, neglect or mistreatment or misappropriation has occurred. The facility policy did not document the required time frames for the reporting of allegation of abuse to the Department of Health. 1.Resident #97 (NY 582) was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) dated [DATE] documented that the resident had severe impairment in cognition with a BIMS score of 3. The MDS also documented the resident had no behaviors. The Facility Internal Investigation dated 12/08/2020 documented that on 12/8/2020 at around 4 pm, recreation aide was conducting/facilitating video call with resident's family when resident verbalized to the family that they were being hit by staff member in the facility. After the video call, recreation aide reported to the charge nurse and DON, and investigation was initiated. The facility Submission Report HERDS dated 12/15/2020 documented Incident date: 12/8/2020 and Incident time: 4:00PM and that the incident was submitted on 12/14/2020 at 3:15 PM and was received by the Department of Health. The report was submitted six (6) days after the allegation was made. On 07/15/22 at 10:29 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that there is a 2 hour window to report any incident of abuse to the state while the investigation is ongoing. The ADON also stated that they just became the ADON and was not aware of allegation of abuse by Resident #97 at that time. 2. Resident #362 (NY 771) was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) dated [DATE] documented Resident # 362 had severe cognitive impairment with a BIMS score of 4 and no physical/verbal behavioral symptoms directed toward others. Resident #120 (NY 771) was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS dated [DATE] documented Resident # 120 was cognitively intact and had no physical/verbal behavioral symptoms directed toward others. The Facility Internal Investigation dated 5/26/2021 documented that on 5/21/2021 at around 6:05 PM that Resident #362 wandered into Resident 120's room. Resident #120 was annoyed and struck Resident #362 with a wooden back scratcher which caused a 1x1 cm bump on Resident #362's frontal head. The report also documented that staff intervened and escorted Resident #362 out of the room immediately and removed the back scratcher from Resident 120. Both Resident #120 and Resident #362 were assessed by nurse. Resident #362 was sent out to hospital for evaluation and treatment. Resident #120 was transferred to ER for evaluation of their aggression. The report also documented that there was no history of alteration between Resident #362 and Resident #120 and Resident #120 was moved to another unit after returning from the hospital. The HERDS report documented the incident occurred on 5/23/2021 at 6:05 PM and was not reported to New York State Department of Health until 5/26/2021 at 1:41 PM. 3. Resident #160 (NY 425) was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS dated [DATE] documented Resident #160 was severely cognitive impaired with a BIMS score of 2 and had no physical/verbal behavioral symptoms that were directed toward others. Resident #361 (NY 425) was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS dated [DATE] documented Resident #361 had intact cognition and no physical/verbal behavioral symptoms that were directed toward others. The Facility Internal Investigation dated 11/15/2021 documented that on 11/10/201 at around 7:30 AM, the Certified Nursing Assistant (CNA) noted and reported a 1x 0.2 cm skin tear at Resident #160's nasal dorsum. The CNA also reported they did not observe the skin tear during rounds conducted at 7:00 AM. The report also documented that Resident #160 alleged that Resident #361 struck them on the face with a shoe. Resident #361 denied the allegation. The report documented that both Resident #160 and #361 were assessed for injuries and Resident #361 was moved to another room after the incident. The HERDS report documented the incident occurred on 11/10/2021 at 7:30 AM and was not reported to New York State Department of Health until 11/15/2021 at 12:31 PM. On 07/14/22 at 11:08 AM, the Director of Nursing (DON) was interviewed and stated the RN manager reported the incident on the unit to the DON and Administrator immediately. The DON also stated the Administrator and DON were responsible for reporting allegations of abuse to the Department of Health (DOH) within five (5) working days through the Health Commerce System (HCS) or hotline. The DON further stated they had a misunderstanding and did not know they had to report to DOH within 2 hours after an allegation of abuse was made. The DON also stated they would revise the facility's abuse policy to update the reporting requirement. On 07/14/22 at 11:47 AM, the Administrator was interviewed and stated the staff on the unit reported incidents to DON and Administrator immediately. The Administrator also stated the DON and themselves reviewed their reporting manual to decide if the incident was reportable to state or not and the reporting requirement. The Administrator further stated they believed they had 5 working days to report allegation involving abuse to DOH through HCS or hotline. The Administrator stated they were not aware they had to report allegation of abuse to DOH within two (2) hours the allegation was made. 415.4 (b)(2)

Based on interviews and record reviews conducted during a Recertification and Complaint Survey (NY 851) 7/11/22 to 7/18/22, the facility did not ensure that medical records were maintained in accordance with accepted professional standards and practices and were complete and accurately documented for each resident. Specifically, the medical record for a resident had multiple missing entries documenting that toileting had been provided for the resident. This was evident for 1 of 1 residents reviewed for Activities of Daily Living (ADLs) out of a sample of 35 residents. (Resident #22) The findings are: There was no facility policy provided that pertained to documentation of Activities of Daily Living and maintaining accurate documentation. Resident #22 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) dated [DATE] documented the resident as cognitively intact and the resident required extensive assistance of one person for toileting. The Point of Care History (CNA documentation) for Resident #22 for February 2022 was reviewed and revealed that no documentation was listed for the day tour on 02/04, 02/09 or 02/26. There was no documentation was listed for the evening tour on 02/02, 02/11, 02/19, 02/20, 02/22 or 02/24. In addition, for March 2022, there was no toileting documentation completed for the night tour. On 07/14/2022 at 12:12 PM, an interview was conducted with the Certified Nursing Assistant (CNA) #3 assigned to Resident #22 during the day shift who provided care in March and April of 2022. CNA #3 stated that the resident is typically changed every 2-3 hours and whenever they ring the call bell. CNA ## also stated that the resident tends to be a heavily soiled and cannot be left longer than 3 hours without soaking the incontinence brief. On 07/15/2022 at 10:11 AM, an interview was conducted with the Registered Nurse Manager (RNM) #2 assigned to the unit. RNM #2 stated that documentation is supposed to be entered into the system once every shift, and staff are trained on how to operate the CNA documentation portal. RNM #2 also stated that the Nursing Supervisor is responsible for supervising the CNAs to make sure that the documentation is in place, but they were not on staff during February or March 2022. RNM #2 further stated that Resident #22 is alert and able to voice any issues, and when they make rounds on the unit in the morning, the resident is always up and dressed, so they know that the resident has been changed. On 07/18/2022 at 9:13 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that it appeared that some CNAs needed to be re-in-serviced about toileting documentation. The DON also stated that although toileting is typically done every 2-4 hours, CNAs are expected to document toileting care just once during each shift because if they had to document every time the care was given, they would never be finished. The DON was unable to give a reason why the documentation for February and March was incomplete and stated that Resident #22 had no urinary tract infections or pressure ulcers, so toileting may have been provided in a timely manner. 415.22(a)(1-4)

Based on observation, record review, and staff interview conducted during the Recertification Survey 7/11/22 to 7/18/22, the facility did not ensure that medication and biologicals were labeled in accordance with currently accepted professional principles. Specifically, eye drops and inhalers did not have labels on the individual bottles and/or devices that specified the resident the medication was prescribed for. In addition, insulin pens were not stored in a sanitary manner to prevent cross-contamination. This was evident for 1 of 4 units observed for Medication Storage and Labeling. (Unit 4). The findings are: The Medication Storage Policy dated 7/7/2019 and reviewed on 4/14/2022 did not document guidance related to labeling of multidose vials or storage of insulin pens to prevent cross contamination. On 7/14/22 at 11:19 AM, an observation of the medication cart on the 4th floor was conducted. There were three boxes of Artificial Tears and one box of Refresh Eye drops labeled with the resident name and room number on the box only. There was no label attached to the a bottle that specified the resident for whom it was prescribed. There were also two [MEDICATION(S)] Diskus cartridges, one Ellipta and one [MEDICATION(S)] delivery devices contained in boxes; the devices had no label that specified the resident for whom it was prescribed. In addition, there were 11 insulin pens located in the top drawer of the cart that were not stored in a manner to prevent cross-contamination. On 7/14/22 at 11:19 AM, an interview was conducted with Licensed Practical Nurse (LPN) #2. LPN #2 stated that the artificial tears are in stock items and the nurses were instructed to place the residents name on each box of tears and the asthma pumps and were never informed that the resident's name should be on the actual bottle/device. LPN #2 also stated that each time an insulin pen is used it is then cleaned with the purple top wipes to prevent cross-contamination and for infection control. On 7/14/22 at 11:41 AM, an interview was conducted with the Assistant Director of Nursing (ADON) who was functioning as the supervisor on the floor. The ADON stated that the education they received was to label the box on the outside for eyedrops and asthma pumps. The ADON also stated that when they put permanent marker on the eye drop bottles the residents name gets erased if the bottle gets wet. Therefore, they put the resident's name and room number on the box or the bag. The ADON further stated that insulin pens are cleaned after use and left to dry for two minutes before being placed back in the cart. On 7/18/22 at 1:29 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that all medication has to be labeled. If the medication comes from the pharmacy, it is already labeled but for facility supply, they can write the residents name on the box and on the medication itself. The DON also stated that insulin pens should be stored separately and that each pen comes in a bag and the pens should be kept in the bag to prevent cross-contamination. The DON further stated that each supervisor on each shift should be ensuring that medications are stored properly 415.18 (e)(1-4)

Based on record review and staff interviews conducted during a Recertification Survey from 7/11/22 to 7/18/22, the facility did not ensure that the resident and their representative were provided with a written summary of the baseline care plan. This was evident for 1 of 2 residents reviewed for Nutrition, and 1 of 1 residents reviewed for [CONDITION(S)] out of 35 sampled residents. (Residents #121 and #103). The findings are: The facility policy titled Baseline Care Plan effective November 2017 and reviewed November 2021 documented that a written summary of the Baseline Care Plan must be provided to the resident or resident's representative at the time of the initial comprehensive care plan meeting. 1). Resident #121 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident was severely cognitive impaired. The MDS also documented that the resident participated in the assessment and family and significant other did not participate in the assessment. The Baseline Care Plan (BCP) was documented as created on 12/10/21 and last reviewed/revised on 12/10/21. Review of the progress notes 12/10/21-1/10/22 revealed no documented evidence that the resident and/or designated representative had been provided with a copy of or had signed the baseline care plan. 2). Resident #103 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident had moderately impaired cognition. The MDS further documented the resident and family or significant other participated in the assessment. The Baseline Care Plan (BCP) was documented as created on 12/12/21 and last reviewed/revised on 12/12/21. Review of the progress notes 12/11/21-2/11/22 revealed no documented evidence that the resident and/or designated representative had been provided with a copy of or had signed the baseline care plan. On 7/18/22 at 12:20 PM, the Registered Nurse Manager (RNM) #3 was interviewed. RNM #3 stated that the Baseline Care Plans (BCP) are given by the Social Work Department 48 hours of admission. RNM #3 also stated they did not know where this would be documented and they would have to ask the Social Work Department. On 7/18/22 at 12:47 PM, the Director of Social Work (DSW) was interviewed. The DSW stated that they schedule a meeting within 48 hours of admission and the residents received the BCP within 48 hours. The DSW also stated that residents generally are really only interested in review of the medications. The DSW further stated that residents are generally given the BCP then the residents sign it and a copy goes into the medical chart and the resident is given a copy once the BCP has been signed. The DSW stated that it was very difficult to get in touch with the family of Resident #121 on admission and Resident #121 was confused and could not sign the BCP. The DSW could not explain why the BCP for Resident #103 was not signed. The DSW also stated that there was no documentation in her notes regarding the BCP's, not being able to reach the resident's representatives or when the residents were provided copies of the BCP's. On 7/18/22 at 1:19 PM, the Director of Nursing (DON) was interviewed. The DON stated that BCP's are done within 48 hours of admission and may be done at the same time as the Comprehensive Care Plans if there is sufficient time. The DON also stated that if the resident is alert enough, they discuss it with the resident within 48 hours and the resident is offered a copy of the BCP although most of the time the residents do not want the copy. The DON further stated that staff does not document that the BCP was given although they may document that it was discussed. Following review of the medical record of Resident #121 and Resident #103, the DON stated they did not see any notes where the BCP's were discussed with either resident. 415.11 (c)

Based on interviews and record review conducted during the Recertification survey from 7/11/22 to 7/18/22, the facility did not ensure that liability notices were provided appropriately to Medicare beneficiaries. Specifically, notices were not provided in a timely manner and notices were not mailed out when telephone notification was made. This was evident for 2 of 3 residents reviewed for Skilled Nursing Facility Beneficiary Protection Notification out of a total sample of 35 residents. (Resident #611 and Resident #612). The findings are: The facility policy and procedure titled Medicare Determination and Notification dated 4/22/2019, documented that it is the policy of the facility that when a resident no longer qualifies for Skilled Nursing and or Skilled/Restorative Rehabilitation the MDS Coordinator will provide Notice Of Medicare Non-Coverage (NOMNC); SNF ABN (Form CMS- ) to the Social Worker within 3 working days prior to the last day of Skilled Services. The policy also documented that the Social Worker secures signature of capacitated resident on the Medicare exhaust letter. If unable to sign, informs the family/designated representative in person or by successful telephonic notification. The Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS- documented the requirement that notification of changes in coverage for an institutionalized beneficiary/enrollee who is not competent be made to a representative. The instructions also state that if the provider is personally unable to deliver a NOMNC to a person acting on behalf of an enrollee, then the provider should telephone the representative to advise him or her when the enrollee's services are no longer covered. The date of the conversation is the date of the receipt of the notice. Confirm the telephone contact by written notice mailed on that same date. 1. Resident #611 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) dated [DATE] documented that Resident #611 was cognitively intact. The Notice of Medicare Non-Coverage form (CMS -NOMNC) documented that skilled services would end on 4/14/22. The form was signed and dated 4/15/22. A note added to the form documented that the resident's representative was spoken to on 4/12/22 and advised of appeal rights and stated they would come to the facility on [DATE] to sign the notification. There was no documented evidence that a written notice had been mailed on that same date to confirm the telephone contact. 2. Resident #612 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) dated [DATE] documented that Resident #612 was severely cognitively impaired. The NOMNC form documented that skilled services would end on 1/25/22. The form was signed and dated 1/26/22. A note added to the form documented that the resident's representative was spoken to on 1/24/22 and advised of last rehab treatment on 1/25/22 and discharge on 1/26/22. The note documented that representative would sign notice on day of discharge. The facility did not ensure that notices were provided at least two calendar days before Medicare covered services ended and there was no documented evidence that a written notice had been mailed on that same date to confirm the telephone contact. On 7/15/22 at 11:29 AM, an interview was conducted with the MDS Coordinator (MDSC). The MDSC stated that 72 hours before discharge they contact the responsible party and if the resident is not able to sign then we notify the family. When family members are contacted, the information is written on the letter and then it is sent through the mail on the day the call was made. The MDSC also stated that sometimes a copy is made of the mailing envelope but they do not always keep a copy. The MDSC further stated that the notices were not mailed to the representatives because they said they were going to come to the facility to sign the form. On 7/18/22 at 1:28 PM, an interview was conducted with the Director of Nursing (DON) The DON stated they were not involved with notification provided once residents are discharged from skilled services. The DON also stated that MDS has a department head who would be responsible for ensuring this is done appropriately. 415.3(g)(2)(i)

Based on observation, record review, and interviews conducted during an abbreviated survey (NY 483) on 07/07/2021, the facility did not provide adequate supervision to prevent elopement. This was evident in of 1 out of 7 residents sampled (Resident #1). Specifically, Resident #1 dislodged the window in the main dining room on the 1st floor and left the facility at 11:40 PM on 06/25/2021. Facility staff became aware that Resident #1 was missing on 06/26/2021 at 7:10 AM (7 hours 30 minutes). Resident #1 was located on 06/26/2021 at 8:00 PM and was under the influence of alcohol. Resident #1 was taken to the hospital and was admitted . Findings are: Review of the facility's policy and procedure titled Elopement Policy and Procedure Code Orange last revised August 2020 documented: To ensure that residents are secure from: elopement, becoming a missing person, or getting harmed while eloping. Safeguard the health and welfare of residents who are cognitively impaired, emotionally disturbed, and are at risk to wander and leave the facility without staff notification and authorization. Ensure staff immediately respond to CODE ORANGE and follow the elopement procedures for a resident suspected of or found to be missing from the facility. Ensure a safe environment for all residents. The Facility's Investigation Report dated 06/26/2021 documented that at approximately 7:10 AM, Resident #1 was noted missing from the unit. Certified Nursing Assistant (CNA) #2 reported to Registered Nurse Supervisor (RNS) that Resident #1 was missing. The RNS called all the units to conduct a head count on all residents. The unit charge nurse and CNAs checked the unit and reported to the nurse supervisor that Resident #1 could not be located. Code Orange (used for elopement) was activated. An extensive search was conducted inside the facility and outside by staff. Resident #1 was not found. The resident's listed contact, Director of Nursing, Administrator, and Medical doctor were notified. 911 was immediately activated. At 8:00. PM on 06/26/2021, Resident #1's friend (listed contact) informed the facility that Resident #1 was found and was under the influence of alcohol. The RNS instructed Resident #1's friend to call 911. Resident #1 was taken to the hospital for psychiatric evaluation. The facility determined that while the existing elopement preventive equipment/measures were functioning optimally, Resident #1 eloped from facility after removing a window and subsequently left facility. Unit staff acted outside of established policy, did not monitor resident's whereabout and did not perform a head count. Resident #1 was admitted to facility on 01/31/2020 with diagnoses including, Alcohol abuse, [CONDITION(S)] and Diabetes. The Minimum Data Set (MDS, a resident assessment tool) dated 04/19/2021 documented that Resident #1 had a Brief Interview for Mental Status (BIMS) and scored 8/15, associated with moderately impaired cognition. Resident #1 required supervision with bed mobility and with locomotion on and off unit. Resident #1's initial Comprehensive Care Plan (CCP), on elopement, dated 01/31/2020 documented that Resident #1 was assessed for elopement risk due to history of alcohol abuse. The interventions documented every 30 minutes monitoring, placement of wander guard and to redirect Resident #1 to the room if the resident was exhibiting elopement behaviors. An Elopement Care Plan dated 01/31/2020 documented that Resident #1 was fitted with a wander guard, due to history of alcoholism and ambulatory status. Interventions were to monitor Resident #1's whereabout and activities, redirect Resident #1 to the room and observe for attempts to leave the facility. The updated CCP dated 05/11/2020 documented that Resident #1 occasionally expressed anger regarding placement in the nursing home. Resident #1 removed the wander guard and refused to wear the wander guard. Resident #1 did not display exit seeking behavior. The interventions documented for visual monitoring, supervision and redirection as needed. There was no documented frequency of monitoring, type of supervision needed and what staff should redirect Resident #1 to do. The Re- Assessment of Elopement Risk Care Plan dated 06/16/2021 documented that Resident #1 was calm and quiet in general. Resident #1 preferred to spend leisure times in room. Resident #1 played dominoes with peers and loved watching Television. Resident #1 sometimes ambulated on and off the unit but was not exit seeking. Resident #1 could be easily redirected by staff. Resident #1 had not made any attempt to leave the facility and conformed to care routines. The elopement risk and constant visual monitoring was discontinued. Record review revealed no care plan addressing Resident #1 leaving the unit late at night to watch Television in the first-floor main dining room till wee hours in the morning. The facility's surveillance camera recording (camera #2) dated 06/26/2021 documented that Resident #1 was observed walking from the direction of the back of the first-floor dining room window towards the street (and out of camera view) at 11:40 PM on 06/25/2021. The Point of Care History, for Resident #1, documentation, on how Resident #1 walked in the room, dated 06/25/2021 documented that Resident #1 required Extensive Assistance with walking. This was evident by the #3. The document also showed that Resident #1 required supervision as evident by the #1. The documentation history on how Resident #1 moved on the unit, documented that Resident #1 required extensive assistance and supervision. The MDS dated [DATE] documented that Resident #1 required supervision with bed mobility and with locomotion on and off unit. The Prescription Order dated 04/20/2021 revealed an order for Resident #1 to receive Vitamin B-1 ([MEDICATION(S)]), 100mgs, 1 Table orally once in the morning at 06:00 AM. The Medication Administration Record dated 06/26/2021 at 6:00 AM, revealed that Resident #1 did not received the 6:00 AM medication. It was documented that Resident #1 was not available. Review of the Nursing Progress Notes dated 06/01/2021-06/25/2021 revealed that there was no documentation that Resident #1 left the unit to watch Television in the first-floor main dining room till wee hours in the morning. A Nursing Progress Note dated 06/26/2021 at 03:21 PM documented that Resident #1 was not in the room and could not be located. Code Orange (facility elopement code) was called, and a head count conducted. Resident #1 could not be accounted for. The Police 911 emergency activated, and the Administrator informed. Staff members searched the floors, basement, vicinity of facility on foot and by car. Calls were made to the hospitals in the area where the facility was located. Resident #1 was not found. An observation of the main entrance was conducted on 07/07/2021 at 11:30 AM. The main entrance had a sliding door which was operated internally by a receptionist. The sliding door was tested and could not be opened form the outside. The receptionist buzzed the surveyor in. A camera and monitoring screen was at the receptionist desk. Pictures of residents deemed elopement risk by facility were placed in a binder at the front desk. The elevators were about 100 feet (ft) from the reception area. Elevators #1 and #2 had a functional wander guard alarm system. Unauthorized exit doors were fitted with an alarm system and required a pass key/code for someone to enter and exit through the doors. A tour was conducted in the main floor dining room on 07/07/2021 at 12:00 PM with the facility Administrator and Director of Maintenance. The entrance door was observed to be fitted with codified electronic keypad and required permission to enter. The dining room back window observed fitted with screws after the elopement on 06/25/2021. An observation was conducted on the 3rd floor, Resident #1's unit, on 07/07/2021 between 04:00 PM and 04:45 PM. The 3rd floor dining room windows had stop guards and could only be opened to four inches. The 3rd floor exit door alarm was triggered and observed to be fully functional with an audible sound. The dining room windows on unit 4 observed with stop guards and could only be opened four inches. The basement exit door to street had an alarm and surveillance camera. During an interview on 07/07/2021 at 10:45 AM, the Director of Nursing Service (DNS) stated that Resident #1 had a calm demeanor, loved spots, played dominoes with peers, and had an affinity for large screen Television (TV). The DNS stated that unit 4 and the main dining room on the first floor had the large screen TVs. The DNS stated that Resident #1 did not exhibit any exit-seeking behavior or voice any plans to leave the facility. The DNS stated that the exits, including the perimeter/surrounding areas are fitted with CCTV (Close-Caption-Television) and that the alarms were not disarmed. The DNS stated that it was very alarming that Resident #1 was able to dismantle a very heavy window that was about 6-8feet high and climbed out and walked away. The DNS stated that no one could have seen it coming. The DNS voiced that Resident #1's action had prompted the facility to re-visit all security measures, re-assess all residents with exit seeking behavior. The DNS stated that Resident #1 had a set predictable routine of going to the main dining room to watch TV because of the large screen TV. Resident #1 would watch TV till wee hours of the morning. Resident #1 would return to the unit for food, care, and medications. The DNS stated that they tried to make Resident #1's stay in the facility homelike. The DNS reported that it is an expectation that the staff would make rounds, verify the resident's whereabouts, and quickly report to the nursing supervisors any resident not found. The DNS stated there was no care planning regarding Resident #1's customary routines and activities. During an interview on 07/07/2021 at 12:30 PM, the Facility Administrator (FA) stated that Resident #1's finding a way to leave the facility was an eye opener and a teaching moment. The FA stated that Resident #1 was not presented as an eloper and had no exit seeking behavior. He/she said that Resident #1 loved watching the huge screen TV in the main floor dining room. The FA stated that the facility security systems on the doors and the elevators were fully functional. The FA further stated that the windows on the units are shatter proof windows that can only be opened to four inches. The first-floor main dining room has a double hung heavy window fitted with a window stopper. The FA stated that a bent heavy metal feeding utensil was discovered by the first-floor window (where Resident #1 eloped from). The window frame and stopper were broken, and both the top and bottom glass pushed down. The FA stated that Resident #1 climbed out of the window onto the grass below and was able to walk away. The FA stated that the area, from which Resident #1 eloped from the facility, had no camera. During an interview on 07/07/2021 at 12:45 PM, the Director of Maintenance (DOM) stated that he/she was responsible for checking the windows in the facility. The DOM stated that they conducted monthly audits of the windows and that more rigorous checks will be done. The DOM stated that the damaged window was repaired and that an electronic keypad was installed on all the dining room doors. During an interview on 07/07/2021 at 3:00 PM, CNA #3 said that on 06/26/2021 Resident #1 could not be located during rounds between 07:00 AM and 07:10 AM. CNA #3 stated that it is customary for Resident #1 to be seated at the table for breakfast, when Resident #1 was not at the table, CNA #3 stated that he/she called the front desk to see if Resident #1 was in the main dining room. CNA #3 stated that Resident #1 was not in the main dining room, therefore, he/she went to the 4th floor and Resident #1 was not on the 4th floor and could not be found. The nurse supervisor was informed, and Code Orange called. During an interview on 07/07/2021 at 04: 00 PM, Registered Nurse Supervisor (RNS) stated that CNA #2 reported that Resident #1 could not be located. The RNS stated that a head count of all the residents was immediately initiated. The DNS, the FA, Resident #1's listed contact, and the Medical Doctor (MD) were notified. The RNS said that Code Orange was activated, and a thorough search was conducted in and out of the facility, but Resident #1 was not found. The RNS also stated that 911 was called and the Police arrived and checked the security cameras. The Policy also checked the exit doors and alarms, but they were not tampered with. The RNS said that Resident #1 did not have any exit seeking behavior and did not express any desire to leave facility. During an interview on 07/07/2021 at 04:13PM, Licensed Practical Nurse (LPN) stated that he/she saw Resident #1 between 11:00 PM and 11:30PM on 06/25/2021. The LPN stated that Resident #1 was sitting in the dining room watching television on the unit. The LPN stated that Resident #1 may have left the unit's dining room to go down to the main dining room to watch sports on the larger screen. The LPN stated that it was Resident #1's usual practice. The LPN stated that Resident #1's assigned CNA #1 did not report seeing Resident #1 during the shift. The LPN said it is a customary routine for Resident #1 to stay in the first-floor dining room watching television till the wee hours of the morning. The LPN stated that Resident #1 always returned to the unit for medication and breakfast. The LPN stated that Resident #1 was not an elopement risk and was not exit seeking. The LPN stated that Resident #1 was calm, easily redirected, cooperative with care routines, but did not want staff knocking on the door, or going in and out of the room often. The LPN said, although Resident #1 presented with a calm demeanor, if staff kept going in and out of Resident #1's room or knocked on the door too much, Resident #1's mood could change to anger in a split second especially during care. The LPN said that Resident #1 was resistive to visual monitoring, but that it was not considered as a behavior, and was not documented or reported. The LPN stated, when Resident #1 did not return to the unit at 6:00 AM for medication, this should have raised a red flag. The LPN also stated that he/she should have conducted a head count at the end of the shift and that it was a lapse of judgment. The LPN stated that he/she did not report to the supervisor that Resident #1 missed the 6:00 AM medication. The LPN voiced that Resident #1's room door was opened, and the bathroom light was on. The LPN contends that it was an opportunity to check on Resident #1 but that he/she did not do so. During an interview on 07/30/2021 at 09:34 AM, CNA #1, assigned to Resident #1, stated he/she worked on 06/25/2021 and arrived at work 10:55 PM. CNA #1 stated that Resident #1 was sitting in the unit dining room watching television. CNA #1 stated that Resident #1 took the elevator at approximately at 11:30 PM and went to the first floor. CNA #1 stated it was customary for Resident #1 to watch sports on the large screen TV in the main dining room. CNA #1 stated that it was also customary for Resident #1 to watch TV till the morning and that Resident #1 usually returned to the unit for medication and to get ready for breakfast. CNA #1 said that Resident #1 was continent of bowel and bladder and was able to make all needs known. CNA #1 stated that he/she did not see Resident #1 return to the unit for care and that he/she did not think anything was [NAME] and did not report it to the charge nurse. During a follow up interview with the DNS on 08/18/2021 and 09/13/2021, the DNS stated that no one could have foreseen any resident climbing out of a window that is almost 6ft-8ft and managed to walk away unharmed. The DNS stated that Resident #1 was monitored as an elopement risk, was fitted with a wander guard and was on every 30 minutes visual observation due to alcohol abuse history. The DNS stated that when Resident #1 became settled, had friends, and found activities of interest, the wander guard and strict monitoring were discontinued. The DNS stated that the #3 (extensive assistance with walking and moving about on the unit) on the Point of Care History was incorrect and that it was an error. The DNS also stated that Resident #1 was independent and that the CNAs do not read, they just document. 415.12(d)(2)

Based on observation, record review and interview conducted during the COVID-19 Focused Infection Control Survey completed on 1/27/2021, the facility did not establish and maintain an Infection Control Program to ensure the health and safety of residents to help prevent the transmission of COVID-19. Specifically, a Certified Nursing Assistant (CNA) did not perform hand hygiene after resident care and in between assisting residents on a unit placed on contact and droplet precautions. This was evident for 1 of 4 units (3rd Floor) observed. The findings are: The Centers for Disease Control and Prevention (CDC) guidance titled Hand Hygiene Recommendations: Guidance for Healthcare Providers about Hand Hygiene and COVID-19, updated 5/17/20, documented: Hand hygiene is an important part of the U.S. response to the international emergence of COVID-19. [MEDICATION NAME] hand hygiene, which includes the use of alcohol-based hand rub (ABHR) or handwashing, is a simple yet effective way to prevent the spread of pathogens and infections in healthcare settings. ABHR effectively reduces the number of pathogens that may be present on the hands of healthcare providers after brief interactions with patients or the care environment. The New York State Department of Health (NYSDOH) Revised Health Advisory entitled COVID-19 Cases in Nursing Homes and Adult Care Facilities, dated 3/13/20 and updated 7/10/2020, documented that if there are confirmed cases of COVID-19 in a Nursing Home, all residents on affected units should be placed on droplet and contact precautions, regardless of the presence of symptoms and regardless of COVID-19 status. HCP and other direct care providers should wear gown, gloves, eye protection (goggles or a face shield), and N95 respirators (or equivalent) if the facility has a respiratory program with fit tested staff and N95s. Otherwise, HCP and other direct care providers should wear gown, gloves, eye protection, and facemasks. Facilities may implement extended use of eye protection and facemasks/N95s when moving from resident to resident (i.e. do not change between residents) unless other medical conditions which necessitate droplet precautions are present. However, gloves and gowns must be changed, and hand hygiene must be performed. The facility policy on Handwashing, revised March 2020, documented handwashing is the most effective method of preventing the spread of infection. Staff must wash hands at indicated times but not limited to: before and after resident care, after removing gloves, after handling dirty items, before food handling and distribution, before and after eating and on completion of duty. On 01/27/2021 at 10:30 AM, the following was observed on the 3rd Floor Unit. Certified Nursing Assistant (CNA #1) was walking in the hallway wearing eye protection and a face mask. CNA #1 stopped to speak to Resident #1 and held the resident's hands briefly with her bare hands. CNA #1 continued to walk down the hall and around the corner to the equipment storage area to retrieve a Hoyer Lift (a mechanical lift used for resident transfers). CNA #1 brought the Hoyer Lift to the hallway and did not perform hand hygiene. CNA #1 walked to the medication cart, picked up a clean cup and the water pitcher, poured a cup water, and gave the cup to Resident #2, who was sitting in the hallway. CNA #1 adjusted the straps on her KN95 mask and returned to the medication cart to pour water for herself twice. CNA #1 did not perform hand hygiene. CNA #1 then transported the Hoyer lift inside room [ROOM NUMBER], exited the room, retrieved a resident's Geri chair (a reclining chair) from the hallway, re-entered room [ROOM NUMBER] with the Geri chair, donned (applied) gloves and an isolation gown after entering the room and did not perform hand hygiene. On 1/27/2021 at 10:43AM, CNA #1 exited room [ROOM NUMBER] wearing eye protection and a KN95 mask holding the used gown and gloves in one hand and a wheelchair (w/c) footrest in the other hand. CNA #1 placed the gown and gloves in a bin outside the room and touched Resident #1 with her hand, as Resident #1. CNA #1 did not perform hand hygiene. She placed the w/c footrest in the seat of an empty w/c in hallway. CNA #1 then proceeded to walk down the hallway and entered room [ROOM NUMBER] to drop off a box of gloves without donning a gown and gloves. After exiting the room [ROOM NUMBER], she retrieved the Hoyer lift and wheeled it down the hallway, stopping at a hallway closet. CNA #1 entered a code on the keypad to open the closet and retrieved a plastic bag closed the door and walked down the hallway. She encountered Resident #1 in the hallway by the nursing station and assisted Resident #1 with adjusting their pants. CNA #1 continued walking down the hall delivered the plastic bag to another CNA. No hand hygiene was performed in between any of her tasks. CNA #1 walked back down the hallway and picked up a magazine on the floor near where Resident #2 was seated. She placed the magazine on the overbed table in front of Resident #2. CNA #1 then wheeled the Hoyer lift down the hallway to return it to the storage area. CNA #1 walked by the nursing station and entered room [ROOM NUMBER] wearing eye protection and a KN95 mask. She did not don an isolation gown or gloves or perform hand hygiene. CNA #1 briefly spoke to the resident and exited the room without performing hand hygiene. Then, she entered room [ROOM NUMBER] to greet a resident and exited the room. On 01/27/2021 at 11:01 AM, CNA #1 was interviewed and stated that she knows that she was supposed to do hand hygiene. She received training about hand hygiene and infection control. She stated hand hygiene is important to prevent passing of germs from one person to another, and it is most important due to COVID-19. On 01/27/2021 at 11:16 AM, the 3rd Floor Licensed Practical Nurse (LPN #1) was interviewed and stated that staff should wash hands in between patients and before entering and exiting rooms. She stated that we are in the COVID-19 pandemic, and this is a part of healthy hand hygiene. Staff should know they have to wash hands or use hand sanitizer after every interaction. She conducts rounds to make sure staff are washing hands and wearing proper Personal Protective Equipment (PPE) 3 to 4 times daily. On 01/27/2021 at 11:36 AM, the 3rd Floor Registered Nurse Supervisor (RN #1) was interviewed and stated hand hygiene should be completed after contact with a patient or objects and equipment in their environment. That is why the staff are surrounded by alcohol hand sanitizer. Hand hygiene should be completed to prevent contamination and the spread of viruses and bacteria. She stated, she completes rounds in the morning, before lunch, after lunch, and before she leaves to ensure staff are completing handwashing and adhering to infection control practices. On 01/27/2021 at 2:02 PM, the Director of Nursing (DON)/Infection Preventionist (IP) was interviewed and stated we talk to staff daily and let staff know what is going on in relation to COVID-19. The DON/IP stated she performs rounds in the morning and requires staff to review daily in-services with the charge nurse. Staff should perform hand hygiene to protect themselves and others. Staff should sanitize or wash hands before and after resident care, after touching surfaces they feel have soiled their hands, and after removing gloves. Hand washing is the single most important tool to prevent the transmission of infection. The third floor is on quarantine due to a nurse testing positive for COVID-19. The DON stated she completes hand hygiene observations two times per year. 415.19 (a)(1),(b)(4); 400.2

Based on observation, record review, and interview during the recertification survey, the facility did not ensure that the MDS accurately reflected the resident's status. Specifically, a resident's [MEDICAL TREATMENT] was not reflected on the Minimum Data Set (MDS) assessment. This was evident for 1 of 1 resident reviewed for MDS accuracy (Resident #140). The finding is: The CMS RAI Version 3.0 Manual (Dated (MONTH) (YEAR)), titled Procedure: General Information documented The RAI, MDS 3.0 process requires input from the health care team to complete the designated areas in a timely and accurate fashion in accordance with State and Federal regulations. Resident #140 was admitted [DATE] with [DIAGNOSES REDACTED]. On 10/25/19 at 09:38 am, the Quarterly Minimum Data Set (MDS), Assessment Reference Date (ARD) 09/30/2019, was reviewed. The MDS documented that the resident had intact cognition. There was no documentation that resident received [MEDICAL TREATMENT] while a resident in Section O - Special Treatment and Programs of the MDS. On 10/24/19 at 9:45 am, during the initial screening process, the resident was not on the unit. The Assistant Director of Nursing (ADNS) supervising the unit stated that resident went to the [MEDICAL TREATMENT] center. On 10/25/19 at 09:50 AM, the resident was interviewed. The resident stated that he has been going to the [MEDICAL TREATMENT] since admission every Tuesday, Thursday, and Saturday. The Comprehensive Care Plan (CCP) for [MEDICAL TREATMENT] updated 10/25/19, documented Resident on [MEDICAL TREATMENT] related to [MEDICAL CONDITION]. Interventions documented includes: Assist resident in preparing for transport to [MEDICAL TREATMENT] every Tuesday, Thursday, Saturday. The current physician's orders [REDACTED]. On 10/28/19 at 02:26 PM, an interview was conducted with the Registered Nurse/ MDS Coordinator (RN #1). RN #1 stated that when completing the MDS, she reviews the physician's orders [REDACTED]. She also interviews the residents. RN #1 stated that the resident's current MDS that did not include the resident's [MEDICAL TREATMENT] was an oversight and was corrected on 10/25/2019. RN #1 stated that the accuracy of MDS before submission is expected to be checked by the assessors that completed the different sections. The MDS coordinator checks for completeness of the MDS before final submission. The RN stated that the mistake is highly regrettable and stated that an in-service will be given to the MDS assessors to be more careful and to ensure accuracy in documentation. On 10/28/19 at 03:52 PM, Assistant Director of Nursing (ADNS) was interviewed. The ADNS stated that RNs and other Interdisciplinary Team members are responsible for assessment and documentation of the MDS. They are certified and trained and are expected to check for the accuracy of documentation. The MDS coordinator is responsible for checking for the completion before submitting the MDS. 415.11(b)

Based on interviews and record review conducted during an abbreviated survey (NY 156), the facility failed to initiate Cardiopulmonary Resuscitation (CPR) for a resident with full code status. This was evident for 1 out of 4 residents sampled (Resident #1). Specifically, on [DATE], Resident #1 was found unresponsive and the facility staff did not initiate CPR. The findings include: The facility's policy and procedure on Basic Cardiac Life Support (BCLS) dated ,[DATE] documented that if the resident does not have a Do Not Resuscitate (DNR) order, BCLS will be initiated. A resident with a DNR order is identified by a red dot sticker on the resident's identification (ID) band, and on the spine of the resident's chart. A resident who refuses to wear an ID band, a red dot is placed at the resident's door, next to his/her name. If CPR is not initiated, documentation will indicate resident is DNR. If a resident is found with clinical signs of death (no pulse, no blood pressure, no breath sounds, pupils fixed and dilated, cyanotic, cold skin, and signs of rigor mortis), a determination of death can be made by the RN. However, if these signs are noted on a resident who is not designated as DNR, CPR must be initiated by any healthcare provider who is CPR certified and can be deactivated when an order is given by the medical provider. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set, an assessment tool, dated [DATE], documented that Resident #1 had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation and ability to recall information) score ,[DATE], associated with severely impaired cognition (,[DATE] severe impairment, ,[DATE] moderate impairment and ,[DATE] cognitively intact). A Comprehensive Care Plan (CCP) dated [DATE] documented that Resident #1 had an Health Care Proxy (HCP). The updated CCP of [DATE] documented that Resident #1 was placed on Hospice for [DIAGNOSES REDACTED]. A nursing progress note dated [DATE] documented that Resident #1 was admitted to Hospice Care effective [DATE] due to [DIAGNOSES REDACTED].#1 continues to be Full Code as preferred by wife/Health Care Proxy. A Social Service evaluation note dated [DATE] documented that Resident #1 had significant change and was on Hospice Care for liver [MEDICAL CONDITION]. As of [DATE], Resident #1 had a Health Care Proxy, but no Advance Directives. A nursing progress note dated [DATE] at 4:45 AM documented that Resident #1 was asleep in bed, warm to touch, no pulse, no respiration, no blood pressure, and no Oxygen saturation. The Physician was called and pronounced Resident #1 deceased at 4:45 AM. Hospice service, Resident #1's wife and the Director of Nursing Services (DNS) were informed. Post mortem care provided. A Physician's progress note dated [DATE] at 4:35 PM documented that Resident #1 expired at 4:45 AM and the family was notified. CPR was not performed; code would have been futile. The Registered Nurse Supervisor (RNS) was interviewed on [DATE] at 11:55 AM and stated that the Licensed Practical Nurse (LPN) informed her that Resident #1 passed away. Resident #1 was cyanotic, she was unable to obtain oxygen saturation and pulse. Resident #1's wife was informed that Resident #1 expired and she said, do not do anything. The RNS further stated that Resident #1 was on Hospice and there was no red sticker (for DNR) on the chart. I did not know a resident can be on Hospice and Full Code Status at the same time. The LPN was interviewed on [DATE] at 9:50 AM and stated on [DATE] at approximately 4:45AM, a Certified Nursing Assistant (CNA) informed her that Resident #1 was unresponsive. The LPN checked Resident #1's chart and Hospice was all over the chart. She checked Resident #1 and he was unresponsive. The RNS was informed that Resident #1 expired and that he was on Hospice. The RNS came to the unit and took over. The LPN asked the RNS what needed to be done and the RNS called the Physician and Hospice representatives. Resident #1's primary Physician was interviewed on [DATE] at 11:11AM and stated that Resident #1's family wanted CPR, but that they never gotten around to it. He never discussed CPR with Resident #1's family. His documentation on [DATE], that CPR would be futile, was an opinion. The DNS was interviewed on [DATE] at 12:15PM and stated that as she was performing her daily Quality Assurance chart review, she noted that Resident #1 expired on [DATE]. Resident #1 was on Hospice and the chart documented that he was Full Code. The DON stated that the RNS did not perform CPR on Resident #1, because he was Hospice and the RNS assumed that the resident had an order for [REDACTED].>The DNS was interviewed on [DATE] at 12:00 PM and stated that when a resident is a full code, found unresponsive, CPR must be initiated immediately by any healthcare provider who is CPR certified. CPR can be deactivated when an order is given by the medical provider to stop the CPR. 415.11 © (3) (i)