Every finding on record at Grandell Rehabilitation And Nu

Based on record review and interviews conducted during a Recertification Survey initiated on 08/21/2025 and completed on 08/27/2025, the facility did not ensure that all alleged violations were thoroughly investigated in response to allegations of abuse, neglect, and mistreatment. This was identified for one (1) (Resident #256) of eight (8) residents reviewed for Accidents. Specifically, Resident #256 with impaired cognition was found on the floor on 06/24/2025. The incident was reported to the facility staff by the resident's roommate. The facility did not thoroughly investigate the incident and did not include a statement from the resident's roommate to identify the root cause of the incident.The finding is:The facility's policy titled Accident Incident Reporting, last revised 12/04/2023, documented that an accident/incident report should be completed if a resident had experienced a fall or a resident was discovered with an abrasion, bruise, or skin tear. The Nursing Supervisor and Licensed Nurses should complete the report. Any witness will write a statement as part of the investigation when the incident/accident occurred. All statements should be reviewed for completeness and accuracy before the change of shift. All incident/accident reports are reviewed by the Assistant Director of Nursing Services, Administrator, and the Medical Director/designee. Resident #256 was admitted with diagnoses including Parkinson's Disease, Alzheimer's Disease, and Anxiety Disorder. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 99, as the resident was unable to complete the interview. The Minimum Data Set assessment documented the resident was usually able to understand others.A Comprehensive Care Plan for Falls dated 10/11/2024, last revised on 08/22/2025, documented that the resident was at risk for falls related to diagnoses of Parkinsonism, Cerebral Infarction, Alzheimer's Disease, and Muscle Wasting and Atrophy. Interventions included but were not limited to ensure the resident had an appropriate call bell within reach, monitor the environment of the room for safety, well-lit and clutter-free free and establishing a customary routine of out of bed/bed to the bathroom. The care plan interventions were updated on 06/24/2025 to include toileting every two (2) hours.An Accident and Incident Report dated 06/24/2025 at 3:04 PM, initiated by Registered Nurse #1, documented that Resident #256 fell in their room. Resident #256's fall was unwitnessed, and the resident was unable to state what happened. The Accident and Incident Report indicated the incident was reported by Resident #256's roommate but did not identify who the roommate was. A staff statement dated 06/24/2025, written by Licensed Practical Nurse #3, documented that Resident #256's roommate saw the resident on the floor and reported to the nurse. Licensed Practical Nurse #3 notified the Registered Nurse Supervisor and triggered the Fall code (Mr. Trip).A nursing progress note dated 06/24/2025, written by Registered Nurse #1, documented that at 3:04 PM, Registered Nurse #1 was notified of Resident #256's fall by Fall code (Mr. Trip). Upon assessment, the resident was lying on their right side in front of their bed. Resident #256 denied hitting their head but complained of pain to their right hip, where a blue/purple ecchymotic (bruised) area was noted. Resident #256 was unable to state what happened, but their brief was soiled. Resident #256 appeared to have been trying to self-transfer to the bathroom. The Physician Assistant was notified and ordered x-rays of the right femur (thigh), bilateral hip, and pelvis. The summary of the investigation dated 06/24/2025 documented that on 06/24/2025, Resident #256 was observed lying on their right side on the floor adjacent to their bed in their room. Resident #256 was unable to recall the event secondary to cognitive impairment. The floor was dry and uncluttered. The investigation concluded that the root cause of the incident was related to the resident's lack of safety awareness and attempting to toilet themselves independently. There was no cause to believe abuse, mistreatment, or neglect occurred.The facility investigation did not include a written statement from Resident #256's roommate, who had initially reported the incident.During an interview on 08/26/2025 at 2:52 PM, Licensed Practical Nurse #3 stated they were at the nursing station at the time of the incident on 06/24/2025. Licensed Practical Nurse #3 stated that Resident #16, who was Resident #256's roommate, notified staff that Resident #256 was on the floor. Licensed Practical Nurse #3 stated they entered Resident #256's room and found the resident on the floor next to the bed. Licensed Practical Nurse #3 stated they did not witness how the fall occurred and did not interview Resident #16 to obtain their statement. During an interview on 8/27/2025 at 10:07 AM, Registered Nurse #1 stated they functioned as Charge Nurse on the 1st floor but were also the Registered Nurse Supervisor for the whole building as needed. Registered Nurse #1 stated they were responsible for initiating an accident/incident report, assessing the resident, notifying the medical provider and family, and ensuring that immediate interventions were put in place. Registered Nurse # 1 stated they were also responsible for conducting interviews with staff and residents as appropriate and obtaining statements. Registered Nurse #1 stated they did not recall if they interviewed and obtained a statement from Resident #256's roommate.During an interview on 08/27/2025 at 10:55 AM, the Director of Nursing Services stated the nursing supervisor should have interviewed all available witnesses, including residents and staff at the time of the incident, and obtained statements. The Director of Nursing Services stated the accident/incident report should be submitted to them, as the facility did not have a Risk Manager. The Director of Nursing Services stated they were responsible for conducting further interviews and collecting statements as necessary to summarize the investigation and determine the root cause of the incident and whether the incident was reportable to the New York State Department of Health. The Director of Nursing Services stated that all Accident and Incident reports should be reviewed and investigated thoroughly. The Director of Nursing Services was unable to identify Resident #256's roommate or locate a statement from Resident #256's roommate. The Director of Nursing Services stated there were unanswered questions in the investigation, and the accident/incident report should have included a statement from the resident's roommate.During an interview on 08/27/2025 at 1:02 PM, the Administrator stated they trusted the Director of Nursing Services to review all accident/incidents report to ensure they were completed and thoroughly investigated before a conclusion is drawn. 10 NYCRR 415.4 (b)(3)

Based on record review and staff interviews during the Recertification Survey initiated on 08/21/2025 and completed on 08/27/2025, the facility did not ensure that the resident maintained, to the extent possible, acceptable parameters of nutritional and hydration status. This was identified for one (1) (Resident #7) of six (6) residents reviewed for Nutrition. Specifically, Dietitian #1 recommended Resident #7 receive a liquid nutritional supplement of Glucerna Shake 240 milliliters twice daily for additional calories and protein; however, the supplement was never ordered. The finding is:The facility's policy titled, Nutritional Status and Recommendations, last reviewed/revised in December 2024, documented the Registered Dietitian will document in a progress note and communicate nutritional recommendations to the Primary Medical Doctor (PMD). The Primary Medical Doctor will review and order nutrition and hydration recommendations.Resident #7 had diagnoses that included Osteomyelitis (bone infection) and Left Above Knee Amputation. The significant change Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognitive skills for daily decision making. Section K - Swallowing/Nutritional Status documented the resident's height was 65 inches, and the resident's weight was 119 pounds. The Minimum Data Set did not indicate significant weight loss in one month or six months. The Dietary re-admission Progress Note dated 06/09/2025, written by Dietitian #1, who was no longer employed by the facility, documented: recommend Glucerna Shake 240 milliliters twice daily, which provided 180 kilocalories and 10 grams of protein per 8 fluid ounces (240 milliliters). The resident was at risk for Malnutrition due to a mechanically altered diet, help needed with feeding, incontinence, above-knee amputation with infection, impaired skin integrity, on pain medication, history of Lasix (a diuretic medication that reduces fluid retention and treats high blood pressure) use, poor intake, Diabetes Mellitus, and other comorbidities.A review of the resident's current Physician Orders revealed no documented evidence that the resident was receiving Glucerna Shakes.A review of the resident's Medication Administration Records (MARs) dated June 2025, July 2025, and August 2025 revealed no documented evidence that the resident was ever provided with Glucerna Shakes.Dietitian #1 was not available for an interview as they no longer worked at the facility. During an interview on 08/26/2025 at 11:00 AM, Registered Dietitian #1 stated that Dietitian #1 (former) was responsible for entering a Physician's Order into the resident's Electronic Medical Record for the Glucerna Shakes they were recommending for the resident's Physician to sign.During a second interview on 08/26/2025 at 12:45 PM, Registered Dietitian #1 stated they would ensure the resident's Physician ordered the Glucerna Shakes today, to prevent the resident from weight loss and help with wound healing. 10 NYCRR 415.12(i)(1)

Based on record review and interviews during the Recertification Survey initiated on 08/21/2025 and completed on 08/27/2025, the facility did not ensure the Facility Assessment was updated to reflect the actual staffing levels. Specifically, the Facility assessment dated [DATE] inaccurately reflected the number of Registered Nurse Supervisors needed during the 11:00 PM-7:00 AM shifts and the number of Registered Nurses needed on the first floor during the 7:00 AM-3:00 PM shifts.The finding is:The facility policy, titled Facility Assessment, dated 01/15/2024, documented the interdisciplinary team members will conduct a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. The interdisciplinary team will review and update the assessment as necessary and at least annually. The interdisciplinary team will also review and update the assessment whenever there are, or the facility plans for, any changes that would require a substantial modification to any part of the assessment.The Facility assessment dated [DATE] documented under the heading: Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies two Registered Nurse supervisors on the 11:00 PM-7:00 AM shift and one Registered Nurse for the 7:00 AM- 3:00 PM shift on the first-floor nursing unit.Review of the projected staffing sheet for 08/22/2025 revealed three (3) Licensed Practical Nurses were scheduled for the first floor during the 7:00 AM-3:00 PM shift, and one Registered Nurse supervisor was scheduled for the 11:00 PM-7:00 AM shift.During an interview on 08/27/2025 at 9:34 AM, Staffing Coordinator #1 stated there are six nursing units at the facility, and each unit is staffed per shift based on the number of nursing staff listed on the par level (the minimum number of staff needed) sheet. Staffing Coordinator #1 stated staffing is not a problem as the facility utilizes a staffing agency to fill nursing staffing needs. Staffing Coordinator #1 stated there is only one Registered Nurse Supervisor required during the 11:00 PM-7:00 AM shift, according to the par level sheet. Staffing Coordinator #1 stated the first floor no longer had a Registered Nurse during the 7:00 AM-3:00 PM shift because the Registered Nurse position was replaced by a Licensed Practical Nurse.A review of the par level sheet revealed three Licensed Practical Nurses were required on the first-floor nursing unit during the 7:00 AM-3:00 PM shift and one Registered Nurse Supervisor for the 11:00 PM-7:00 AM shift.During an interview on 08/27/2025 at 10:50 AM, the Director of Nursing Services stated the Administrator entered the staffing numbers in the Facility Assessment. On the 11:00 PM-7:00 AM shift, the facility usually has one Registered Nurse supervisor assigned, but sometimes an extra Registered Nurse is scheduled to work, because there are a lot of admissions at night. The Facility Assessment documented the need for two Registered Nurse Supervisors during the 11:00 PM-7:00 AM shift and used the staffing on 03/06/2025 and 03/08/2025 as a guide; however, the staffing listed in the facility assessment related to Registered Nurse Supervisor and the Registered Nurse on the first floor is not constant.During an interview on 08/27/2025 at 11:17 AM, the Administrator stated they reviewed the staffing for 03/06/2025 and 03/08/2025 to document the staffing needs in Facility Assessment, but the numbers indicated in the Facility Assessment did not reflect daily staffing needs. The Registered Nurse requirement documented in the Facility Assessment for the first floor during the 7:00 AM-3:00 PM shift was no longer valid because the Licensed Practical Nurse replaced the Registered Nurse position. The change occurred about a month ago. The par levels have changed since the Facility Assessment was updated in March 2025, and the facility only needs one Registered Nurse Supervisor during the 11:00 PM-7:00 AM shift. 10 NYCRR 415.26

Based on record review and interviews during the Recertification Survey initiated on 08/21/2025 and completed on 08/27/2025, the facility did not ensure the Minimum Data Set assessment was completed to accurately reflect each resident's status. This was identified for one (1) (Resident #142) of three (3) residents reviewed for Transmission Based Precautions and for one (1) (Resident #7) of six (6) residents reviewed for Nutrition. Specifically, 1) Resident #142's Interim Payment Assessment (IPA), dated 07/25/2025, did not correctly reflect Resident #142's Isolation or Quarantine status for an active infectious disease. 2) Resident #7 had a significant weight loss, which was not identified in the significant change Minimum Data Set assessment dated [DATE]. The findings are: The facility's policy titled Comprehensive Assessment and Comprehensive Care Planning Process, last revised on 12/2024, documented that the Registered Professional Nurse, in collaboration with other disciplines, resident, and designated representative, shall be responsible for developing a comprehensive assessment (Minimum Data Set 3.0) for each resident within 14 days following admission. The Minimum Data Set (MDS) coordinator is responsible for coordinating the assessment and care planning process in order to ensure the timely and accurate completion of the Minimum Data Set (MDS) and care plan. The breakdown of completion included Section K for Nutritional Services and Section O for Special Treatment, Procedures, and Programs to be completed by Nursing and the Minimum Data Set coordinator. All disciplines completing the section in the assessment are required to sign for their section. The Minimum Data Set coordinator, who is a Registered Nurse, is mandated to sign the Minimum Data Set to verify accuracy and completion. 1) Resident #142 was admitted with diagnoses including Candidiasis (a fungal infection caused by an overgrowth of the yeast Candida), Type 2 Diabetes, and Chronic Kidney Disease. The Interim Payment Minimum Data Set assessment, dated 07/25/2025, documented a Brief Interview for Mental Status score of 15, which indicated that Resident #142 had intact cognition. The Interim Payment Minimum Data Set assessment Section I (Active Diagnoses) documented that Resident #142 had a Multidrug Resistant Organism (microorganisms that have developed resistance to multiple classes of antimicrobial drugs, making infections difficult to treat). The Interim Payment Minimum Data Set assessment, Section O (Special Treatments, Procedures, and Programs), did not document that Resident #142 was on Isolation or Quarantine for an active infectious disease. A Physician's Order dated 04/16/2025 documented Contact Precautions for positive Candida Auris (a multidrug-resistant fungus that can cause severe, invasive infections). A Comprehensive Care Plan (CCP) dated 04/15/2025 titled, Candida Auris documented interventions including contact isolation protocol as ordered, observe for signs and symptoms of infection, and provide staff and resident education. During an observation on 08/21/2025 at 11:28 AM, Resident #142 was in bed. A sign was posted outside Resident #142's room documenting that Resident #142 was on Contact Precautions. The instructions on the sign included wearing a gown and gloves before entering the room, and performing hand hygiene before and after entering Resident #142's room. During an interview on 08/26/2025 at 1:39 PM, the Minimum Data Set Director stated that Section O of the Minimum Data Set (MDS) assessment should have documented that Resident #142 was on Isolation for an active infectious disease. The Minimum Data Set Director stated that the missing information was an omission on their part, and they should have checked the Minimum Data Set assessment for accuracy. During an interview on 08/27/2025 at 8:43 AM, the Director of Nursing Services stated all Minimum Data Set assessments should be accurate and reflect the resident's condition. 2) Resident #7 had diagnoses that include Osteomyelitis (bone infection) and Left Above Knee Amputation. The significant change Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognitive skills for daily decision making. Section K - Swallowing/Nutritional Status documented the resident's height was 65 inches, and the resident's weight was 119 pounds. The Minimum Data Set documented that the resident had no weight gain or loss of 5% or more in the last one (1) month or 10% or more in the last six (6) months. Section K was completed by Dietitian #1 on 06/18/2025. The resident's weight history documented the resident weighed 132.8 pounds on 04/16/2025 and 119 pounds on 05/13/2025, which reflected a 10.39% weight loss in one (1) month. The resident weighed 142 pounds on 11/13/2024 and 119 pounds on 05/13/2025, which reflected a 16.20% weight loss in six (6) months. Dietician #1 was not available for an interview as they no longer worked at the facility. During an interview on 08/26/2025 at 11:00 AM, Registered Dietitian #1 stated Dietitian #1 (former) should have documented in the resident's significant change Minimum Data Set (MDS) assessment dated [DATE] the resident's weight of 119 pounds reflected a weight loss of 5% or more in the last one (1) month and a weight loss of 10% or more in the last six (6) months. During an interview on 08/27/2025 at 9:55 AM, the Minimum Data Set Director stated each discipline was responsible for the accuracy of their own section when completing a resident's Minimum Data Set assessment. The Minimum Data Set Director stated they did not review every section of the Minimum Data Set assessment for accuracy and that their signature on any Minimum Data Set assessment was only attesting to the fact that the Minimum Data Set assessment was complete. During an interview on 08/27/2025 at 1:10 PM, the Director of Nursing Services stated the Minimum Data Set Director was responsible for the completion and ensuring accuracy of all sections of the Minimum Data Set, not just the sections that pertain to nursing. 10 NYCRR 415.11(b)

Based on observation, record review, and interviews during the Recertification Survey initiated on 3/4/2024 and completed on 3/8/2024 the facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles. This was identified for one (Resident #156) of six residents observed during medication administration task. Specifically, the label on Resident #156's eye drop medication bottle, Timolol (administered for Glaucoma), did not match the physician's order. The finding is: The facility's policy titled Administration of Ophthalmics, dated 5/2/2023, documented for the nurses to check medication labels against medication administration records three times to ensure the correct resident, drug, dose, and time of administration. Resident #156 was admitted with diagnoses including Multiple Sclerosis, Muscle Wasting and Atrophy, and Peripheral Vascular Disease. The 2/12/2024 Quarterly Minimum Data Set assessment documented a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. The Minimum Data Set documented the resident had adequate vision. An Optometry consult dated 1/23/2023 documented that the resident had Glaucoma and to add Timolol 0.5% one drop to both eyes each day. A physician's order effective 1/27/2023 and active as of 3/5/2024 documented Timolol Maleate Ophthalmic Solution 0.5 %, 1 drop(s) to both eyes every day for unspecified open-angle Glaucoma, indeterminate stage. A review of the Medication Administration Record for March 2024 revealed that Timolol Maleate Ophthalmic Solution 0.5 %, one drop to both eyes was administered from 3/1/2024 through 3/5/2024 every day as evidenced by staff signature. During the medication pass observation on 3/5/2024 at 8:22 AM, Licensed Practical Nurse #2 prepared medications to be administered to Resident #156. The label on the Timolol eye drops documented one drop into the affected eye(s) each day. The surveyor asked the nurse which eye was the affected eye. Licensed Practical Nurse #2 stated the resident usually just wants the medication in the left eye. Licensed Practical Nurse #2 then read the eye drop bottle label and stated that the label on the bottle was unclear and did not match the physician's order. Licensed Practical Nurse #2 stated the eye drop bottle label should be changed to match the physician's order. On 3/5/2024 at 8:25 AM, as Licensed Practical Nurse #2 was administering the Timolol eye drops, the resident stated they (resident) wanted the eye drops to their left eye only. Pharmacist #1 was interviewed on 3/5/2024 at 10:03 AM and stated the label on the medication bottle should be specific. Pharmacist #1 stated they did not know why the Timolol medication label did not match the physician's order. Pharmacist #1 stated there may have been a coding error; however, the label should have been corrected by the Pharmacist who filled the order. Registered Nurse #2 (unit charge nurse) was interviewed on 3/5/2024 at 10:54 AM and stated they are going to speak to the resident to educate them that the Timolol drops are for both eyes, and this is what the doctor prescribed. Registered Nurse #2 stated the nurses administering medications should have identified the discrepancy and brought the discrepancy to their attention. A nursing note dated 3/5/2024 at 11:14 AM, written by Registered Nurse #2, documented that on 1/23/2023 the physician ordered Timolol ophthalmic solution one drop to both eyes; however, the resident informed the writer today (3/5/2024) that the resident only wants the drops to the left eye. The writer spoke to a physician who gave a telephone order to change the Timolol order to one drop to the left eye only. The writer educated the resident that the Timolol medication was for treating Glaucoma in both eyes. The resident was aware but only wanted the drop to the left eye. The Director of Nursing Services was interviewed on 3/7/2024 at 9:15 AM and stated the medication nurse should have brought the discrepancy to the charge nurse's attention sooner to have the order clarified because the medication label should match the physician's order. The Director of Nursing Services stated that the Physician should have been notified sooner that the resident only wanted the drop in the left eye. 10 NYCRR 415.18(d)

Based on observations, record review, and interviews during the Recertification Survey initiated on 3/4/2024 and completed on 3/8/2024, the facility did not ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice. This was identified for one (Resident #233) of six residents reviewed for Respiratory Care. Specifically, Resident #233 had a physician's order to receive oxygen at 3-10 Liters per minute via a nasal cannula. There were no physician's orders or parameters established to guide the facility staff on when and how much oxygen to administer to the resident (3-10 liters per minute) based on the resident's clinical condition. The finding is: The facility's policy and procedure titled, Oxygen Therapy, last revised on 11/22/2021 documented that residents will be provided with oxygen therapy as ordered by the medical doctor. The delivery of supplemental oxygen will be provided in a safe, efficient manner by competent staff. The nurse will place the delivery system on the resident and adjust flow rates ordered by the medical doctor. The nurse will monitor the response to oxygen therapy, noting respiratory rate and oxygen saturation (oxygen level in the blood). The nurse will check the liter flow on the tank and the concentrator and sign the treatment record each shift. Resident #233 was admitted with diagnoses of Malignant Neoplasm of Intrathoracic Lymph nodes, Pneumonia, and Neuromuscular Dysfunction of the Bladder. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 15 which indicated that Resident #233 was cognitively intact. The Minimum Data Set documented the resident utilized oxygen therapy. A Comprehensive Care Plan (CCP) titled, Breathing Pattern, dated 12/30/2023 documented COVID-19 Positive and a history of Cancer with Lung Metastases (cancer that starts in one part of the body and spreads to the lungs). The interventions included but were not limited to administering oxygen at 3-10 Liters per minute via nasal cannula, monitoring oxygen saturation as ordered by the Physician, and ongoing monitoring and assessment of the respiratory status. A Physician's Order dated 1/4/2024 documented to administer oxygen at 3-10 Liters per minute via nasal cannula every shift. Obtain oxygen saturation every shift. Change the oxygen tubing weekly and clean the oxygen concentrator filter once a week. There were no parameters included in the oxygen orders to indicate established parameters regarding when to administer 3 liters to 10 liters of oxygen. Resident #233 was observed on 3/4/2024 at 11:46 AM lying in bed and receiving oxygen from an oxygen concentrator at 8 Liters per minute via a nasal cannula. A subsequent observation was completed on 3/5/2024 at 9:07 AM. Resident #233 was observed in bed and was receiving oxygen from an oxygen concentrator at 8 Liters per minute via a nasal cannula. During an observation on 3/6/2024 at 12:07 PM, Resident #233 was observed in bed receiving oxygen from an oxygen concentrator at 10 Liters per minute via a nasal cannula. The Medical Director, who was also the resident's Primary Care physician, was interviewed on 3/6/2024 at 3:28 PM and stated that Resident #233 is on comfort care. Resident #233 started on a low dose of oxygen, but the oxygen saturation level dropped at times. The Medical Director stated that there were no parameters to determine the amount of oxygen to be administered and this was an oversight on their part. Certified Nursing Assistant #3 was interviewed on 3/7/2024 at 8:30 AM and stated that Resident #233 was alert and oriented but at times Resident #233 did not wear the oxygen cannula properly. Certified Nursing Assistant #3 stated if Resident #233 has shortness of breath or is in respiratory distress they would notify the nurse. Licensed Practical Nurse #6 was interviewed on 3/7/2024 at 10:30 AM and stated that they check the resident's oxygen saturation level every shift and would change the level of oxygen if Resident #233 complained of respiratory distress or shortness of breath and would call the Physician if the oxygen saturation level was below 90%. Licensed Practical Nurse #6 stated that there were no parameters for the oxygen saturation level or when to call the Physician. Licensed Practical Nurse #6 stated the resident has an order for oxygen to be administered at 3-10 liters per minute via nasal cannula. Registered Nurse #5 was interviewed on 3/7/2024 at 11:59 AM and stated that Resident #233 has a physician's order to administer Oxygen from 3-10 Liters per minute via nasal cannula. Registered Nurse #5 stated that they check the resident's oxygen saturation level and call the Physician if the oxygen saturation level is below 90%; however, the physician's order did not include the oxygen saturation level parameter. Registered Nurse #5 was unable to state how they determined the amount of oxygen to be administered to the resident as the physician's order has a broad range of 3-10 liters per minute. The Director of Nursing Services was interviewed on 3/7/2024 at 4:00 PM and stated that Resident #233 should have the parameters documented for the oxygen order of 3-10 Liters per minute. The order to check the oxygen saturation level every shift should be clear and should include parameters to indicate what amount of oxygen should be used based on the oxygen saturation levels. 10 NYCRR 415.12(k)(6)

Based on observations, record review, and interviews during the Recertification Survey initiated on 3/4/2024 and completed on 3/8/2024, the facility did not ensure that a comprehensive person-centered care plan (CCP) was implemented to meet the resident's medical and nursing needs to include the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. This was identified for one (Resident #156) of six residents observed during the medication administration task Specifically, Resident #156 had a physician's order to administer Timolol Maleate Ophthalmic solution eye drops to both eyes every day for Glaucoma. The comprehensive care plan initiated on 7/6/2020 for the visual function was not updated to reflect the administration of the Timolol Maleate Ophthalmic solution eye drops until 3/5/2024. The finding is: The facility's policy and procedure titled, Care Plans effective 2/14/2019 reviewed and updated on 6/1/2023 documented a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. Resident #156 was admitted with diagnoses including Multiple Sclerosis, Muscle Wasting and Atrophy, and Peripheral Vascular Disease. The 2/12/2024 Quarterly Minimum Data Set assessment documented a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. The Minimum Data Set documented the resident had adequate vision. An Optometry consult dated 1/23/2023 documented that the resident had Glaucoma and to add Timolol 0.5% one drop to both eyes each day. A physician's order effective 1/27/2023 and active as of 3/5/2024 documented Timolol Maleate Ophthalmic Solution 0.5 %, 1 drop(s) to both eyes every day for unspecified open-angle Glaucoma, indeterminate stage. A Comprehensive Care Plan titled Visual Function effective 7/6/2020 was last updated on 3/5/2024 with a new intervention to administer Timolol Maleate Ophthalmic Solution 0.5%, 1 drop to the left eye every day. No other previous updates or interventions in the care plan addressed the use of eye drops. During the medication pass observation on 3/5/2024 at 8:22 AM, Licensed Practical Nurse #2 prepared medications to be administered to Resident #156. The label on the Timolol eye drops documented one drop into the affected eye(s) each day. The surveyor asked the nurse which eye was the affected eye. Licensed Practical Nurse #2 stated the resident usually just wants the medication in the left eye. Licensed Practical Nurse #2 then read the eye drop bottle label and stated that the label on the bottle was unclear and did not match the physician's order. Licensed Practical Nurse #2 stated the eye drop bottle label should be changed to match the physician's order. On 3/5/2024 at 8:25 AM, as Licensed Practical Nurse #2 was administering the Timolol eye drops, the resident stated they (resident) wanted the eye drop to their left eye only. Registered Nurse #2 (unit charge nurse) was interviewed on 3/5/2024 at 10:54 AM and stated they were going to speak to the resident to educate them that the Timolol drops are for both eyes, and this is what the doctor prescribed. Registered Nurse #2 stated the nurses administering medications should have identified the discrepancy and brought the discrepancy to their attention. A nursing note dated 3/5/2024 at 11:14 AM, written by Registered Nurse #2, documented that on 1/23/2023 the physician ordered Timolol ophthalmic solution one drop to both eyes; however, the resident informed the writer today (3/5/2024) that the resident only wants the drops to the left eye. The writer spoke to a Physician who gave a telephone order to change the Timolol order to one drop to the left eye only. The writer educated the resident that the Timolol medication was for treating Glaucoma in both eyes. The resident was aware but only wanted the drop to the left eye. The Director of Nursing Services was interviewed on 3/7/2024 at 9:15 AM and stated the medication nurse should have brought the discrepancy to the charge nurse's attention sooner to have the order clarified because the medication label should match the physician's order. The Director of Nursing Services stated that the physician should have been notified sooner that the resident only wanted the drop in the left eye. The Director of Nursing Services further stated that the comprehensive care plan should reflect the resident's current clinical status and preference. 10 NYCRR 415.11 (c)(1)

Based on observation, record review, and interviews during the Recertification Survey initiated on 3/4/2024 and completed on 3/8/2024 the facility did not ensure that each resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. This was identified for one (Resident #192) of three residents reviewed for skin conditions. Specifically, Resident #192, with a chronic large salivary gland mass with a history of intermittent oozing from the mass, was observed on 3/4/2024 with a dressing to the right side of the jaw/neck area. The Electronic Medical Record lacked documented evidence of a physician's order for the dressing or treatment to the affected site. The finding is: The facility's policy titled Wound Care Treatments, effective 12/2/2017, last revised 6/14/2021, documented to check physician orders for the resident's treatment and document that treatment was completed in the Electronic Medical Record. Resident #192 was admitted with diagnoses including Non-Alzheimer's Dementia, Chronic Obstructive Pulmonary Disease, and Hypertension. The 12/6/2023 Quarterly Minimum Data Set assessment documented a Brief Interview for Mental Status score of 10, indicating the resident had moderate cognitive impairment. There were no ulcers, wounds, or skin problems documented in the Minimum Data Set assessment. Resident #192 was observed in bed on 3/4/2024 at 9:16 AM. There was an updated dressing to the right side of the face near the rear part of the jaw and neck area. The resident stated they (resident) did not know what the condition was that required the dressing but It leaks all over. A review of the medical record revealed that there was no physician's order for the dressing or treatment to the resident's right jaw/neck area. A Comprehensive Care Plan titled Other Skin Problems, initiated 4/4/2023 and last updated 3/5/2024, documented on 4/4/2023: dermatological disorder, large protruding mass at the right side of neck, resident states it is an enlarged salivary gland that has been there for years. Interventions included to administer treatment as ordered, monitor for effectiveness of treatment, and to notify the physician of any changes. The care plan was updated on 3/5/2024 with an intervention to clean the mass to the right neck with normal saline, pat dry and apply a small clean dressing daily as per the resident's preference. An ultrasound report dated 9/23/2022 documented an area of concern, right ear showed complex soft tissue mass measuring 37 millimeters x 25 millimeters. Further evaluation with Magnetic Resonance Imaging is recommended. A Dermatology consult dated 4/10/2023 documented the patient was seen for a large salivary gland mass that developed a blister on it. Previously, the family declined further work-ups with an Ear, Nose, and Throat physician who recommended Magnetic Resonance Imaging to rule out underlying malignancy. The area has grown larger over the past few months. The patient would like to keep the area covered with a 3 inch x 5 inch bordered gauze. The Dermatologist recommended a re-evaluation with an Ear, Nose, and Throat physician and a Magnetic Resonance Imaging if the patient and Health Care Proxy agree. A review of the comprehensive care plan revealed that the intervention to keep the area covered at all times as per the resident's preference was not added until 3/5/2024. Licensed Practical Nurse #3, the 2nd-floor charge nurse, was interviewed on 3/4/2024 at 12:38 PM. Licensed Practical Nurse #3 stated they did not apply the dressing to the resident's jaw or neck area and did not know that the resident needed the dressing. Licensed Practical Nurse #3 stated the dressing may have been put on by one of the nurses from the previous shifts. Licensed Practical Nurse #3 advised the surveyor to check with the wound care nurse regarding the dressing. Licensed Practical Nurse #3 stated they think the dressing is covering a mass that the resident has had for a while. Registered Nurse #4, the wound care nurse, was interviewed on 3/4/2024 at 12:48 PM and stated the resident has a mass on the right side of the jaw and neck area, and from time to time the mass oozes. The resident's family refused a follow-up or surgery. The mass is covered when it is needed to be covered as per the resident's preference. The drainage from the mass is intermittent and comes and goes; however, there should be an order for the dressing to be applied as needed. A progress note written by Registered Nurse #4 dated 3/5/2024 at 9:34 AM documented that after speaking with the resident they (resident) preferred to have the mass on their right neck covered with a bandage daily. The resident told Registered Nurse #4 that sometimes the mass has drainage and drips. The resident stated they prefer to have the mass covered at all times. A physician's order dated 3/5/2024 documented to cleanse the mass to the right neck with normal saline, pat dry, and apply a small clean dry dressing daily as per the resident's preference. A review of the March 2024 Treatment Administration Record revealed no entry for the dressing change to the right neck mass until 3/5/2024. On 3/6/2024 at 8:58 AM the mass on Resident 192's right face/neck area was observed with Registered Nurse #4 (wound care nurse). Registered Nurse #4 removed the dressing, which revealed a large growth that was reddened with a small, circular dark opening in the middle. The dressing appeared to be dry. Physician Assistant #1 was interviewed on 3/6/2024 at 10:43 AM and stated that the resident's family did not want to pursue any further aggressive treatment for the mass and wanted to keep the resident comfortable. Physician Assistant #1 stated they did not know why there was no dressing change order because there was potential for infection. The Director of Nursing Services was interviewed on 3/7/2024 at 9:21 AM and stated at times there is drainage from the mass, but the drainage is not constant. The Director of Nursing Services stated that, at a minimum, there should have been an as-needed treatment order in place. Licensed Practical Nurse #4, who worked the 11:00 PM-7:00 AM shift on 3/3/2024-3/4/2024, was interviewed on 3/7/2024 at 2:04 PM. Licensed Practical Nurse #4 stated they did not administer any treatment to Resident #192. Licensed Practical Nurse #4 stated the dressing was most likely placed by the 3:00 PM-11:00 PM nurse on 3/3/2024. Licensed Practical Nurse #5, who worked the 3:00 PM-11:00 PM shift on 3/3/2024, was interviewed on 3/7/2024 at 2:11 PM. Licensed Practical Nurse #5 stated they could not recall anything related to Resident #192's treatment administration. Licensed Practical Nurse #5 stated if there was an order for the dressing change, then they signed for the treatment and administered the treatment. If there was no order, then they did not administer the treatment. 10 NYCRR 415.12

Based on observation, record review, and interviews during the Recertification Survey, the facility did not ensure that all investigations were thoroughly investigated to rule out abuse, neglect, exploitation, or mistreatment. This was identified for one (Resident #206) of eight residents reviewed for Accidents. Specifically, Resident #206 was noted with swelling and ecchymosis (bruise) of unknown source to the left shoulder and chest on 1/5/2024. The facility did not have documented evidence that an investigation was conducted to rule out abuse, neglect, or mistreatment. The finding is: The facility policy titled, Accident Incident Reporting dated 12/4/2023 documented that if a staff member discovers an abrasion, bruise, or skin tear on a resident an accident/incident report should be completed. Appropriate statements will be requested by personnel who may have been involved, or on the unit, or at the site. If the incident/accident is reported to the nurse by a certified nurse aide, the certified nurse aide must write a statement. For unwitnessed occurrences or injuries of unknown origin, statements will be obtained from staff on the shift when the injury was identified and from staff members who were responsible for caring for the resident for the prior 48-72 hours. Resident #206 was admitted with the diagnoses of Dementia, Anxiety Disorder, and Delusional Disorder. The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #206 had a Brief Interview for Mental Status score of 99, indicating severely impaired cognition. The resident required moderate assistance of one person where the helper does less than half of the effort for upper body dressing, transfers, and ambulation. The Comprehensive Care Plan entitled, At Risk for Falls dated 6/9/2023 and revised on 1/2/2024 documented that Resident #206 was at risk for falls due to Dementia and Anxiety Disorder. The interventions included to provide close oversight, dayroom supervision, and bilateral rubber mats on both sides of the bed. The Accident/Incident report dated 1/2/2024 documented that at 7:30 AM Resident #206 was observed lying on their left side on their roommate's floor mat. Resident #206 was alert, ambulatory, and had no visible injury. The undated accident incident summary documented that Resident #206 was unable to state how they (Resident #206) fell due to cognitive deficits. Resident #206 had no complaints of pain, and no injuries were noted. The Physician was notified of the fall. The root cause of the fall was cognitive impairment. The added intervention to prevent reoccurrence was to place Resident #206 in the day room when out of bed for close monitoring. A review of nursing progress notes on 1/3/2024 and 1/4/2024 revealed that there were no signs and symptoms of pain, discomfort, distress, or delayed injury during the post-fall observations. Resident #206 received 30-minute visual monitoring. Resident #206 was noted to have periods of restlessness and made attempts to get out of the wheelchair unassisted. The nursing progress note dated 1/5/2024 at 7:36 AM, written by Licensed Practical Nurse #8, documented Resident #206 was noted with a large discoloration and swelling to the left shoulder. The injury was tender to the touch. Licensed Practical Nurse #8 documented that the injury was likely due to a recent fall on 1/2/2024. Registered Nurse #2 was made aware, and the plan of care was discussed. The nursing progress note dated 1/5/2024 at 7:36 AM, written by Registered Nurse #1, documented Resident #206 was noted to have discoloration on the left shoulder. A documented fall occurred on 1/2/2024 during which Resident #206 was discovered lying on the left side on the roommate's floor mat with no apparent injuries. This morning (1/5/2024), Resident #206 was experiencing pain, holding the shoulder, and a purple discoloration was discovered on their left shoulder. Resident #206 had limited range of motion due to the pain. The nursing progress note dated 1/5/2024 at 2:18 PM documented that Resident #206 received an X-ray of the left shoulder. The nursing progress note dated 1/5/2024 at 3:36 PM, written by Registered Nurse #2, documented they (Registered Nurse #2) were called to the unit to speak with Resident #206's family at the bedside. Resident #206 was status post fall, and the family requested an emergency room evaluation due to edema and ecchymosis to the left shoulder and chest. Range of motion was limited, and Resident #206 was hunched over, voicing complaints of pain. The Nurse Practitioner was made aware and agreed to transfer the resident to the emergency room . A nursing progress note dated 1/6/2024 at 1:59 AM documented that Resident #206 returned to the facility at 9:50 PM on 1/5/2024 from the hospital with a diagnosis of a left clavicle (collar bone) fracture. Resident #206 was stable with no complaints of pain or discomfort. A review of Accident and Incident reports revealed that there was no investigation conducted on 1/5/2024 related to Resident #206's identified injury. Resident #206 was observed seated with an arm sling in a high-back wheelchair in the 6th floor dining room on 3/4/2024 at 1:03 PM. Licensed Practical Nurse #8, the 7:00 AM-3:00 PM nurse, was interviewed on 3/8/2024 at 11:15 AM. Licensed Practical Nurse #8 stated that they were assigned to Resident #206 during the day shift. Licensed Practical Nurse #8 stated that they initiated the Accident Incident report on 1/2/2024 when the assigned Certified Nurse Aide reported finding Resident #206 on the floor mats. Licensed Practical Nurse #8 stated that on 1/5/2024 at 7:30 AM, Certified Nursing Assistant #8 was assigned to Resident #206 and had reported to them (Licensed Practical Nurse #8) that Resident #206 had discoloration of the left shoulder. Licensed Practical Nurse #8 stated they observed Resident #206 and it appeared that the bone was protruding from Resident #206's left shoulder; however, the protruding bone did not break through the skin. Licensed Practical Nurse #8 stated that the area was also discolored. Licensed Practical Nurse #8 stated that they did not recall speaking to the 11:00 PM-7:00 AM staff about the injury and they did not report the injury at the change of their shift. Licensed Practical Nurse #8 stated that they reported the injury to Registered Nurse Supervisor #1. Licensed Practical Nurse #8 stated that they initiated the fall Accident Incident Report on 1/2/2024 but did not initiate a new report on 1/5/2024 because the injury was on the same affected side (left side) from the 1/2/2024 fall. Licensed Practical Nurse #8 stated that they assumed that the injury was from the fall on 1/2/2024 and did not consider that a new incident may have occurred. Licensed Practical Nurse #8 stated Resident #206 had no complaints of pain between 1/2/2024 to 1/4/2024 and they (Licensed Practical Nurse #8) did not observe any injuries. Certified Nurse Aide #8 was interviewed on 3/8/2024 at 11:22 AM. Certified Nurse Aide #8 stated that on 1/5/2024 at 7:30 AM, they (Certified Nurse Aide #8) went to provide morning care to Resident #206 and observed that Resident #206's collar bone was sticking up on the left shoulder. Resident #206 complained of shoulder pain on the left side while Certified Nurse Aide #8 attempted to get Resident #206 dressed. Certified Nurse Aide #8 stated that the previous shift Certified Nurse Aide did not report any changes. Certified Nurse Aide #8 stated that they (Certified Nurse Aide #8) usually do provide a statement for a new injury but could not remember if they wrote a statement on 1/5/2024. Certified Nurse Aide #8 stated that they must report a new injury because something new could have happened to Resident #206. Registered Nurse #1 was interviewed on 3/8/2024 at 11:40 AM. Registered Nurse #1 stated that they are the Registered Nurse Supervisor on the 7:00 AM-3:00 PM shift. On 1/5/2024 at 7:30 AM, Licensed Practical Nurse #8 reported Resident #206 had an injury to the left shoulder. Registered Nurse #1 assessed Resident #206 and observed discoloration and a small bump on the left shoulder. Registered Nurse #1 called the Nurse Practitioner who ordered an X-ray. Registered Nurse #1 stated that they were not sure if the bump was anything more than a swelling. Registered Nurse #1 stated that they did not speak to the previous shift because the staff from the previous shift were already gone at 7:30 AM. Registered Nurse #1 stated they did not initiate a new Accident Incident Report because they assumed that the injury was related to the fall that occurred on 1/2/2024. Registered Nurse #1 stated that they did not get statements from the previous shift to ensure that no new incidents had occurred. Registered Nurse #1 stated that they did review the nurse's note from the previous shift which documented that there were no complaints of pain or injuries. Registered Nurse #1 stated that they believed the injury that was identified on 1/5/2024 was from the 1/2/2024 fall. Registered Nurse #2 was interviewed on 3/8/2024 at 11:50 AM and stated that they wrote the investigation summary for the 1/2/2024 fall and did not know when they concluded the investigation as the investigation summary was not dated. Registered Nurse #2 stated that on 1/5/2024, they were called by Resident #206's family who reported the bruising and bone protrusion to Registered Nurse #2. Resident #206's family requested an emergency room visit to address Resident #206's injury. RN #2 stated that they assumed that the injury was from the fall on 1/2/2024 and did not initiate a new Accident Incident report. Registered Nurse #2 did not communicate with the previous shifts on 1/5/2024 to determine if Resident #206 had any new accidents or incidents after the 1/2/2024 fall. The Director of Nursing Services was interviewed on 3/8/2024 at 12:13 PM and stated that they reviewed the 1/2/2024 Accident Incident report on 1/4/2024. The Director of Nursing Services stated after the discovery of the left shoulder injuries on 1/5/2024, a verbal interdisciplinary meeting was held on 1/5/2024. The interdisciplinary team concluded that the injuries were related to the fall on 1/2/2024. The Director of Nursing Services stated they interviewed the staff from 1/4/2024 and 1/5/2024 to ensure that the injuries did not occur from a new incident on 1/4/2024; however, they did not document those interviews. The Director of Nursing Services stated that there should have been an addendum to the 1/2/2024 Accident Incident report to reflect the discovered injuries on 1/5/2024. The Director of Nursing Services stated that the interviews that were completed should have been documented to ensure that the injuries were not related to a new incident. The Director of Nursing Services stated that the investigation summary should reflect the date of the conclusion and when it was reviewed by the Administration. The Director of Nursing Services stated that they did not believe that a new Accident Incident report should have been written for the injury on 1/5/2024. The Director of Nursing Services stated that the 1/2/2024 investigation report was not thorough. 10 NYCRR 415.4(b)

Based on observation, interview and record review during the Recertification and Abbreviated survey (Complaint #NY 890) initiated on 4/26/2022 and completed on 5/3/2022, the facility did not ensure it established and maintained an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #269) of 3 residents reviewed for Activities of Daily Living. Specifically, Resident #269 was administered the first Mantoux Purified Protein Derivative (PPD) on 9/27/2021, however, the facility staff did not document the site of administration and did not read the results as per the facility policy. The finding is: The Policy and Procedure for Screening and Preventing the spread of [CONDITION(S)]- F880 last updated 4/2/2022 documented [CONDITION(S)] is an infectious disease caused by [CONDITION(S)] [CONDITION(S)]. The procedure to prevent [CONDITION(S)] for residents included the residents will be screened for a history and signs of active [CONDITION(S)] disease upon admission. Residents will be given PPD within three days of admission and a second dose will be given 14 to 21 days after the initial test by a licensed nurse. The results will be read by a licensed nurse within 48 to 72 hours after administration of the PPD. The license nurse will document the manufacturer, the lot number, and the date in the resident's chart. Resident #269 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Physician admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Administration Record (MAR) for September 2021 documented the resident had their 1st step PPD on 9/27/2021. The PPD lot # and the site of the test was not documented on the MAR or in the nursing progress notes. The results for the 1st step PPD were not documented on the MAR or in the resident's medical record. The 2nd step Mantoux PPD test was administered on October 9, 2021, lot # 1, and read on 10/11/2021 as negative. Licensed Practical Nurse (LPN) # 1 was interviewed on 5/3/2022 at 11:40 AM and stated they (LPN #1) read the PPD results on October 11 for the 2nd step PPD that was administered on October 9th. LPN #1 was not aware that the 1st step PPD was not read and just followed orders and completed the 2nd step PPD. LPN # 5 was interviewed on 5/03/2022 at 12:50 PM and stated they (LPN #5) worked on 9/27/2021 and administered the 1st step PPD for Resident #269. LPN #5 stated that it was an oversight that the lot number was not recorded. LPN #5 stated they were not assigned as medication nurse on 9/29/2021. The LPN stated they were assigned as Nursing Care Coordinator (NCC) and reading the PPD results was not their responsibility. LPN #5 further stated that reading the PPD results was the medication nurse's responsibility and that the medication nurse that worked on 9/29/2021 was no longer employed by facility. The Infection Control Registered Nurse (RN) # 3 was interviewed on 5/03/2022 at 1:45 PM and stated the NCC should have monitored the medication nurse to ensure the PPD results were documented. The medication nurses should be documenting the lot # of the PPD. RN #3 stated there is currently no tracking system in place to monitor residents' PPD status. The Director of Nursing Services (DNS) was interviewed on 5/3/22 at 11:30 AM and stated PPD results should have been documented and this was not picked up until it was brought to their attention during the survey. 415.19 (a) (1-3)

Based on record review and staff interview during the Recertification Survey initiated on 4/26/2022 and completed on 5/3/2022 the facility did not ensure that the ordering Physician was notified promptly of laboratory results that fall outside of clinical reference ranges. This was identified for 1 (Resident #97) of 4 residents reviewed for tube feeding. Specifically, Resident #97 had an elevated Blood Urea Nitrogen (BUN) and Creatinine level (blood levels used to determine kidney function). There was no documented evidence that the laboratory results were reviewed by the nursing staff and that the ordering Physician was notified of the abnormal levels. The finding is: The facility Laboratory Test Orders and Review Policy and Procedure last updated 11/12/2021 documented the Primary Medical Doctor (PMD) will be notified of all abnormal lab results during the 7 AM-3PM shift. Resident #97 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 13 which indicated the resident was cognitively intact. The resident had a feeding tube and received 51% or more of their total calories through tube feeding. A Comprehensive Care Plan (CCP) dated 11/12/2015 and last updated on 4/19/2022 for tube feeding documented the resident will receive adequate nutrition via feeding tube, Two Cal HN total formula volume 1422 centimeters (cc) daily, and 237 cc Bolus feeds 6 times daily. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The laboratory reports dated 4/19/2022 documented the resident's BUN was 41 High (H), and the Creatinine level was 1.52 milligram (mg)/deciliter (dL) H. The normal reference range for BUN is (9-23 mg/dL) and for Creatinine is (0.70-1.30 mg/dL) A Physician's Admission/Readmission History and Physical (H&P) dated 4/19/22 documented the resident was readmitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Intravenous (IV) antibiotic was given, [CONDITION(S)] improved, the resident was discharged from the hospital on oral [MEDICATION(S)] (antibiotic). The H&P did not include documentation of the elevated BUN and creatinine levels that were identified on the 4/19/2022 laboratory report. The Licensed Practical Nurse (LPN #9) was interviewed on 4/29/2022 at 11:44 AM. LPN #9 stated that the resident's BUN runs high on and off, but the Physician usually addresses the abnormal laboratory results and orders to provide extra fluid. LPN #9 stated they (LPN #9) were not aware if the laboratory results on 4/19/2022 were reported to or reviewed by the physician. The Registered Nurse (RN #5), Nursing Care Coordinator (NCC) was interviewed on 4/29/2022 at 11:52 AM. The RN stated that the resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Physician ordered to repeat the laboratory blood work on 4/18/2022. The RN stated the resident started having swelling in their feet and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #5 stated the resident was discharged to the hospital for evaluation and treatment on 4/13/2022. The RN stated after the resident returned from the hospital on 4/18/2022. The Physician gave orders to repeat the blood work. RN #5 stated when laboratory reports are received, and there are abnormalities the nurse would notify the Physician and after review, physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #5 stated that the Physician should have been made aware of the laboratory results and the nurse who notified the Physician should have documented the notification in the progress note. RN #5 further stated that there were no notes in the medical record regarding the laboratory result notification to the Physician. The Physician was interviewed on 4/29/2022 at 2:25 PM and stated that they did not recall being made aware of the laboratory results on 4/19/2022. The Physician stated that the BUN and Creatinine levels were not critical, however, they (Physician) should have been notified. The Physician stated had they been notified water flush would have been increased and repeat blood work would have been ordered. The Director of Nursing Services (DNS) was interviewed on 5/2/2022 at 9:40 AM. The DNS stated that any nurse can review the laboratory results and notify the Physician. The DNS stated the nurse should document in the progress note and on the 24-hour report that the Physician was notified of the abnormal laboratory result. The DNS stated that the laboratory results should have been reviewed and the Physician should have been notified as soon as the staff were aware of the results. 415.20

Based on record review, and interviews during the Recertification Survey and Abbreviated Survey (NY 986) initiated on 4/26/2022 and completed on 5/3/2022, the facility did not ensure that each resident received adequate supervision to prevent an avoidable accident. This was identified for 1 (Resident #65) of 7 residents reviewed for accident hazards. Specifically, Resident #65, with a history of multiple falls was assessed as high risk for falls and required 30-minute monitoring as per the Comprehensive Care Plan. On 11/22/2021, Resident #65 breached an alarmed door without the staff knowledge and fell down a flight of stairs with their wheelchair. Additionally, the facility did not have documented evidence that the resident was monitored every 30 minutes as per their Comprehensive Care Plan. The finding is: The facility Safeguarding Residents Specific to the opening of stairwell doors policy and procedure dated 6/24/2014 (revised on 2/9/2021) documented that any staff member that hears an activated door alarm is responsible to respond immediately and investigate. The Door Alarm is activated when the exit door is opened. When a staff member hears the door alarm activated on the floor, they must stop what they are doing and immediately respond. When the staff members have checked the stairs and did not find a resident of cause for the alarm, the Registered Nurse Supervisor (RNS) is to be paged and Code Yellow activated. Staff members must never reset the door alarm without knowing how the alarm was activated. The facility Elopement/Wandering policy and procedure dated 10/10/2016 (revised 9/19) documented that it is the policy of the facility to utilize all possible measures to maintain the safety and wellbeing of all residents. The facility will have a system and tools in place to do all that is reasonable to identify and prevent unsafe wandering. All staff must promptly and thoroughly investigate door exits/personal alarms which may have been activated (alarm ringing) for the cause of the activation. The Hall Monitor must carefully watch residents who pace up and down the hallway to ensure that they do not wander into another resident's room. Resident #65 was admitted with the diagnoses of [CONDITION(S)], Alzheimer's Disease, and Major Depressive Disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #65 had a Brief Interview for Mental Status (BIMS) score of 3, indicating severely impaired cognition. Resident #65 required extensive assistance of one staff member for transfers, setup assistance with supervision and oversight, and cueing for locomotion on and off the unit. The MDS documented that Resident #65 did not walk in the room or in the corridor during the assessment look-back period. The MDS documented that Resident #65 had impairment on one side of the upper extremity and used a wheelchair for mobility. Resident #65 was not steady and was only able to stabilize with staff assistance while moving from a seated to a standing position, walking, and transferring from surface to surface. The MDS further documented that Resident #65 had 1 fall since the last admission with a minor injury. The Fall Risk assessment dated [DATE] documented that Resident #65 had a fall risk score of 16, indicating a high risk for falls. The Falls Care plan dated 11/10/2015 last revised on 2/17/2022 documented that Resident #65 had a fall on 2/9/2021, 3/18/2021, 10/28/2021, and 11/22/2021. The interventions included but were not limited to day room monitoring when out of bed (initiated on 1/26/2016), 30-minute visual checks (initiated 2/12/2018), chair alarm (initiated 8/11/2020), and the resident's room was moved closer to the nurse's station (initiated 10/28/2021). The Certified Nursing Assistant Accountability Record (CNAAR) for November 2021 did not document 30-minute monitoring for Resident #65. The facility was unable to provide documented evidence of 30-minute monitoring for Resident #65. The Accident and Incident report, initiated and signed by the Licensed Practical Nurse (LPN) #2 and the Registered Nurse (RN) # 2, Supervisor, on 11/22/2021 at 5 PM, documented that the resident was discovered lying in the 6th floor stairwell. The report indicated there were no witnesses to the incident. The Accident and Incident report indicated that the resident had bleeding to the back of their head and pain to the right wrist. The body diagram indicated the resident's nose being affected however the extent of the injuries was not documented for the head, the right wrist, or the nose. The Accident and Incident report did not include whether the resident was utilizing the wheelchair for mobility when they (Resident #65) were found in the stairwell. RN #2 documented that the resident was on 30-minute visual monitoring. The Certified Nurse's Assistant (CNA) #2's written statement form dated 11/22/2021 at 4:11 PM (49 minutes prior to the incident documented time) indicated that Resident #65 was last seen at approximately 3:30 PM by CNA #2. The Nursing Progress Note dated 11/22/2021 at 5:11 PM written by RN #2 documented that they (RN #2) responded to a call to the 6th floor. Upon arrival, the resident (#65) was found laying in the stairwell. The resident was alert and verbally responsive with no change in the level of consciousness. The resident was noted with blood coming from the occipital area. 911 was called and responded promptly. The resident was transferred to the emergency room (ER) for evaluation. The Director of Nursing Services (DNS)/Designee summary dated 11/23/2021 indicated that a review of the video surveillance, medical records, medications, on-site assessment, and interviews were used in the investigation. The attached undated investigation summary narrative completed by the facility Administrator documented that on 11/22/2021 at about 4:15 PM, Resident #65 set off the door alarm of stairwell 4 on the Dementia Unit and went through the doorway. CNA #3 responded immediately and did not see anyone in the area of the alarm, they (CNA #3) panicked, and quickly went to check the next exit door. CNA #4 [from another unit] responded to a loud noise in the stairwell and found the resident had fallen into the landing of the stairwell 4. CNA #4 then went to the 6thfloor hallway to call for help. The resident was transferred to the hospital for evaluation. Resident #65 did not sustain significant injury. The Director of Maintenance checked the door alarms which were found to be functioning appropriately. The summary documented that CNA #3 displayed poor judgment and ultimately failed to follow facility policy in the area of [responding to] the alarms. The facility concluded that there was no significant injury to the resident and no reason to believe that any abuse, neglect, or mistreatment occurred. The nursing note dated 11/23/2021 documented that Resident #65 arrived at approximately 7 PM (returned from the hospital) and had multiple areas of abrasions and bruising to the right shoulder to the scapular area, face, bridge of the nose, bilateral knees, and to the bilateral upper and lower extremities. Resident #65 had multiple superficial scratches on the top of their head and a hematoma to the occipital area measuring approximately 2 centimeters (cm) x 2 cm. Resident #65's face and bridge of the nose were noted with abrasions. CNA #2 who was the assigned CNA to Resident #65, was interviewed on 4/28/2022 at 3:28 PM and stated that Resident #65 had a history of getting up unassisted and would fall often. On 11/22/2021 when they (CNA #2) started their shift they saw Resident #65 in the dining room at 3 PM. CNA #2 stated that they (CNA #2) were providing care to another resident whose room was located at the end of the hallway. CNA #2 stated they (CNA #2) could not hear the alarm because the room door was closed. After the care was rendered, CNA #2 exited the resident's room and saw staff running down the hall. CNA #2 stated that they (CNA #2) did not recall hearing any alarms. CNA #2 stated that Resident #65's wheelchair was not in the dining room or in the area outside of the stairway 4 door. CNA #2 stated that the incident occurred approximately an hour or an hour and a half after they (CNA #2) last saw Resident #65 at 3:30 PM. CNA #2 stated that the facility always had a hallway monitor. The hallway monitor is usually there from 3 pm until 11 pm. CNA #2 could not recall who the hallway monitor was on 11/22/2021. CNA #2 stated that the hallway monitor was responsible for completing the 30-minute visual checks for Resident #65 and should be observing the hallway and the areas near the stairway 4. The 30-minute checks are documented on a log sheet at the nurse's station. CNA #2 stated that CNAs were only responsible to monitor residents for 30-minute rotations when covering the dining room. CNA #2 stated that they did not provide dining room monitoring coverage on 11/22/2021 from when they first started the shift until the time Resident #65 was found in stairway 4. On 4/29/2022, the facility provided a typed written statement dated 4/28/2022 (after CNA #2 was interviewed on 4/28/2022 at 3:28 PM) that documented CNA #2 worked the evening shift (3 PM-11 PM) on the 6th floor on 11/22/2021 and conducted the 30-minute checks on all the residents assigned to CNA #2 including Resident #65. The statement was signed by CNA #2. CNA #3 was interviewed on 4/28/2022 at 3:45 PM. CNA #3 stated that they were in the dining room at 4 PM and at around 4:10 PM while they were looking for a resident who had a history of wandering into other resident rooms, CNA #3 heard the door alarm at stairway 4. CNA #3 stated that the alarm sound was faint. CNA #3 approached the door, however, they (CNA #3) did not open the stairwell 4 door to look in the stairway, they (CNA #3) went to the stairway 3 door to continue the search. At that time CNA #4 came from stairway 4 and informed CNA #3 that Resident #65 was in stairway 4. CNA #3 stated that the unit usually has a hallway monitor to assist with redirecting residents but on that day, 11/22/2021, there was no hallway monitor. CNA #4 was interviewed on 4/28/2022 at 3:57 PM. CNA #4 stated that they (CNA #4) work on Unit 4. CNA #4 stated that on 11/22/2021 they (CNA #4) heard a bang sound as they were walking down the hallway on Unit 4. CNA #4 stated that they could not recall the exact time. CNA #4 stated that they followed the sound to stairway 4 and found Resident #65 on the 6th floor landing in a seated position, face down with the wheelchair on Resident #65's back. CNA #4 stated that they stepped around Resident #65 and ran up to the unit and could hear the door alarm. CNA #4 called the operator to announce the fall and to get the RN Supervisor. Recreation Aide (RA) #1 was interviewed on 4/29/2022 at 10:29 AM. RA #1 stated that at 4:00 PM, RA #1 heard the stairway door alarm and saw CNA #3 pass by the dining room to the stairway 4 door. RA #1 was in the dining room facilitating activities with the residents. RA #1 stated that they (RA #1) stayed in the dining room because CNA #3 was responding to the alarm. RA #1 stated that they saw Resident #65 leave the dining room area at 1 PM and redirected Resident #65 back to the dining room to participate in the activity. RA #1 stated that they did not monitor the resident after 1 PM and did not know Resident #65 had left the dining room until they were notified that the resident was found in the stairwell. RA #1 stated they were not aware that Resident #65 needed every 30-minute monitoring. RN #2 was interviewed on 4/29/2022 at 11:26 AM. RN #2 stated that they (RN #2) were the RN Supervisor on 11/22/2021 during the 3 PM-11 PM shift. RN #2 stated that at some time between 5 PM and 6 PM, RN #2 responded to a call on the overhead speaker. RN #2 went to stairway 4 on the 6th floor and observed Resident #65 at the landing down one flight with LPN #2 beside Resident #65. Resident #65 was face down on the landing and the wheelchair beside Resident #65. Resident #65 was alert and talking and was saying I want to get up. Resident #65 did not indicate that they felt pain or what had occurred. Resident #65 was bleeding at the back of the head and LPN #2 applied pressure to the area to stop the bleeding. A staff member alerted 911. RN #2 recalled that a few scratches were on the bridge of Resident #65's nose and it was bruised. RN #2 did not recall any other injuries. RN #2 stated that they completed the assessment and documented their assessment on the Accident and Incident form. LPN #2, the unit charge nurse, was interviewed on 4/29/2022 at 12:11 PM. LPN #2 stated that they were on Unit 6 on 11/22/2021 during the 3 PM-11 PM shift and Resident #65 was assigned to LPN #2. LPN #2 was giving care to another resident and as they (LPN #2) came out of the room they saw CNA #4 from Unit 4. CNA #4 was waving for help in the hallway, and LPN #2 ran to CNA #4. LPN #2 could not recall the time. LPN #2 went with CNA #4 into stairway 4 and observed Resident #65 lying on the platform at the bottom of the first set of steps. The stairway door alarm sound was faint, but it was on. LPN #2 stated that they did not see any injury to the face or the front of Resident #65's body. Recreation Aide (RA) #2 was interviewed on 4/29/2022 at 12:33 PM. RA #2 was in the dining room with the residents on 11/22/2021 during the 3 PM-11 PM shift. While in the dining room there was a CNA (could not recall the name) assigned to provide one-to-one monitoring for another resident. At one point, Resident #65 was in the dining room, but RA #2 could not recall at what time. RA #2 did not see Resident #65 leave the room. RA #2 stated that the chair alarms were going off because other residents were getting up and RA #2 was focused on helping those residents. RA #2 stated that they were not aware that Resident #65 required monitoring while in the dining room. RA #2 heard the fire door alarm sounding and stepped out to the hallway. When RA #2 went to the doorway, RA #2 observed a CNA (did not recall CNA's name) going to the stairway 4. RA #2 went back to the dining room because they (RA #2) assumed the CNA was taking care of the door alarm. The DNS was interviewed on 5/2/2022 at 9:15 AM. The DNS stated that on 11/22/2021 at 4:30 PM, the DNS was in their office and heard a stat call to stairway 4. The DNS stated that they went to the 6th floor and saw staff members running in the hallway. On the first landing at the bottom of the 6thfloor stairs, Resident #65 was seen laying on their left side. Resident #65's wheelchair was next to Resident #65 and tilted to the side. The DNS stated that no other injuries were noted, and Resident #65 did not complain of pain. The 911 attendants came quickly, and Resident #65 was transferred out of the stairwell by the 911 attendants. The DNS stated that they (DNS) and the Administrator later reviewed the surveillance footage and determined that CNA #3 did not respond to the alarm as per facility protocol. CNA #3 should have opened the door to check the stairway to investigate and could have redirected Resident #65 out of the stairway. The DNS reviewed the statements and the accident investigation and stated that CNA #2 reported that they last saw Resident #65 at 3:30 PM and that the incident occurred at 4:11 PM, indicating that 41 minutes had passed since CNA #2 last saw Resident #65. The investigation did not identify who was responsible for supervising Resident #65. The DNS stated there was no 30-minute monitoring log sheet for Resident #65 on 11/22/2021 and the assigned CNA #2 was responsible for the 30-minute monitoring. The DNS stated that Resident #65 was in the dining room and should have been supervised by the 3 staff members in the dining room however, Resident #65 was permitted to move about the unit. The DNS stated that Resident #65 did not receive supervision to prevent the accident when the resident got into the stairwell. The Administrator was interviewed on 5/2/2022 at 10:03 AM. The Administrator stated that they reviewed the statements, reviewed the surveillance footage, and wrote the summary for Resident #65's investigation. The Administrator stated that the surveillance video was not available for review. The Administrator stated that they did not note what time everything occurred because the Administrator did not think the time on the cameras was accurate. The Administrator stated that the time of 4:15 PM on the investigation summary was based on the staff interviews. The times on the staff interviews are inconsistent and should have been clarified. The Administrator stated that there are discrepancies in the investigation after reviewing it again now. The Administrator stated that they did not focus on the 30-minute checks at the time of the investigation and did not have documented evidence that anyone was doing the 30-minute checks. The Administrator stated that the hallway monitor was pulled to do another assignment due to staffing needs on 11/22/2021. The investigation did not specify who was responsible for supervising Resident #65. The Administrator further stated in this incident, Resident #65 should have been supervised to prevent the accident. 415.12(h)(2)

Based on record review and staff interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY 844) initiated on 4/26/2022 and completed on 5/3/2022, the facility did not ensure that services provided or arranged by the facility met professional standards of quality. This was identified for one (Resident #319) of two residents reviewed for Infection Control. Specifically, 1)Resident #319 was diagnosed with Pneumonia on 3/13/2022 and treated with intravenous (IV) antibiotics, however, there was no documented evidence in the resident's Electronic Medical Record (EMR) that indicated when the IV line was placed, where the IV line was placed (the access site), and the type of catheter used for the IV line. 2) There was no documented evidence that the IV line was flushed before and after the administration of the IV antibiotics. The finding is: The facility's policy titled Intravenous Therapy last revised on 1/17/2020 documented that 1) the Nurse starting the IV therapy will document in the progress note the site of access, the size and type of catheter used, flow rate, type of IV fluid, and the resident's response to the procedure and 2) all medications, flushes, and fluids given through a venous access device will be documented on the E- MAR (Electronic Medication Administration Record); Saline locks will be flushed with 5-10 cubic centimeter (cc) of normal saline in a 10 cc syringe before and after antibiotic therapy; Saline locks will be flushed every shift with 5-10 cc of normal saline if antibiotic therapy is not in use each shift. Resident #319 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident needed extensive physical assistance of one person for transfers, walking in their room, locomotion on the unit, dressing, toilet use, and bathing. 1) The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Nursing Progress Note dated 3/13/2022, written by the Registered Nurse (RN) Supervisor (RN #4), documented [MEDICATION(S)] 500 mg IV for 7 days was ordered and started for Left Basal Infiltrate [Pneumonia]. A review of the resident's EMR revealed there was no documented evidence of the site of access, the size, and the type of catheter used to administer the IV antibiotic. The Director of Nursing Services (DNS) was interviewed on 5/3/2022 at 2:40 PM and stated that when the RN Supervisor (RN #4) wrote their Nursing Progress Note on 3/13/2022, their (RN #4) note should have included that they (RN #4) put in a peripheral IV line, which arm they placed the line in, and which gauge needle was used. 2) The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's entire Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The Director of Nursing Services (DNS) was interviewed on 5/3/2022 at 2:40 PM and stated the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DNS stated that the order to flush the IV line never appeared in the eMAR or the eTAR because when the RN Supervisor (RN #4) put the order into the computer, all the necessary elements of the order were not put in for the order to go to the eMAR/eTAR. RN #4 was interviewed on 5/3/2022 at 4:40 PM and stated that they obtained a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #4 stated at that time, they were new to the facility and did not know there were preset orders in the eMAR when starting a resident on an IV, but they are aware of it now. The resident's Primary Physician, who is also the facility's Medical Director, was contacted on 5/3/2022 at 5:45 PM and was not available for an interview. 415.11(c)(3)(i)

Based on record review and staff interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY 844) initiated on 4/26/2022 and completed on 5/3/2022, the facility did not develop a Comprehensive Care Plan (CCP) for each resident that includes measurable objectives and timeframes to meet a resident's medical and nursing needs that are identified in the comprehensive assessment. This was identified for one (Resident #319) of two residents reviewed for Infection Control. Specifically, Resident #319 was diagnosed with Pneumonia on 3/13/2022 and treated with intravenous (IV) antibiotics, however, there was no CCP developed to address the resident's Pneumonia diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The finding is: The facility's policy titled Comprehensive Care Plans last revised on 2/24/2019 documented that the resident's CCP will be updated by the Interdisciplinary Team (IDT) with any episodic changes to include, but not limited to: Newly diagnosed infection. Resident #319 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident needed extensive physical assistance of one person for transfers, walking in their room, locomotion on the unit, dressing, toilet use, and bathing. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Nursing Progress Note dated 3/13/2022 and written by the Registered Nurse (RN) Supervisor (RN#4) documented [MEDICATION(S)] 500 mg IV for 7 days was ordered and started for Left Basal Infiltrate [Pneumonia]. A review of the resident's Electronic Medical Record (EMR) revealed no documented evidence that a CCP was developed to address the presence of Pneumonia, IV antibiotic treatment, or care of the IV site. RN #4 was interviewed on 5/2/2022 at 3:05 PM and stated that they had only worked at the facility for 3 months. After reviewing the resident's EMR, RN #4 stated that they did not see a CCP developed addressing the resident's Left Basal Infiltrate [Pneumonia], the IV, or the antibiotics that was started on 3/13/2022. RN #4 stated that they had never initiated a CCP when there was a change in condition for a resident at this facility. The Director of Nursing Services (DNS) was interviewed on 5/3/2022 at 9:00 AM and stated that it was an oversight that RN #4 had not developed a CCP addressing the resident's Left Basal Infiltrate [Pneumonia], the IV, or the antibiotics started on 3/13/2022. The DNS stated that when RN #4 had obtained the order from the Physician on 3/13/2022, they (RN #4) should have initiated the CCP right away. The DNS stated that a Licensed Practical Nurse (LPN) can put a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 415.11(c)(1)

Based on record review and interview during the Recertification Survey and Abbreviated survey (NY 986) initiated on 4/26/2022 and completed on 5/3/2022, the facility did not ensure that all accidents and incidents are thoroughly investigated to rule out Abuse, Neglect, or Mistreatment. This was identified for 1 (Resident #65) of 7 residents reviewed for Accidents. Specifically, Resident #65 exited an alarmed stair door and was found in the stairwell on 11/22/2021. The facility did not determine a timeline of preceding events that led up to the fall and if the resident was adequately supervised by staff. Additionally, an assessment of the events including the mobility device used by the resident, the position of the resident upon discovery of the falls, and the extent of the resident's injuries were not documented on the facility's investigation report. The finding is: The facility Elopement/Wandering policy and procedure dated 10/10/16 (revised 9/19) documented that every incident of unsafe wandering will be thoroughly investigated to determine the root cause, both to help prevent recurrence and establish interventions which may prevent an episode of elopement in the future. The facility Fall Prevention/ Actual Falls policy and procedure dated 9/11/13 (revised 3/20/19) documented that when a resident sustains a fall, the Inter-Disciplinary Team (IDT) will attempt to identify the root cause and will perform the following reviews including but not limited to video surveillance and re-enactment. Residents who require day room monitoring will have this clearly documented on the Certified Nursing Assistant Accountability Record (CNAAR). The policy and procedure did not address documentation of 30-minute checks. The facility Accident Incident Reporting policy and procedure dated 10/28/15 (revised 11/5/21) documented those incidents and accidents must be recorded on the forms provided by the facility. The RN Supervisor and the licensed nurse are to complete the Incident/Accident Report, the information should be specific and accurate with emphasis on the Date, time, and the location of the incident/accident; how the incident occurred, or what was observed when the resident was found; and the extent of the injury. Staff should complete the forms including each box and line of the accident/incident form. Resident #65 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #65 had a Brief Interview for Mental Status (BIMS) score of 3, indicating severely impaired cognition. Resident #65 required extensive assistance of one person for transfers, setup assistance with supervision, oversight, and cueing for locomotion on and off the unit. Resident #65 was not steady and only able to stabilize with staff while moving from a seated to a standing position, walking, turning around, and transferring from surface to surface. The MDS documented that Resident #65 did not walk in the room or corridor during the assessment period. Resident #65 had impairment on one side of the upper extremity and used the wheelchair for mobility. The MDS further documented that Resident #65 had 1 fall since the last admission with a minor injury. The Fall Risk assessment dated [DATE] documented that Resident #65 had a fall risk score of 16, indicating a high risk for falls. The Falls Care plan dated 11/10/2015 (revised 2/17/2022) documented that Resident #65 was diagnosed with [CONDITION(S)] and age-related [CONDITION(S)]. Resident #65 had fallen on 2/9/2021, 3/18/2021, 10/28/21, and 11/22/21. The interventions included but were not limited to day room monitoring when out of bed (initiated 1/26/2016), 30-minute visual checks (initiated 2/12/2018), chair alarm (initiated 8/11/2020), and the resident's room was moved closer to the nurses' station (initiated 10/28/2021). The Accident and Incident (A/I) report face sheet documented that on 11/22/2021 at 5:00 PM, Resident #65 was lying in the staircase at the 6th Floor Stairwell. The time resident was last seen and by who section was incomplete. The RN assessment at 5:15 PM and the body diagram used to describe the location and size of the area(s) affected indicated the back of the head, nose, and left wrist were affected with no indications of size or description. The assessment documented that Resident #65 was on out of bed monitoring, 30-minute visual checks, and the dining room was being monitored; however, the name of the dining room monitor was not specified in the space provided on the assessment. The RN assessment also documented Resident #65 was a safety hazard and was non-ambulatory. The nurse on duty when the A/I was reported was noted to be LPN #3 and the Certified Nursing Aide on duty was CNA #2. The summary of the investigation indicated that Resident #65 fell down the 6th floor stairway. The accident and incident report lacked documented evidence of an assessment of the resident's position in the stairwell, the extent of injuries sustained, and if the resident was utilizing a wheelchair at the time of the incident. The Certified Nurses Aide Accident and Incident form was dated 11/22/2021 at 4:11 PM, 49 minutes before the documented time of the incident at 5:00 PM. CNA #2 documented that they were told by a staff member that Resident #65 was found at the bottom of the stairway. CNA #2 documented that the last approximate time they saw Resident #65 was around 3:30 PM by the dining room. CNA #4's employee statement dated 11/24/2021 documented that on 11/22/2021 at about 4 PM, an hour before the documented time of the incident at 5:00 PM, CNA #4 heard a loud noise coming from the stairwell. CNA #4 was working on the 4th floor at the time and proceeded to the nearest stairwell door. CNA #4 proceeded up the stairs to the 5th floor and found nothing. Then CNA #4 continued up the stairs further and found Resident #65 laying on the landing. CNA #4 entered the 6th floor and called the operator using the phone in the hallway and had the operator page the supervisor immediately for help. The Director of Nursing Services (DNS)/Designee summary dated 11/23/2021 indicated that a review of the video surveillance, medical records, medications, on-site assessment, and interviews were used in the investigation. The investigation summary documented that on 11/22/2021 at about 4:15 PM, Resident #65 set off the door alarm of stairwell 4, on the Dementia Unit, and went through the doorway. After a thorough investigation, the facility concluded that there was no significant injury to Resident #65 and no reason to believe that any abuse, neglect, or mistreatment occurred. The DNS was interviewed on 5/2/2022 at 9:15 AM. The DNS stated that they were responsible for completing the investigation. The DNS stated that they (DNS) reviewed surveillance footage and spoke to staff members and requested written statements for the investigation related to Resident #65's fall on 11/22/2021. The DNS stated that the Administrator wrote the summary. The DNS stated that the investigation was incomplete with information missing. RN #2 mistakenly documented that the incident occurred at 5 PM. The DNS stated that the investigation did not address the timeline of events and that the staff wrote inconsistent times on the forms and their statements. The investigation should have been more descript about the position of Resident #65 when found. The investigation did not address where the wheelchair was when Resident #65 was found. The body assessment diagram does not indicate measurements of the areas affected. The investigation also did not address who was responsible for supervising Resident #65 at the time of the incident. The Administrator was interviewed on 5/2/22 at 10:03 AM. The Administrator stated that they reviewed the statements, reviewed the surveillance footage, and wrote the summary of the investigation. The Administrator stated that they (Administrator) did not note what time everything occurred because the Administrator did not think the time on the cameras was accurate. The times on the staff interviews were inconsistent and should have been clarified. The Administrator stated that now reviewing the investigation again there are discrepancies in time. The Administrator stated that parts of the accident incident forms were not completed, and RN #2 should have completed all parts of the investigation. The staff statements and the investigation should have described the position of Resident #65 when found. The investigation did not address where the wheelchair was when Resident #65 was found. The Administrator stated that Resident #65's position and the location of the mobility device are usually addressed in the investigations. The Administrator stated that they did not have documentation that anyone was conducting the 30-minute checks for Resident #65. The 30-minute checks should have been included as part of the investigation to rule out neglect or a break in the resident's plan of care. The Administrator stated that they did not know why the 30-minute checks and the out-of-bed monitoring were not addressed in the investigation summary including the staff responsible for supervising Resident #65. The Administrator further stated that after considering the missing parts, the investigation was not thorough. 415.4(b)(3)

Based on record review and staff interviews during the Recertification Survey the facility did not ensure that each residents Comprehensive Care Plan (CCP), with person-centered approaches to care, was implemented to meet the resident's needs. This was identified for 1 (Resident # 259) of 2 residents reviewed for Rehabilitation. Specifically, Resident # 259 has physician's orders [REDACTED]. The Resident Care Profile, which provides direction to the Certified Nursing Assistants (CNA) regarding resident care needs, was not updated to reflect the physicians order for PROM and did not document that PROM was provided to the resident. The finding is: The policy and procedure dated 08/01/2013, titled Communicating Change in Resident's Care for Nursing Assistants, documented all changes in the resident's plan of care that pertain to the Nursing Assistants will be documented and communicated by the Nursing Department to ensure that all staff are aware of and carrying out resident care in accordance with the comprehensive care plan. The Nursing Care Coordinator/Charge Nurse will inform the nursing assistant of the changes in the Resident's plan of care. Resident #259 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 12 indicating the resident's cognition was moderately impaired. The resident exhibited impairment of both upper and lower extremities in functional limitation in range of motion. The resident was not on a restorative nursing program for range of motion. An Occupational Therapy (OT) progress note dated 6/05/2019, documented the resident presents with bilateral upper extremities PROM Within Normal Limits and Bilateral lower extremities with limited ROM at the knee and ankle. The OT recommended gentle PROM, 10 repetitions twice a daily with nursing care to maintain ROM. physician's orders [REDACTED]. The Resident Care Profile dated 06/05/2019 through 07/23/2019 revealed no documented evidence that PROM, 10 repetitions twice a day during nursing care was being performed. An interview with CNA #1 was held on 7/23/2019 at 11:37 AM. The CNA stated that she cares for Resident #259 and could not identify instruction on the Resident Care Profile for Passive Range of Motion, 10 repetitions twice daily. The CNA stated that PROM instructions were not documented on the Resident Care Profile sheet. An interview with the Assistant Director of Nursing Services (ADNS) was conducted on 7/23/2019 at 11:45 AM. The ADNS could not identify any documentation on the Resident Care Profile sheet to instruct the CNA to perform passive range of motion, 10 repetitions twice daily. An interview with the Director of Nursing Services (DNS) was conducted on 7/24/2019 at 10:21 AM. The DNS stated that the LPN who documented the physician's orders [REDACTED]. 415.11(c)(1)

Based on observations, record reviews, and staff interviews during the recertification survey, the facility did not ensure that a resident's medical record was maintained in accordance with accepted professional standards and practices that are complete and accurately documented. This was identified for 1 (Resident #114) of 2 residents reviewed for positioning and for 1 (Resident #41) of 2 residents reviewed for vision/hearing. Specifically, 1) Resident #114 had a physician's orders [REDACTED]. The Certified Nursing Assistant Accountability Record (CNAAR) and the Resident Care Profile for (MONTH) 2019 documented a Left Knee splint instead of a Right Knee splint. 2) Resident #41 had a right hearing aid. The Comprehensive Care Plan for Hearing documented that the resident preferred to have herself or her daughter apply the hearing aid. The Certified Nursing Assistant Accountability Record (CNAAR) revealed no instruction for application of the right hearing aid. The findings are: 1) Resident #114 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had short and long term memory problems and had severely impaired cognition. The MDS also documented the resident had impairment of functional range of motion to both upper and lower extremities. The physician's orders [REDACTED]. The resident was observed in the day room in a recliner chair on 7/18/19 at 11:00 AM and on 7/24/19 at 9:50 AM. The Right Knee splint was worn by the resident. Review of the CNAAR for (MONTH) 2019 revealed documentation that a Left Knee splint was to be worn during the day. The documentation was signed by the CNAs from 7/1/19 through 7/23/19. The current Resident's Care Profile documented a left knee splint to be worn during the day. An interview with the 7:00 AM- 3:00 PM shift CNA was conducted on 7/24/19 at 9:58 AM. The CNA stated that the knee splint was already applied when she reported for night shift. The CNA stated that the nurses are responsible to apply the braces and the CNA only checks the skin integrity of the area. An interview with Registered Nurse (RN) Unit Manager was conducted on 7/24/19 at 9:59 AM. The RN stated that the nurses are responsible to apply the splint and the CNAs are responsible to check the skin integrity when giving care or removing the splint. The RN further stated it is the responsibility of the RN charge nurse to complete the CNAAR and the Resident Care Profile. An interview with the Director of Rehabilitation was conducted on 7/24/19 at 11:04 AM. The Director stated that when the resident was discharged from Physical Therapy on 6/12/19, the resident was referred to the nursing department for application of the Right Knee splint. 2) Resident #41 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The MDS Significant Change in Status assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 11, indicating the resident was moderately impaired in cognition. The MDS documented the resident had the ability to hear with use of hearing aid. The Care Plan Report initiated on 6/4/18 documented the resident used a right hearing aid. The resident was observed in her room seated in a wheelchair on 7/23/19 at 9:25 AM in the presence of the CNA. The resident refused to have the CNA's assistance when the resident was about to apply her right hearing aid. The resident was able to remove the hearing aid from its case and applied the hearing aid independently. An interview with the 7:00 AM- 3:00 PM shift CNA was conducted on 7/23/19 at 9:30 AM. The CNA stated that the resident does not want the staff to apply the hearing aid to her right ear. The CNA stated that the resident preferred the hearing aid to be applied by either herself or by her daughter. Review of the Resident Care Profile revealed no instruction for the CNAs to be guided on the application of the right hearing aid. Review of the CNAAR did not document this was the arrangement that the resident preferred. The CNAAR stated right hearing aid with no further instructions to guide the CNA. The RN Unit Manager was interviewed on 7/23/19 at 10:32 AM. The RN stated the CNAAR should document the right hearing aid instructions as per the resident's preference. 415.22(a)(1-4)

Based on observation, record review, and interviews during the recertification survey, the facility did not ensure that each Minimum Data Set (MDS) assessment accurately reflected the resident's status. This was identified for 1 (Resident #41) of 2 residents reviewed for communication/language. Specifically, Resident #41 is of Asian Indian descent. Review of the resident's MDS Assessments dated 6/8/18, 8/30/18, 11/19/18, 2/10/19 and 5/13/19 revealed that the resident was classified under Section A1000 (Race/Ethnicity) as American Indian or Alaska Native. The MDS assessment did not accurately reflect the resident's race/ethnicity. The finding is: The MDS Section A1000 (Race/Ethnicity) defined Asian as a person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, Vietnam. Resident #41 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The MDS Significant Change Status assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 11, indicating the resident was moderately impaired in cognition. The MDS Section A 1000 documented Race/Ethnicity as an American Indian or Alaska Native and under Section A1100- Language that the resident's preferred language was Hindi. The resident was observed in her room seated in a wheelchair. The resident spoke only in Hindi. Review of the resident's MDS assessments revealed that the Quarterly MDS assessment dated [DATE], Quarterly MDS dated [DATE], Quarterly MDS dated [DATE], and Admission MDS dated [DATE], all documented the resident as American Indian or Alaska Native. An interview with the Registered Nurse (RN) MDS Coordinator was conducted on 7/24/19 at 10:00 AM. The RN stated that the resident is an Asian Indian and the MDS assessments should have documented her race in that category. The RN stated that she does not know who is responsible to document the MDS assessment race section. An interview with the RN Unit Manager was conducted on 7/24/19 at 10:05 AM. The RN stated that Section A1000 documentation of American Indian or Alaska Native was an error. An interview with the Director of Social Services was conducted on 7/24/19 at 10:20 AM. The Director stated that it was not her department that completed the resident's demographic section of the MDS. The Director stated that the Admission Coordinator completes the demographic section of the MDS. An interview with the Admissions Coordinator was conducted on 7/24/19 at 10:35 AM. The Admissions Coordinator stated that she just follows what was written on the completed Patient Review Instrument (PRI) from the hospital on admission. The PRI documented the resident as American Indian. The Coordinator stated that the MDS Section A1000 should have been rectified. 415.11(b)

Based on observation, interview and record review during an abbreviated survey (Complaint ID # NY 114), the facility did not ensure that one of three residents reviewed for accidents was provided safe and effective assistance devices to prevent an avoidable accident (Resident #1). Specifically, Resident #1 had a physician order [REDACTED]. The resident sustained [REDACTED]. The findings were: The Facility's Policy titled Transfer and Transporting of Residents dated 8/2/13 reviewed by the facility on 2/23/18 with no changes. The policy documented the residents will be assessed for transfer status by the Registered Nurse Supervisor (RNS) on admission and the rehab will make the final determination regarding the transfer status. The RNS will obtain order for the transfer status and the nurse case coordinator/charge (NCC) will update the resident profile to reflect the current transfer status when a change occurs. The NCC will communicate all new or revised orders for transfer to staff during the shift report. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- an assessment tool) dated 12/28/17 documented severely impaired cognition for the resident. She required extensive assistance of 2 persons for bed mobility and transfers. She had impairment of both upper and lower extremities. The Comprehensive Care Plan (CCP) titled Activities of Daily Living (ADLs) dated 9/22/16 documented the resident required extensive assistance of two persons secondary to [DIAGNOSES REDACTED]. The Physical Therapy (PT) Note dated 12/27/17 documented the resident was discharged from PT and recommended use of Beasy board for transfers. The CCP was updated on 1/9/18 and documented that the resident required two-person assistance with transfers using a Beasy board. The Resident Care Profile (RCP-CNA Care Plan) dated 1/23/18 documented two-person assistance for transfers with Beasy board. The physician's orders [REDACTED]. The Nursing Progress Note (NPN) dated 2/9/18 at 4:24 PM by the Registered Nurse (RN) documented the resident was transferred to bed with assistance of two persons. Left lower leg was noted with large skin tear and a deep laceration. Pressure dressing was applied. The (Primary Care Physician) PMD was notified and ordered to transfer the resident to the hospital for suture to the leg laceration. The NPN dated 2/10/18 at 3:05 AM by the RN documented the resident returned from the hospital with 8 stitches. The hospital recommended [MEDICATION NAME] (antibiotics) for 7 days and the resident also received tetanus [MEDICATION NAME]. The facility's investigation dated 2/14/18 documented Resident #1 was noted with a skin tear/laceration to left leg after being transferred to bed with two-persons assistance. The resident was assessed by the wound care nurse, and local treatment was provided. The Director of Nursing (DON) assessed the resident and he denied pain. The resident was transferred to the hospital and had eight sutures. The facility's investigation documented the DON re-enacted the transfer with the involved nursing assistants and noted that the staff (CNA #1 and CNA #2) did not use the Beasy Board as listed in the RCP. The resident sustained [REDACTED]. The personnel file of CNA #1 and CNA #2 lacked documented evidence of education related to use of the Beasy board. The 3:00 PM- 11:00 PM CNA #2 was interviewed on 7/27/18 at 3:35 PM and stated CNA #1 asked her for assistance to transfer Resident #1 from the chair to bed. Resident #1 was transferred using two-persons assistance. They did not use the Beasy board. CNA #2 stated she did not know what a Beasy board was. She also did not know if Resident #1 needed the Beasy board. After the transfer the CNAs noticed blood on the resident's leg and they called the nurse (LPN). CNA #2 stated she did not get an in-service related to use of the Beasy board prior to the incident. The RN In-service Coordinator (RNIC) was interviewed on 7/27/18 at 4:09 PM and stated that all CNAs were given in-service related to transfers and use of devices such as sliding board and Beasy board. CNA #2 watched a video on Beasy board transfers (The RNIC could not recall the date). The RNIC stated there were no competencies related to use of the Beasy board and transfers. The RNIC stated that the assigned CNA, and CNA assisting with the transfers were expected to check the RCP for the resident's transfer status. If CNAs did not understand the documented interventions, they should have asked for clarification. The 3:00 PM- 11:00 PM Licensed Practical Nurse (LPN) was interviewed on 7/27/18 at 3:10 PM and stated she was the assigned nurse for the resident. CNA #1 and #2 did not ask her to clarify what a Beasy board was or ask questions related to Resident #1's transfer status. The Director of Nursing (DON) was interviewed on 7/27/18 at 1:25 PM and 4:28 PM and she stated the involved staff (CNA #1 and CNA #2) did not complete competencies for using a Beasy board but they were in-serviced on general transfers. The CNAs failed to carefully read the resident's care profile and transferred the resident without using the Beasy board. The resident sustained [REDACTED]. CNA #1 was interviewed on 8/24/18 at 1:04 PM and stated she worked on 2/9/18 and was assigned to the resident. CNA #1 stated this was not the first time she worked on the unit, but it was the first time assigned to Resident #1. She knew Resident #1 required two-person assistance for transfer. CNA #2 told CNA #1 that she knew Resident #1 and was going to help her. CNA #1 and CNA #2 lifted the resident manually and placed her in the bed. After the transfer CNA #1 saw blood, the RNS was called. CNA #1 stated she checked the RCP prior to providing care to Resident #1 but did not remember if Beasy board was documented on the RCP. CNA #1 stated she did not know what a Beasy board was prior to the incident. CNA #1 could not recall if she received in-service specific to the Beasy board. After the incident she was shown how use the Beasy board. Based on the following corrective actions taken, there was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance at the time of this survey for this specific regulatory requirement. - The resident's transfer status was reassessed by physical therapist and continued use of the Beasy board. -Involved staff (CNA #1 and CNA #2) received education and counseling and were suspended for failure to fully implement the plan for care for the resident which resulted in injury. -The facility submitted documented evidence dated 2/12/18 indicating inservice education for all Certified Nursing Assistants related to safe transfers of residents and use of sliding board transfer that included the Beasy board. -The facility also submitted competencies for use of sliding board transfer that included the Beasy board completed by CNAs. Last documented competency was dated 7/24/18. - CNA #1 stated she received in-service after the incident. -Four CNAs were observed by the surveyor on 7/27/18 at 9:51 AM and 10:22 AM using Beasy board to transfer Resident #1 and #2. No issues were identified with the transfers. 415.12(h)(1)(2)

Based on interviews and record review during an abbreviated survey (Complaint # NY 075), the facility did not ensure resident rights to be free from abuse for one of three residents reviewed for Abuse (Resident #1). Specifically, the Recreation Aide (RA) intentionally threw water at the resident with [DIAGNOSES REDACTED]. The findings were: The facility policy titled Abuse Prohibition dated 11/28/2016 defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, punishment or exploitation with resulting physical harm, pain or mental anguish. Physical abuse included hitting, slapping, punching and kicking. The resident (Resident #1), was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS- an assessment tool) dated 10/16/17 documented the resident with severely impaired cognition. The Comprehensive Care Plan (CCP) titled Cognition dated 9/30/2015 documented the resident had impaired cognition related to a [DIAGNOSES REDACTED]. Interventions included to plan and implement consistency of care, approach in a calm, slow manner, give simple directions using simple words and short sentences. The CCP titled Behavior dated 6/2/2016 documented the resident had a history of [REDACTED]. Interventions included to redirect resident with calm approach, monitor and assess behaviors. The Nursing Progress Note (NPN) dated 11/21/17 by the Assistant Director of Nursing Services (ADNS) documented: on 11/20/17 the RA self-reported to the Recreation Director (RD) that she threw a cup of drinking water in response to the resident's unfiltered derogatory verbiage to her. The facility investigative summary dated 11/22/2017 documented that on 11/20/2017 at 10:25 AM, the RA was observed throwing a cup of water at Resident #1 in the dining room. Caregivers that were present in the dining room immediately informed RA that this action was wrong and not allowed in the facility. The RA stated that when she asked Resident #1 to move, he began to verbalize profanities and abusive language towards her. The RA informed the caregivers that she could not tolerate Resident #1's abusive language towards her. Resident #1 reported she wet me. The video surveillance was reviewed on 4/18/2017 at 10:58 AM with Director of Nursing (DON). On Camera 9 (dining room-6th floor) dated 11/20/17 at 10:25 AM the RA was seen talking and pointing at Resident #1. She reached out, picked a cup from the table with clear liquid and threw it at Resident #1 and then left the dining room. The Licensed Practical Nurse (LPN), a Certified Nurse's Aide (CNA) and the Nurse Care Coordinator (NCC) were present in the dining room at the time. The LPN was interviewed on 4/18/2018 at 12:53 PM and stated at approximately before 11 AM she was in the dining room and observed the RA with a cup of water in her hand and Resident #1's shirt was wet. The LPN reported her observation to the NCC and NCC reported the incident to the supervisor. The LPN asked Resident #1 what happened and he stated that the RA threw water on him. The LPN spoke to RA who told her that she (RA) was tired of all the abuse from the resident and she took a cup of water and threw it on Resident #1. The CNA was interviewed on 4/18/2018 at 1:17 PM, he stated at approximately 10:30 AM, the CNA saw the RA with a cup of water in her hand and she threw water at Resident #1. The NCC was in the dining room and the CNA informed the NCC. The NCC was interviewed on 4/18/2018 at 1:33 PM, she stated on 11/20/17 the LPN reported to her that the RA threw water at Resident #1. The NCC evaluated the resident and the resident said the RA threw water on him. The DON was interviewed on 4/18/2018 at 5:29 PM and stated that the RA admitted she threw water on the resident. The RA was interviewed on 5/2/18 at 3:42 PM and stated she was working on 11/20/17. She was preparing her program and seating residents on their tables. Resident #1 was on the table and the RA asked the resident to move because normally he did not sit on that table. The resident was nasty towards the RD, cursing and saying hurtful words and it was painful for her and she threw water at the resident. 415.4(b)

Based on observations, staff interviews and record review during an abbreviated survey (Case # NY 207), the facility staff did not notify a physician of a significant change in respiratory status for one (Resident#1) of three residents reviewed for significant change in condition. Specifically, Resident #1 had respiratory distress for 2 hours and 25 minutes and also verbalized not being able to breathe. The Primary Care Physician (PMD) was not notified of the change in Resident #1's respiratory status. Additionally the facility staff provided interventions without guidance from the PMD. Subsequently, Resident #1 was found unresponsive, pulseless, without respiration and blood pressure and was pronounced dead by the Registered Nurse Supervisor (RNS #1). This resulted in actual harm for Resident #1 that is not Immediate Jeopardy. The findings were: The facility Policy and Procedure Titled Change in Condition/Physician Notification revised on [DATE], documented the PMD would be informed by the RNS of change in resident's condition. The RNS would obtain additional orders from the PMD for additional assessments/interventions and or transfer to the emergency room (ER) for evaluation. The RNS and charge nurse would document all communications with the physician as well as the assessment findings including vital signs for resident experiencing a change in condition. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 assessment ((MDS) dated [DATE] documented the resident's cognitive status as being severely impaired. He required extensive to total assistance with Activities of Daily Living (ADL). The MDS noted the resident did not have shortness of breath and was not receiving oxygen. The Medical Orders for Life Sustaining Treatment (MOLST) dated [DATE] documented that Resident #1 had a Do Not Resuscitate (DNR) and Do Not Intubate (DNI) order. The treatment guidelines included instructions to not send the resident to the hospital unless pain or severe symptoms could not be otherwise controlled. The MOLST was last reviewed on [DATE]. The Comprehensive Care Plan (CCP) titled Breathing Pattern dated [DATE] documented the resident had history a of Mesothelioma. Interventions included ongoing monitoring and assessment of respiratory status, and to monitor oxygen saturation as ordered. The CCP dated [DATE] titled [MEDICAL CONDITIONS] documented interventions to monitor for signs and symptoms of respiratory distress, observe respiratory status every shift, and position resident to ensure adequate oxygenation. The review of the physician's orders [REDACTED]. The Nursing Progress Note (NPN) dated [DATE] at 9:22 PM by RNS #1 documented that RNS #1 was called to the resident's room around 5 PM to assess the resident. He was breathing heavily and was congested; oxygen saturation was 82% (normal range-above 92%). Oxygen was given via non-rebreather (This type of mask is used to deliver high concentrations of oxygen and does not allow for the rebreathing of exhaled air) mask and oxygen saturation came up to ,[DATE]%. The Licensed Practical Nurse (LPN #1) was instructed to give a nebulizer treatment as ordered. The NPN dated [DATE] at 10:28 PM entered by RNS #1 documented RNS #1 was called into the room at 7:20 PM by the charge nurse (LPN #1) to assess the resident who was unresponsive. Upon assessment the resident was not breathing had no blood pressure or pulse were present and the pupils were fixed and dilated. The resident was a DNR and DNI. The resident was pronounced dead at 7:25 PM. The PMD was made aware. The physician progress notes [REDACTED]. The patient was DNR and DNI. The death certificate was filled out with [DIAGNOSES REDACTED]. The NPN, late entry, by LPN #1 dated [DATE] at 2:58 PM for [DATE] documented approximately at 5:30 PM, CNA #1 informed LPN #1 that the resident was breathing hard. Vital signs were done. Pulse rate=47/Minute normal range ,[DATE]/minutes), respiratory rate=26 (normal ,[DATE]/minutes), blood pressure=,[DATE] (normal ,[DATE]) and oxygen saturation of 85%. The resident was provided with oxygen via face mask as he was mouth breathing. RNS #1 was notified and vital signs were given to the RNS. The resident remained alert and responsive. Oxygen saturation checked again and it was 89%. RNS #1 told the LPN that he had assessed the resident and his oxygen saturation was 92%. Around 6:30 PM, LPN #1 informed the RNS #1 that the resident's condition did not change. RNS #1 told the LPN that he spoke to the PMD. The RNS instructed LPN #1 to give a nebulizer treatment. LPN #1 got the nebulizer mask and machine and when LPN #1 went to the resident's room to administer nebulizer treatment, he was unresponsive with dark fluid on his gown. RNS #1 was informed and confirmed the resident was dead. There was no documentation in the medical record that a physician was notified of the change in Resident #1's condition . The undated and unsigned facility investigative summary documented the Director of Nursing (DON) reviewed the progress notes on [DATE] for the preceding day. The DON was alerted that there was no documentation that the PMD was notified of the resident's change in condition. The DON initiated an investigation into the events leading to resident's death. The facility investigation concluded that the nursing assistants reported a change in condition to the LPN who contacted the RNS. The RNS failed to follow the facility policy regarding a change in condition. The RNS never informed the PMD of the change in resident's respiratory status. The RNS reported that he assessed the resident twice and noted oxygen saturation was 92% and appeared stable however, statements from caregivers documented that the resident was restless and had labored breathing on and off after 5PM. The RNS failed to follow standards of practice for an RN. The RNS failed to obtain an order for [REDACTED]. Review of medical record for the month of (MONTH) 1st through January19th (YEAR) revealed no symptoms of respiratory distress for Resident #1. The PMD was interviewed on [DATE] at 1:31 PM and she stated that, on [DATE], RNS #1 called her and informed her that Resident #1 expired. The PMD stated that RNS #1 or LPN #1 did not call her prior to Resident #1's expiration and did not give her details about the circumstances of his death. On [DATE], the PMD was made aware by the DON that Resident #1 had problems with breathing, the staff gave oxygen and were going to give a nebulizer treatment. The PMD stated the nurse should have called her when Resident #1 was hypoxic (low oxygen) and his pulse was dropping. The PMD stated she was not aware Resident #1 had [MEDICAL CONDITION] symptoms prior to his demise on [DATE] until [DATE]. The PMD stated she did not document the [DIAGNOSES REDACTED]. She was not aware of the circumstances at the time she filled out the death certificate. The PMD was again interviewed on [DATE] at 10:13 AM and she stated, if she was made aware of the change in resident's condition, although she knew Resident #1 had a DNR and DNI order in place, she would have called the family and would have given them an option to decide if they wanted Resident #1 sent out to the hospital via 911 or receive supportive treatment at the facility. The PMD stated the nurses should have informed her of the change in Resident #1's condition. The Medical Director (MD) was interviewed on [DATE] at 5:29 PM and stated that when Resident #1 had changes in medical condition and changes in vital signs and the PMD should have been informed by the nurse. If the PMD was not available, the MD should have been notified. The MD stated he could not recall receiving any calls from RNS #1 or LPN #1 on [DATE]. The MD was informed by the DON that the PMD was not called until Resident #1 died . The MD stated if the resident was wheezing, the PMD should have been notified immediately when the staff became aware of Resident #1's change in condition. RNS #1 was interviewed on [DATE] at 10:28 PM and stated, at approximately 5 PM, LPN #1 reported that Resident #1 was short of breath and complained of being unable to breathe properly. Resident #1 told RNS #1 that he could not breathe. RNS #1 took Resident #1's pulse oxygenation and it was between ,[DATE]%. Resident #1 had heavy labored breathing. A rebreather mask (a mask utilized to deliver high concentration of oxygen. This type of mask allows the person to rebreathe some of the carbon [MEDICATION NAME], which acts as a way to stimulate breathing) was applied with oxygen at 10 liters/minute because the resident did not want a nasal cannula, and did not want to keep the mask on either. Resident #1 had audible wheezing (Wheezing is a high-pitched, coarse [MEDICATION NAME] sound most often is caused by an obstruction (blockage) or narrowing of the small [MEDICATION NAME] tubes in the chest and sometimes could be heard without a stethoscope). The RNS was not aware or informed that Resident #1 had a low pulse rate. LPN #1 told him that the vital signs were within normal limits except for oxygen saturation of 82%. He took the vital signs with LPN #1 before 5:45 PM, he did not remember the readings but he recalled they were ok except for wheezing and congestion. RNS #1 stated the resident's oxygen saturation went up to ,[DATE]%. He instructed LPN #1 to give a nebulizer treatment and to let him know how Resident #1 was doing. RNS #1 stated he did not call the PMD because Resident #1 was stable and there was no emergency to call the PMD about. RNS #1 was waiting for LPN #1 to give a nebulizer treatment and planned to evaluate the outcome and then call the PMD if necessary. He instructed LPN #1 to monitor Resident #1 every 15 minutes and inform him of any changes. At approximately 6:30 PM, he asked LPN #1 how Resident #1 was doing and LPN #1 stated he was ok but still wheezing. At 7:20 PM, LPN #1 informed RNS #1 that Resident #1 passed away. At approximately 7:20 - 7:25 PM, he went to the resident's room and observed Resident #1 lying on his back with a nasal cannula around his neck. The rebreather mask was on the table. RNS #1 took vital signs and the resident had no BP, no pulse, no oxygen saturation, the pupils were dilated and his eyes wide open. RNS #1 pronounced the resident dead at 7:25 PM. RNS #1 called the PMD and the DON before 8:00 PM and informed the PMD of the resident's expiration. RNS #1 stated he was supposed to notify the PMD regarding Resident #1's low oxygenation and difficulty breathing however, he was so busy and did not notify the PMD. RNS #1 stated he knew he was supposed to inform the PMD for a change in condition and he was supposed to reassess Resident #1 but he got busy and he relied on LPN #1. He told LPN #1 to call the PMD before he left to go to the dining room on another unit but she did not call the PMD because she said she was busy. He had instructed LPN #1 to monitor Resident #1 and to notify him of any changes. The video surveillance was reviewed on [DATE] at 2:33PM with the Director of Nursing (DON) who identified the staff. Camera 9 that showed the 3rd floor hallway on [DATE] revealed that no licensed staff went to the resident room from 6:55 PM-7:25 PM. RNS #1 was observed entering Resident #1's room at 7:25 PM when Resident #1 was pronounced dead. LPN #1 was interviewed on [DATE] at 1:13 PM and she stated, at approximately 5:30 PM, CNA#1 reported that Resident #1 was breathing hard. LPN #1 went to Resident #1 room; he was a little pale and out of breath. LPN #1 checked the oxygen saturation and it was 85%. LPN #1 stated she administered oxygen at 10 liters/minute via nasal cannula and the oxygen saturation went up to 88%. LPN #1 informed RNS #1. RNS #1 asked her if she took the vital signs and she stated she did and gave him the vital signs that included the oxygen saturation and the pulse rate. RNS #1 told the LPN that Resident #1 had no fever and to continue to monitor him and leave the oxygen on. LPN #1 applied the face mask and left the pulse oximeter on Resident #1's finger. RNS #1 knew about the resident's pulse rate of 47/minute. LPN #1 stated at 6:30 PM CNA #3 informed her that Resident #1 was restless, pale and was not keeping the oxygen mask on. LPN #1 stated she told RNS #1 when he came back to the unit to check Resident #1. RNS #1 did not physically go and check Resident #1 and he stated to LPN #1 that he spoke to PMD and instructed to give Resident #1 a breathing treatment right away. LPN #1 could not find the nebulizer machine and called RNS #1 for it. RNS #1 instructed her to go to another unit to find one. She borrowed a nebulizer machine from another resident. When LPN #1 went to Resident #1's room to administer the nebulizer treatment at approximately 6:30 - 7:30 PM she found Resident #1 unresponsive. LPN #1 called RNS #1 to assess Resident #1 because Resident #1 looked dead to her and she could not give the nebulizer treatment. RNS #1 told LPN #1 that Resident #1 was DNR. LPN #1 stated she could have called the PMD to inform her of the change in the resident's condition however, LPN #1 was waiting for instruction from RNS #1. LPN #1 denied that she was instructed by RNS #1 to call the PMD. LPN #1 did not call the PMD. The DON was interviewed on [DATE] at 3:13 PM and she stated that, upon routine review of progress notes on [DATE], the DON was concerned that there was no documentation that the PMD was notified of Resident #1's change in condition. On [DATE], she initiated an investigation. The DON called the Medical Director (MD) and PMD and ascertained that they were not called about Resident #1's change in condition on [DATE]. The DON determined that RNS #1 failed to notify the MD of the change in Resident #1's condition. The DON stated that the PMD was readily accessible and if the PMD was not available the MD should have been called. The RNS should have called the PMD when the staff reported a change in the resident's condition to get clear directives from PMD and that is why RNS #1 was terminated. The DON stated LPN #1 also failed to obtain an order for [REDACTED].>The Administrator was interviewed on [DATE] at 4:09 PM and he stated that the DON informed him on [DATE] that RNS #1 did not notify a physician for change in Resident #1's condition. Based on facility policy and procedure the RNS should have notified the PMD immediately after his assessment. Based on the following corrective actions taken, there was sufficient evidence the facility corrected the noncompliance on [DATE] and was in substantial compliance for this specific regulatory requirement at the time of this survey: The facility: - Reviewed the Policy and Procedure in Residents Change in Condition and was found in compliance. - Re-educated all Licensed Staff (RN and LPN) including per diem staff on their specific responsibilities with regards to a change in resident condition, as per policy and procedures, on [DATE]. - Interviews conducted on [DATE] with the Licensed Professional Staff (6 Licensed Practical Nurses (LPN), 2 Assistant Directors of Nursing (ADON) and 1 Registered Nurse Supervisor (RNS)) to ascertain the post incident in-service training/education regarding the facility's procedures on managing a change in resident condition, it was determined that the staff interviewed were aware of the facility's expectation of Licensed Nursing Staff regarding the procedure to manage and report a change in a resident's condition to the physician. All LPN staff consistently stated that they would monitor the resident's vital signs, call the Registered Nurse Supervisor, call the Medical Doctor as necessary and document their findings and interventions. All staff interviewed stated they would work as a team to manage the residents care. Additionally, all staff interviewed were aware of the procedure for obtaining a nebulizer machine, should one become necessary for resident treatment. All staff consistently stated that they would report to the Nursing Supervisor should there be a delay in obtaining the equipment. All RNS interviewed verbalized awareness of the policy and to notify the physician of a change in residents' condition immediately after their assessment. The facility continued their evaluation of the compliance of the licensed staff role when residents experience a change in condition. 415.3(e)(2)(11)(b)

Based on observations, staff interviews and record review during an abbreviated survey (Case # NY 2017), the facility did not ensure that one of three residents reviewed for quality of care was provided with necessary care and services to maintain the highest practicable physical, mental and psychological wellbeing according to the Comprehensive Care Plan (CCP). Specifically, on [DATE] Resident #1 had respiratory distress for 2 hours and 25 minutes and verbalized not being able to breathe. The facility failed to administer a physician ordered breathing treatment and failed to notify the physician of a change in a resident's condition. Also the facility failed to obtain a physician order [REDACTED]. This resulted in actual harm for Resident #1 that is not Immediate Jeopardy. The findings are: The facility Policy and Procedure Titled Change in Condition/Physician Notification, revised on [DATE], documented that all changes in residents' condition would be reported to the Registered Nurse Supervisor (RNS). The unit nurse would evaluate the resident via verbal interview and obtain vital signs. A medical emergency such as significant change in vital signs, circulatory changes including changes in respiratory status such as congestion and dyspnea required the RNS to assess the resident and document findings in the medical record. The Primary Medical Doctor (PMD) would be informed by the RNS of change in resident's condition. The RNS would obtain additional orders from the PMD for additional assessments/interventions and or transfer to the emergency room (ER) for evaluation. The RNS and charge nurse would document all communications with the physician as well as the assessment findings including vital signs for resident experiencing a change in condition. The facility Policy and Procedure Titled Oxygen Therapy Respiratory Treatment Equipment, revised [DATE], documented residents would be provided with oxygen therapy as ordered by the physician. The PMD would order Supplemental Oxygen Therapy, specify the route, the flow rate and frequency. Residents experiencing shortness of breath, low oxygen saturation, and or an unstable medical condition would immediately be provided with oxygen therapy by the nurse. The following supplies would be available on each unit attached to the Emergency oxygen tank: nasal cannula, nonrebreather mask ((This type of mask is used to deliver high concentrations of oxygen and does not allow for the rebreathing of exhaled air) and face mask. The nurse would notify the PMD and obtain order for oxygen therapy for the resident. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 assessment ((MDS) dated [DATE] documented the resident's cognitive status as being severely impaired. He required extensive to total assistance with Activities of Daily Living (ADL). The MDS noted the resident did not have shortness of breath and was not receiving oxygen. The Medical Orders for Life Sustaining Treatment (MOLST) dated [DATE] documented that Resident #1 had a Do Not Resuscitate (DNR) and Do Not Intubate (DNI) order. The treatment guidelines included instructions to not send the resident to the hospital unless pain or severe symptoms could not be otherwise controlled. The MOLST was last reviewed on [DATE]. The Comprehensive Care Plan (CCP) titled Breathing Pattern dated [DATE] documented the resident had a history of [REDACTED]. The CCP dated [DATE] titled [MEDICAL CONDITIONS] documented Interventions to monitor for signs and symptoms of respiratory distress, observe respiratory status every shift, and position resident to ensure adequate oxygenation. The physician's orders [REDACTED]. The Nursing Progress Note (NPN) dated [DATE] at 9:22 PM by RNS #1 documented that RNS #1 was called to the resident's room around 5 PM to assess the resident. He was breathing heavily and was congested; oxygen saturation was 82% (normal range-above 92%). Oxygen was given via non-rebreather mask and oxygen saturation came up to ,[DATE]%. The Licensed Practical Nurse (LPN #1) was instructed to give a nebulizer treatment as ordered. The NPN dated [DATE] at 10:28 PM entered by RNS #1 documented that RNS #1 was called into the room by the charge nurse (LPN #1) to assess the resident at 7:20 PM who was unresponsive. Upon assessment the resident was not breathing, no blood pressure or pulse were present. Pupils were fixed and dilated. The resident was a DNR and DNI. Resident was pronounced dead at 7:25 PM. The PMD was made aware. The physician progress notes [REDACTED]. The patient was DNR and DNI. Death certificate was filled out with [DIAGNOSES REDACTED]. The NPN, late entry, by LPN #1 dated [DATE] at 2:58 PM for [DATE] documented approximately at 5:30 PM, CNA #1 informed LPN #1 that the resident was breathing hard. Vital signs were done. Pulse rate=47/Minute normal range ,[DATE]/minutes), respiratory rate=26 (normal ,[DATE]/minutes), blood pressure=,[DATE] (normal ,[DATE]) and oxygen saturation of 85%. The resident was provided with oxygen via face mask as he was mouth breathing. RNS #1 was notified and vital signs were given to the RNS. The resident remained alert and responsive. Oxygen saturation checked again and it was 89%. RNS #1 told the LPN that he had assessed the resident and his oxygen saturation was 92%. Around 6:30 PM, LPN #1 informed the RNS #1 that the resident's condition did not change. RNS #1 told the LPN that he spoke to the PMD. The RNS instructed LPN #1 to give a nebulizer treatment. LPN #1 got the nebulizer mask and machine and when LPN #1 went to the resident's room to administer nebulizer treatment, he was unresponsive with dark fluid on his gown. RNS #1 was informed and confirmed the resident was dead. The undated and unsigned facility investigative summary documented the Director of Nursing (DON) reviewed the progress notes on [DATE] for the preceding day. The DON was alerted that there was no documentation that the PMD was notified of the resident's change in condition. The DON initiated an investigation into the events leading to resident's death. The facility investigation concluded that the nursing assistants reported a change in condition to the LPN who contacted the RNS. The RNS failed to follow the facility policy regarding a change in condition. The RNS never informed the PMD of the change in resident's respiratory status. The RNS reported that he assessed the resident twice and noted oxygen saturation was 92% and appeared stable however, statements from caregivers documented that the resident was restless and had labored breathing on and off after 5PM. The RNS failed to follow standards of practice for an RN. The RNS failed to obtain an order for [REDACTED]. The 3:00 PM-11:00 PM CNA #1 was interviewed on [DATE] at 11:00 AM and stated that, on [DATE] at approximately 4:,[DATE]:15 PM, CNA #1 observed Resident #1's breathing was labored. CNA #1 alerted LPN #1 who came to the room and instructed her to put Resident #1 in bed. LPN #1 came back to the room with portable oxygen and nasal cannula and oxygen was administered. At approximately 5:,[DATE]:00 PM LPN #1 instructed CNA #1 to feed Resident #1 and he had a few sips of soup and apple juice. CNA #1 stated she checked Resident #1 approximately 6:30 PM and she did not notice any changes. CNA #1 checked Resident #1 at 7:00 PM; The RNS #1 and LPN #1 were in the room and LPN #1 informed her that Resident #1 was gone and at that time LPN #1 was getting ready to give him a nebulizer treatment. The 3:00 PM-11:00 PM CNA #2 was interviewed on [DATE] at 5:02PM and stated, on [DATE], at approximately 4:,[DATE]:30 PM, CNA #2 noticed that Resident #1 was breathing heavy when she and CNA #1 went to assist the resident to the bed. CNA #2 asked Resident #1 if he was ok and Resident #1 did not respond. CNA #1 informed LPN #1 and LPN #1 came right away, left and came back with oxygen and applied a nasal cannula. At approximately 6:00 PM, CNA #2 brought Resident #1's supper tray to his room and noted him with oxygen mask. CNA #2 stated Resident #1 was still breathing heavy, a little pale and the oxygen was not helping. The mask came off Resident #1's face and CNA #2 fixed the mask. CNA #2 stated she informed LPN #1 that Resident #1 was still breathing heavy and did not look good. LPN #1 stated she spoke to RNS #1. CNA #2 saw Resident #1 again at approximately 7 PM and she was informed by LPN #1 that Resident #1 passed away. The PMD was interviewed on [DATE] at 1:31 PM, was familiar with the resident, described cardiac history and reported multiple [DIAGNOSES REDACTED]. The PMD stated that, on [DATE], RNS #1 called the PMD and informed her that the patient just expired and the time of expiration. The PMD stated that RNS #1 or LPN #1 did not call her prior to Resident #1's expiration and did not give her details of events or resident status leading up to the death on [DATE]. The PMD was made aware by DON on [DATE] that Resident #1 had problems with breathing, the staff gave oxygen and was going to give a nebulizer treatment. The PMD further stated the nurse should have called her when Resident #1 was hypoxic and his pulse was dropping. The PMD stated that she did not document a [DIAGNOSES REDACTED]. She was not aware of the symptoms that resident was experiencing prior to his death. The PMD was interviewed again on [DATE] at 10:13 AM and she stated although she knew Resident #1 had a DNR and DNI order in place, she would have called the family and allowed them to decide if they wanted to send Resident #1 via 911 to the hospital or give him supportive treatment at the facility if she was informed that Resident #1 had a change in respiratory condition. The PMD stated the use of non-rebreather mask could be a medical emergency and is used to efficiently deliver oxygen. The PMD stated if the resident was wheezing, oxygen should have been administered right away along with the nebulizer treatment. The Medical Director (MD) was interviewed on [DATE] at 5:29 PM and stated when Resident #1 had changes in medical condition and changes in vital signs, the PMD should have been informed by the nurse and if the PMD was not available, the MD should have been notified. The MD stated if the resident was wheezing, the PMD should be notified immediately and administration of nebulizer treatment should be a priority; however, the MD stated that Resident #1 had cardiac symptoms not respiratory. RNS #1 was interviewed on [DATE] at 10:28 PM and stated, at approximately 5 PM, LPN #1 reported that Resident #1 was short of breath and complained of being unable to breathe properly. Resident #1 told RNS #1 that he could not breathe. RNS #1 took Resident #1's pulse oxygenation and it was between ,[DATE]%. Resident #1 had heavy labored breathing. A rebreather mask (a mask utilized to deliver high concentration of oxygen. This type of mask allows the person to rebreathe some of the carbon [MEDICATION NAME], which acts as a way to stimulate breathing) was applied with oxygen at 10 liters/minute because the resident did not want a nasal cannula, and did not want to keep the mask on either. Resident #1 had audible wheezing (Wheezing is a high-pitched, coarse [MEDICATION NAME] sound most often is caused by an obstruction (blockage) or narrowing of the small [MEDICATION NAME] tubes in the chest and sometimes could be heard without a stethoscope). The RNS was not aware or informed that Resident #1 had a low pulse rate. LPN #1 told him that the vital signs were within normal limits except for oxygen saturation of 82%. He took the vital signs with LPN #1 before 5:45 PM, he did not remember the readings but he recalled they were ok except for wheezing and congestion. RNS #1 stated the resident's oxygen saturation went up to ,[DATE]%. He instructed LPN #1 to give a nebulizer treatment and to let him know how Resident #1 was doing. RNS #1 stated he did not call the PMD because Resident #1 was stable and there was no emergency to call the PMD about. RNS #1 was waiting for LPN #1 to give a nebulizer treatment and planned to evaluate the outcome and then call the PMD if necessary. He instructed LPN #1 to monitor Resident #1 every 15 minutes and inform him of any changes. At approximately 6:30 PM, he asked LPN #1 how Resident #1 was doing and LPN #1 stated he was ok but still wheezing. At 7:20 PM, LPN #1 informed RNS #1 that Resident #1 passed away. At approximately 7:20 - 7:25 PM, he went to the resident's room and observed Resident #1 lying on his back with a nasal cannula around his neck. The rebreather mask was on the table. RNS #1 took vital signs and the resident had no BP, no pulse, no oxygen saturation, the pupils were dilated and his eyes wide open. RNS #1 pronounced the resident dead at 7:25 PM. RNS #1 called the PMD and the DON before 8:00 PM and informed the PMD of the resident's expiration. RNS #1 stated he was supposed to notify the PMD regarding Resident #1's low oxygenation and difficulty breathing however, he was so busy and did not notify the PMD. RNS #1 stated he knew he was supposed to inform the PMD for a change in condition and he was supposed to reassess Resident #1 but he got busy and he relied on LPN #1. He told LPN #1 to call the PMD before he left to go to the dining room on another unit but she did not call the PMD because she said she was busy. He had instructed LPN #1 to monitor Resident #1 and to notify him of any changes. The video surveillance was reviewed on [DATE] at 2:33PM with the Director of Nursing (DON) who identified the staff. Camera 9 that showed the 3rd floor hallway on [DATE] revealed that no licensed staff went to the resident room from 6:55 PM-7:25 PM. RNS #1 was observed entering Resident #1's room at 7:25 PM when Resident #1 was pronounced dead. LPN #1 was interviewed on [DATE] at 1:13 PM and she stated, at approximately 5:30 PM, CNA#1 reported that Resident #1 was breathing hard. LPN #1 went to Resident #1 room; he was a little pale and out of breath. LPN #1 checked the oxygen saturation and it was 85%. She administered oxygen at 10 liters/minute via nasal cannula and the oxygen saturation went up to 88% and informed RNS #1. RNS #1 asked her if she took the vital signs and she stated she did and gave him the vital signs that included the oxygen saturation and pulse rate. RNS #1 told the LPN that Resident #1 had no fever and to continue to monitor him and leave oxygen on. LPN #1 applied the face mask and left the pulse oximeter on Resident #1's finger. RNS #1 knew about the resident's pulse rate of 47/minute. At 6:30 PM CNA #3 informed her that Resident #1 was restless, pale and was not keeping the oxygen mask on. LPN #1 stated she told RNS #1 when he came back to the unit to check Resident #1. RNS #1 did not physically go and check Resident #1 and he stated to LPN #1 that he spoke to PMD and instructed to give Resident #1 a breathing treatment right away. LPN #1 could not find the nebulizer machine and called RNS #1 for it. RNS #1 instructed her to go to another unit to find one. She borrowed a nebulizer machine from another resident. When LPN #1 went to Resident #1's room to administer the nebulizer treatment at approximately 6:30 - 7:30 PM she found Resident #1 unresponsive. LPN #1 called RNS #1 to assess Resident #1 because Resident #1 looked dead to her and she could not give the nebulizer treatment. RNS #1 told LPN #1 that Resident #1 was DNR. LPN #1 stated she could have called the PMD to inform her of the change in the resident's condition however, LPN #1 was waiting for instruction from RNS #1. LPN #1 denied that she was instructed by RNS #1 to call the PMD. LPN #1 did not call the PMD. The DON was interviewed on [DATE] at 3:13 PM and stated she contacted both the MD and the PMD and both confirmed that they were not called regarding Resident #1's change in condition. The DON determined that RNS #1 failed to follow safe practice and did not assess the resident. The RNS never documented that a full assessment was completed for the resident that included checking the lungs and abdomen. The RNS did not notify the MD/PMD of the change in Resident #1's condition. If the RNS was following the standards of practice he should have come back to check that Resident #1 received the nebulizer treatment. The DON stated that the RNS was working out of his scope of practice and failed to contact the physician. The DON stated that Resident #1's breathing pattern had changed and the RNS should have obtained the vital signs for the resident. Had this been done the correct way, and had the RNS assess the resident and called the physician then there would be a clear directive from the PMD. The DON further stated that after the RNS noted Resident #1 wheezing it was expected that the nebulizer treatment be administered right away. The RNS denied listening to the resident's lung sound. It was difficult to determine if the resident had respiratory distress because an assessment was not done, however, there was a change in the residents condition that needed to be addressed. According to the DON the real problem was that an assessment was not done by the RNS and the physician was not notified of the change in the resident's condition. The nebulizer machine was usually kept in the medication room and there was one in the supervisor office. LPN #1 failed to obtain orders for supplemental oxygen and document her findings in medical record. The Administrator was interviewed on [DATE] at 4:09 PM and stated that the DON informed him on [DATE] that RNS #1 did not follow the facility policy on notifying the PMD of a change in the resident's condition. The Administrator stated the RNS should have notified the PMD after his assessment. The facility assessed the availability of nebulizer machine and had plenty of nebulizer machines in the building. The RNS did not inform the PMD of his resident assessment. Based on the following corrective actions taken, there was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance for this specific regulatory requirement prior to and during the time of this survey: The facility -Reviewed the Policy and Procedure in Residents Change in Condition and was found in compliance. -Re-educated all Licensed Staff (RN and LPN) including per diem on their responsibilities with regards to a change in resident condition on [DATE]. -Educated licensed staff on where to locate emergency nebulizer machine on [DATE]. - Interviews conducted on [DATE] with the Licensed Professional Staff (6 Licensed Practical Nurses (LPN), 2 Assistant Directors of Nursing (ADON) and 1 Registered Nurse Supervisor (RNS)) to ascertain the post incident in-service training/education regarding the facility's procedures on managing a change in resident condition, it was determined that the staff interviewed were aware of the facility's expectation of Licensed Nursing Staff regarding the procedure to manage and report a change in a resident's condition to the physician. All LPN staff consistently stated that they would monitor the resident's vital signs, call the Registered Nurse Supervisor, call the Medical Doctor as necessary and document their findings and interventions. All staff interviewed stated they would work as a team to manage the residents care. Additionally, all staff interviewed were aware of the procedure for obtaining a nebulizer machine, should one become necessary for resident treatment. All staff consistently stated that they would report to the Nursing Supervisor should there be a delay in obtaining the equipment. All RNS interviewed verbalized awareness of the policy and to notify the physician of a change in residents' condition immediately after their assessment. -The facility continued their evaluation of the compliance of the licensed staff role when residents experience a change in condition. 415.12

Based on record review and staff and resident interviews conducted during an abbreviated and partial extended survey, the Medical Director failed to coordinate medical care in the facility and failed to provide clinical guidance and oversight regarding the implementation of resident care policies. Specifically, the Medical Director failed to ensure that policies and procedures were in place to ensure the appropriate assessment and monitoring of residents with a change in medical condition. The Medical Doctor also failed to develop and implement policies and procedures that address a resident's request to be transferred to the hospital. This resulted in actual harm to a resident (Resident #1) and the potential for serious harm that is Immediate Jeopardy for 40 residents. Cross-References - Refer to: F 309 - Quality of Care F 520 - Quality Assessment and Assurance. Complaint ID Number: NY 927 The findings are: An interview was conducted with the Director of Nursing (DON) on 2/7/13 at 11:16 AM. The DON stated that prior to the resident's death, there was no specific facility policy that addressed a resident's change in medical condition and no policies and procedures to guide staff on how to respond to a resident who requests to be sent out to the hospital. An interview was conducted with the Medical Director (MD) on 2/12/13 at 11:05 AM. The MD stated that he was aware of the situation involving Resident #1 and reviewed the case with the DON and Administrator. He knew Resident #1 had been asking to go to the hospital, had diarrhea throughout the shift and was later found unresponsive. The MD also stated that he thought nursing was following Resident #1 during the shift and he was not sure that there was any delay in treatment but thinks that staff followed policies. The MD further stated, "I didn't see that Resident #1 was having any chest pain. Otherwise, if he was having chest pain, he wouldn't be able to transfer himself out of the wheelchair. I don't feel any neglect of care was done." 415.15 (a)

Based on record reviews and resident and staff interviews conducted during an abbreviated and partial extended survey, the facility failed to ensure that each resident was provided with the necessary care and services to maintain the highest practicable physical, mental and psychosocial well being in accordance to the Comprehensive Care Plan (CCP). Specifically, one resident (Resident #1) of 11 residents reviewed for quality of care was visibly shaking, verbalized that he was not feeling well and pleaded with staff for six hours to transfer him to the hospital. Resident #1 was not thoroughly assessed in a timely manner and nursing staff did not notify the physician timely of a change in condition. Hours later, the resident became unresponsive and facility staff could not immediately determine his Advanced Directive status. He was then transferred to the hospital, where he was pronounced dead. This resulted in actual harm to Resident #1 and the potential for serious harm that is Immediate Jeopardy and Substandard Quality of Care for 40 residents. Complaint ID Number: NY 927 The findings are: Resident #1 was [AGE] years old and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Brief Interview for Mental Status (BIMS) dated [DATE] documented that Resident #1 was cognitively intact. The Comprehensive Care Plan (CCP) for [MEDICAL CONDITION] dated [DATE] and updated [DATE] documented interventions including but not limited to notifying the Medical Doctor (MD) of any changes, monitoring for chest pain, change in Blood Pressure (BP) and abnormal pulse. The CCPs for Elimination Needs and Bowel Patterns dated [DATE] and updated [DATE] documented that Resident #1 was always continent of bowel. The CCP for Activities of Daily Living (ADL) dated [DATE] and updated [DATE] documented an intervention including but not limited to communication to all staff regarding resident's special care needs and goals. The CCP for Advanced Directives dated [DATE] and updated [DATE] documented that the resident was competent to make health care decisions, had a health care proxy and did not wish to execute a Do Not Resuscitate (DNR) order. The Advanced Directives Progress Notes dated [DATE] documented that Resident #1 was not a DNR. The Nursing Progress Notes (NPN) dated [DATE] at 4:00 PM (written by LPN #1) documented that Resident #1 stated that he thought he had a fever but temperature orally was 98.0. Resident #1 then complained of having loose stool. The nurse supervisor (Assistant Director of Nursing) was notified. She came and checked the resident. At 5:00 PM the resident took pills and went to bed. At 10:00 PM, he had another loose stool and the doctor was notified, ordering the resident to be transferred to the hospital for an evaluation. The vital signs were Temperature: 97.8, Pulse: 110, Respirations: 20, Blood Pressure: ,[DATE]. At 10:10 PM Resident #1 was found unresponsive in his wheelchair, Code Blue was called, CPR performed and 911 was called. The resident was transferred to the emergency room at 10:35 PM. The doctor was aware and the resident's family was called by the nurse supervisor. The medical record revealed no documented evidence that Resident #1 was assessed by the Assistant Director of Nursing (ADON) on [DATE] between 4:00 PM and 10:00 PM. The NPN dated [DATE] at 10:15 PM written by the Registered Nurse Supervisor (RNS) documented that Resident #1 was found unresponsive in his wheelchair, was transferred to his bed and noted with no heart rate and no respirations. Cardiopulmonary Resuscitation (CPR) was initiated, 911 called and responded. The resident was transferred to the hospital, where he was pronounced dead at 10:58 PM. The facility's undated Time Line Summary and Investigation Conclusion (TLSIC) documented that there was no willful neglect on the part of nursing staff; that the resident's behaviors and actions were in accordance with his customary routines; and that the resident did not exhibit any clinical signs or report any symptoms of a medically unstable condition. The TLSIC further concluded that LPN #1 failed to contact the physician or obtain a complete set of vital signs when the resident reported a complaint. The ADON failed to perform a thorough assessment, document the medical record and ensure the physician was notified. The RNS failed to activate Code Blue as per facility policy. The Resident Monitoring and Assessment Policy and Procedure dated [DATE] documented that the charge nurse on each shift will obtain vital signs on assigned residents, notify the Primary Medical Doctor (PMD) of any resident changes when indicated and document in the medical record and on the twenty four hour report sheet. The [MEDICAL CONDITION]/Respiratory Arrest Policy and Procedure dated [DATE] documented that any resident who is not responding in his or her normal way will be evaluated immediately by the nurse, who ascertains if the resident has a DNR and check for the absence of pulse and respiration. CPR will be started on all residents with no pulse or respiration and who do not have a DNR order. The nurse will stay with the resident and instruct one staff member to announce an overhead page, " Doctor Blue Room ___ " three times while a second staff member will call 911. The undated Abuse Investigation and Reporting Policy and Procedure documented that neglect is a failure to provide timely, consistent, safe, adequate, or appropriate services, treatment, and/or care. An interview was conducted with the ADON on [DATE] at 11:18. The ADON stated that she was the nursing supervisor on [DATE] from 3:00 PM to 10:00 PM. She was called by the charge nurse (LPN #1) around 4:00 PM to see Resident #1, who was requesting to go to the hospital. The ADON stated that when she arrived on the unit, she thought LPN #1 was either taking Resident #1's pulse oximetry or temperature. The ADON noticed that Resident #1 was shaking but thought he was intentionally shaking, although the ADON stated that she was not aware of the resident ever previously shaking. The ADON stated that she told Resident #1 to go back to his room and try to relax and asked LPN #1 to call the doctor if there were any changes. She was not aware if the doctor had ever been called. The ADON stated that, shortly after 7:00 PM, she received an overhead page from Resident #1's aide (CNA #2), who told her the resident was shaking and CNA #2 had never seen him act like this before. The ADON stated that she did not necessarily believe CNA #2 because CNA #2 tends to over-report everything about a resident. She spoke to LPN #1, who told her that the resident was fine and there was no reason to page the ADON. The ADON stated that she did not do an assessment of Resident #1 because she was waiting for LPN #1 to get the resident's vital signs. There was no documented evidence in the medical record to indicate that LPN #1 obtained the resident's vital signs . The ADON further stated that she had not heard that Resident #1 wanted to go to the hospital and then added, "I think I may have heard it in passing but didn't pay a lot of attention to it." She concluded by saying that she thought the resident was engaged in attention-seeking behavior because of his history of substance abuse but then said that she had not known of the resident's history until after an investigation was started. An interview was conducted with the 3:00 PM to 11:00 PM charge nurse LPN #1 on [DATE] at 11:57 AM. She stated that around 4:00 PM on [DATE], Resident #1 came to her asking to go to the hospital and she thought the resident did not look any different except for the fact that he was shaking. She took the resident's temperature, which was 98.0 orally. She called for the nursing supervisor and the ADON came and observed the resident. The ADON told LPN #1 that the resident looked fine and instructed her to observe the resident and call the doctor for any changes . LPN #1 stated that, just before it was time for his medications, Resident #1 came to her in the hallway saying again that he wanted to go to the hospital. The resident told LPN #1 that if she did not call an ambulance, he would call for an ambulance himself. She stated that she thought the resident was joking and told him that he would have to pay for the ambulance himself. She administered medications to Resident #1 around 5:30 PM and went to the dining room to monitor the dinner meal for other residents. Resident #1 did not come to the dining room for dinner that evening which was unusual for him. He was served his tray in his room. LPN #1 stated that CNA #2 did tell her that the resident did not eat his dinner. LPN #1 thought that the resident was just not hungry. LPN #1 stated that sometime between 7:00 PM and 8:00 PM, the ADON called her on the phone because CNA #2 had paged the ADON regarding the resident. She told the ADON that the resident was quiet because she saw him lying on his bed. She said that she did not enter his room to ask him how he was feeling. LPN #1 stated, "I didn't want to disturb him." Around 9:30 PM she administered medications to Resident #1, who was seated in his wheelchair. The resident had been having loose stools and again wanted to go to the hospital. She stated that it was unusual for the resident to have loose stools and since the resident still wanted to go to the hospital, she called the doctor, who asked her for vital signs. She told the doctor that the resident had a temperature less than 98.0. The doctor told her that if the resident wants to go to the hospital, then she should send him. LPN #1 told the resident that she would be sending him to the hospital. The resident wanted to get dressed, so she told CNA #2 to help the resident get ready to go to the hospital. A few minutes later, CNA #2 called her to Resident #1's room. She went to the room and observed him slumped over in his wheelchair and unresponsive. She stated that she checked for a carotid pulse but was uncertain if there was a pulse, so she ran to the phone to call the operator in order to page a Code Blue. LPN #1 stated that the operator was on an important call, she did not recall hearing a Code Blue, and went back to the resident's room. She then left to go to the nursing station to call the operator again. LPN #1 stated that she was not sure how long it took, but the RNS showed up and the resident was transferred from his wheelchair to the bed. She stated that, at first, it was not certain whether or not Resident #1 was a DNR, but once they realized that he was not a DNR, CPR was started and 911 arrived to take him to the hospital. An interview was conducted with the daily 7:00 AM to 3:00 PM charge nurse LPN #2 on [DATE] at 1:01 PM. She stated that Resident #1 would come to the desk throughout the day to make sure that his wife's care was being given. The resident never talked about his own care and he was not attention-seeking. LPN #2 further stated that she had not known the resident to have loose stools. She said if anything, he would lean more towards constipation, requiring an enema once in a while. An interview was conducted with the assigned 6:00 AM to 2:00 PM CNA #1 on [DATE] at 1:18 PM. She stated that Resident #1 did a lot for himself and would never ask for help unless he needed it. She had never seen him shake or have loose stools. An interview was conducted with the RNS on [DATE] at 1:28 PM. The RNS stated that she took over as supervisor after the ADON left at 10:00 PM on [DATE]. The ADON had reported that Resident #1 was fine and had some diarrhea. The RNS stated that around 10:10 PM on [DATE], she received a call from 911, saying that a resident from room [ROOM NUMBER] called in an emergency. The RNS did not know of any emergency and went to the 1st floor. When she arrived on the floor, she observed several staff in the resident's room. He was sitting slumped over in his wheelchair and she could not assess Resident #1 the way he was positioned. She asked staff to transfer the resident into bed. The RNS stated that once he was in bed, she felt for a pulse but did not find one and there were no respirations. She thought Resident #1 was in [MEDICAL CONDITION] and went out of the resident's room to call for assistance. She said she did not actually call a Code Blue but once it was obvious he was not a DNR, the RNS had LPN #1 start CPR. The RNS was unable to say how long it took to determine the resident's DNR status or the reason why his DNR status was unknown. The RNS further stated that she did not know whether or not a Code Blue had ever been called. An interview was conducted with LPN #3 on [DATE] at 9:39 AM. LPN#3 stated that she was the charge nurse from 7:00 AM to 4:00 PM on [DATE] but is usually Resident #1's daily medication nurse. She stated that Resident #1 "was not a complainer at all. He was regimented about receiving his medication and when it was time for his medications he would stay with me until he got them and then leave to do his own thing. He never asked about himself, just about his wife." LPN #3 stated that he did not have loose stools during her shift on [DATE] and she never knew him to have loose stools. LPN #3 stated that if a resident was unresponsive, she would personally call a Code Blue on the overheard page but some staff will go through the operator. "I don't think there's a right or wrong way to do it." An interview was conducted with the Director of Nursing (DON) on [DATE] at 11:16 AM. She stated that prior to the resident's death, there was no specific policy about a resident change in condition or what staff should do when a resident wants to go to the hospital. An interview was conducted with a cognitively intact Resident #2 on [DATE] at 10:10 AM. Resident #2 stated that he was Resident #1's roommate. He said Resident #1 had been "shaking like a leaf all evening. He was never like that." Around 9:35 PM on [DATE], he saw Resident #1 walk to his closet shaking, went back to his wheelchair and opened the bathroom door. He saw Resident #1 leaning over in his wheelchair. He rang the call bell and was screaming out, "Man Down, Help, "but no one came to the room for a long time. He decided to call 911 himself because "the staff were just leaving him to die." He further stated that CNA #2 finally came to the room and ran out yelling, returning with LPN #1. Someone pulled his privacy curtain over, so Resident #2 did not see anything else until about ten minutes later when a male nurse (LPN #3), who Resident #2 did not know, came over to Resident #2's side of the curtain and "was turning pages in a chart saying, 'We have to find out if he's a DNR.'" Resident #2 further stated, "I told (the Administrator) that I'm scared to be here. If this is the way they treated him and I have a heart condition, how will they treat me?" An interview was conducted with a cognitively intact Resident #5 on [DATE] at 11:30 AM. Resident #5 resides four doors down from Resident #1 and stated that she heard Resident #2 yelling for help around 9:30 PM and but did not see staff respond for a while. Resident #5 further stated that she does not usually use the call bell because staff only want the call bells to be used for emergencies. Resident #5 stated that, earlier in the evening, Resident #1 went to LPN #1 outside Resident #5's door. Resident #1 was "shaking like crazy and kept yelling that he didn't feel well and wanted to go to the hospital. She (LPN #1) told him she called the doctor and the doctor said you're not going to the hospital so, if he wanted to go, he would have to pay for an ambulance." Resident #5 further stated, "I know people pass on here but I myself thought he was neglected." An interview was conducted with the Attending Physician (AP) on [DATE] at 12:40 PM. The AP stated that she was very angry regarding the situation with Resident #1 because the AP was not called by staff the entire day. The AP stated that the first call she received was at 10:00 PM on [DATE] from LPN #1, who told the AP that Resident #1 wanted to go to the hospital. The AP asked LPN #1 for Resident #1's vital signs and LPN #1 told the AP that his vital signs were normal but the resident was having diarrhea about six times. The AP stated that LPN #1 was not really telling the her what was wrong with the resident. She ordered him to be sent to the hospital because he was asking to go to the hospital. The AP stated that she received another call from LPN #1 at 10:39 PM saying that Resident #1 was unresponsive. The AP stated she began questioning LPN #1 regarding her earlier report that the resident's vital signs were normal. The AP stated that LPN #1 admitted , at that point, that Resident #1's vital signs were never actually taken and that the temperature she reported to the AP was actually taken five hours earlier. The AP stated that Resident #1's primary [DIAGNOSES REDACTED]. The AP stated, "After backtracking into the day and the fact that he wasn't feeling well, shaking and asking to go to the hospital, he probably had an arrhythmia going on." The AP further stated, "I'm hands-on with my patients. There was no reason not to call me. He (Resident #1) should have been sent to the hospital much earlier." An interview was conducted with Resident #7 on [DATE] at 1:32 PM. Resident #7 stated that her husband (Resident #1) was acting weird all afternoon, shaking all over and asking to be sent to the hospital. She was told that LPN #1 and another nurse looked at him and he was fine. Resident #7 stated that her husband "would always have dinner, kiss me good night and come back in the morning for breakfast but he didn't come. I knew something was wrong that day but how could I question the nurses?" An interview was conducted with a cognitively intact Resident #6 on [DATE] at 2:04 PM. She stated that Resident #1 was shaking all day and was never like that. Resident #6 stated that Resident #1 was begging LPN #1 to go to the hospital but LPN #1 shrugged it off, telling him that the doctor said he couldn't go. Resident #6 stated that she heard the resident's roommate yelling for help but no one came. Resident #6 stated, "It's very scary to be here. I think he was dead already by the time they came. This whole thing is disgusting. He obviously was sick and no one took him seriously." An interview was conducted with the assigned 3:00 PM to 11:00 PM CNA #2 on [DATE] at 2:31 PM. CNA #2 stated that she had been telling LPN #1 that Resident #1 was shaking and asking to go to the hospital since 4:30 PM on [DATE]. CNA #2 stated that the resident did not eat dinner, which was not normal for him, and a few times throughout the evening he was upset because his stools were loose and he was having trouble getting to the bathroom in time. She stated that she had never seen the resident like this before and told LPN #1 several times that Resident #1 was not acting like himself. She stated that around 7:00 PM she decided to call for the supervisor herself and spoke with the ADON. She told the ADON that Resident #1 was not normal and shaking but the ADON wanted to talk to LPN #1 on the phone, so CNA #2 gave LPN #1 the phone and walked away. CNA #2 stated that the ADON never came to see Resident #1. CNA #2 stated that, around 10:00 PM, LPN #1 saw her taking care of another resident and told her to help Resident #1 when she was finished. CNA #2 stated that once she finished with the other resident, she went in to the Resident #1's room and found him slumped over in the wheelchair between the wheelchair and the bathroom door. There was a string tied to the doorknob and draped, but not tied, over his shoulder, which she pulled off and ran screaming down the hallway for help. CNA #2 stated that LPN #1 came to the resident's room and ran in and out a couple of times. She stated that, after a few minutes, she helped move Resident #1 in to bed and the RNS came. CNA #2 further stated, "I've always been taught to report something I see with my residents but they (nurses) say I'm too much. I'm too much and look what happens!" An interview was conducted with LPN #4 on [DATE] at 2:43 PM. He stated that he was working on the 3rd floor on the evening of [DATE]. Sometime around 10:15 PM LPN #4 heard a page overhead, calling him by name and asking him to come to the 1st floor. He did not know he was responding to a Code Blue situation so he did not rush nor get the Automated External Defibrillator (AED). When he arrived in the resident's room, Resident #1 was in bed and the RNS and LPN #1 were next to the bed. CPR had not been started and the RNS was saying, "We have to be sure that he's not a DNR." So LPN #4 went to the nursing desk to get Resident #1's medical record. He returned to the room and stood at the roommate's side of the room, quickly going through the medical record. He told the RNS that Resident #1 was definitely a full code and LPN #1 started CPR while the RNS left the room. LPN #4 said he never heard a Code Blue called. LPN #4 further stated, "I don't know the protocol here. I've been here for three years and some staff will call the operator for a Code and others do it themselves. I would do it myself but that may not be the protocol." An interview was conducted with the Front Desk Operator (FDO) on [DATE] at 2:58 PM. He stated that on [DATE] he received a call from LPN #1. He stated he asked LPN #1 if she could hold for a moment because he was trying to transfer 911 to the RNS. He stated that he was never asked to announce a Code Blue, otherwise he would have so done immediately. The FDO followed-up with the RNS 15 to 20 minutes later to ask the RNS if 911 was coming. He explained to the surveyor that he needs to know if 911 is called because he must secure one of the elevators so 911 can get in and back out fast. The FDO stated that in times of an emergency, sometimes staff call him to announce a Code Blue but other times they do not. He further stated, "It's frustrating, because when there's an emergency I need to know where to send 911 when they come, but no one does anything the same." An interview was conducted with the Medical Director (MD) on [DATE] at 11:05 AM. He stated that he was aware of the situation involving Resident #1 and reviewed the case with the DON and Administrator. The MD stated that he knew the resident had been asking to go to the hospital, had diarrhea throughout the shift and was later found unresponsive. He thought nursing was following him during the shift. He was not sure if there was any delay in treatment but thinks that staff followed policies. The MD stated, "I didn't see that (Resident #1) was having any chest pain. Otherwise, if he was having chest pain, he wouldn't be able to transfer himself out of the wheelchair." The MD further stated, "I don't feel any neglect of care was done." An interview was conducted with a Registered Nurse Nursing Care Coordinator (RNNCC) on [DATE] at 12:40 PM. The RNNCC stated that, in the absence of the In-Service Director she provides in-service training to staff. She has not been involved with Code Blue in-servicing except when an employee is new to the facility. She said she was not aware of any recent Code Blue in-servicing or in-servicing regarding a resident who asks to go to the hospital. An interview was conducted with the In-service Director (ISD) on [DATE] at 12:49 PM. The ISD stated that staff response to a Code Blue is mandatory and an annual in-service is conducted. The ISD said that if a resident is found unresponsive, the operator should be called and a Code Blue announced over the PA (public address) system with the location of the emergency. The ISD further stated that she is not aware of any in-service presently being done on Code Blue or aware of any facility policy that addresses a resident's request for transfer to the hospital. During a subsequent interview with the DON on [DATE] at 9:05 AM, the DON stated that LPN #1, the ADON and the RNS failed to provide a complete assessment of Resident #1, although the ADON "did observe the resident and, in that respect, some semblance of an assessment was done." The DON stated that the AP should have been called at 4:00 PM on [DATE] when Resident #1 was asking to go to the hospital. The DON further stated that there was a delay in initiating CPR on Resident #1 because there was uncertainty regarding his DNR status. When the surveyor asked the DON whether there was any actual neglect in this case, the DON did not respond. An interview was conducted with the Administrator on [DATE] at 11:00 AM. When the Administrator was specifically asked about possible neglect of Resident #1, the Administrator stated, "It's a very hard call to make. I don't know everybody's story, so it's possible in a certain sense. I would have felt more comfortable if the doctor had been involved." Regarding the care of Resident #1 the Administrator further stated, "It wasn't aggressive enough." 10 NYCRR 415.12

Based on observation, record review and resident and staff interviews conducted during an abbreviated and partial extended survey, the facility's administration failed to ensure that each resident reached or maintained his/her highest practicable level of physical, mental and psychosocial well-being. Specifically, the administration failed to have an adequate policy and procedure in place for staff response to a resident's change in condition. This resulted in actual harm to Resident #1 and the potential for serious harm that is Immediate Jeopardy for 40 residents. Cross-References - Refer to: F 309 - Quality of Care, F 501 - Medical Director, F 520 - Quality Assessment and Assurance. Complaint ID Number: NY 927 The findings are: An interview was conducted with the Director of Nursing (DON) on [DATE] at 11:16 AM. She stated that prior to the resident's death, there was no specific policy about a resident change in condition or what staff should do when a resident wants to go to the hospital. An interview was conducted with the Medical Director (MD) on [DATE] at 11:05 AM. The MD stated that he was aware of the situation involving Resident #1 and reviewed the case with the DON and Administrator. The MD stated that he knew Resident #1 had been asking to go to the hospital, had diarrhea throughout the shift and was later found unresponsive. The MD stated that he thought nursing was following Resident #1 during the shift. The MD stated that he was not sure that there was any delay in treatment but thinks that staff followed policies. The MD stated, "I didn't see that (Resident #1) was having any chest pain. Otherwise, if he was having chest pain, he wouldn't be able to transfer himself out of the wheelchair." The MD further stated, "I don't feel any neglect of care was done." During a subsequent interview with the DON on [DATE] at 9:05 AM, the DON stated that LPN #1, the ADON and the RNS failed to provide a complete assessment of Resident #1, although the ADON "did observe the resident and, in that respect, some semblance of an assessment was done." The DON stated that the AP should have been called at 4:00 PM on [DATE] when Resident #1 was asking to go to the hospital. The DON further stated that there was a delay in initiating CPR on Resident #1 because there was uncertainty regarding Resident #1's DNR status. However, when a surveyor asked the DON whether there was evidence of actual neglect of Resident #1, the DON did not respond. An interview was conducted with the Administrator on [DATE] at 11:00 AM. The Administrator stated that he was made aware of the situation with Resident #1 by the DON and directed the DON to immediately start an investigation. The Administrator stated that he spoke with residents to try to assure them that an investigation was being done and had a Quality Assurance meeting with the DON and Medical Director two days later to review policies. With regard to possible neglect of Resident #1 the Administrator stated, "It's a very hard call to make. I don't know everybody's story, so it's possible in a certain sense. I would have felt more comfortable if the doctor had been involved." Regarding the care of Resident #1 the Administrator further stated, "It wasn't aggressive enough." 415.26

Based on record review and staff and resident interviews conducted during an abbreviated and partial extended survey, the facility failed to ensure for one resident (Resident #1) of eleven residents reviewed for assessment and quality of care that its quality assessment and assurance program (QAA) developed and implemented policies and procedures to readily identify and address issues related to a change in residents' medical condition and failed to develop policies to guide staff on how to respond to residents' request for a transfer to the hospital. In addition, the QAA Committee failed to determine the root cause and prevent further instances of resident neglect. This resulted in actual harm to Resident #1 with the potential for serious harm that is Immediate Jeopardy and for 40 residents. Cross-References - Refer to F 309 - Quality of Care F490 - Administration F 501 - Medical Director. Complaint ID Number: NY 927 The findings are: The undated Time Line Summary and Investigation Conclusion (TLSIC) documented that there was no willful neglect on the part of nursing staff. The resident's behaviors and actions were in accordance with his customary routines. The resident did not exhibit any clinical signs or report any symptoms of a medically unstable condition. The TLSIC further concluded that LPN #1 failed to contact the physician or obtain a complete set of vital signs when the resident reported a complaint. The Assistant Director of Nursing failed to perform a thorough assessment, failed to document the medical record and failed to ensure the physician was notified. The RNS failed to activate Code Blue as per facility policy. The undated Abuse Investigation and Reporting Policy and Procedure documented that neglect is a failure to provide timely, consistent, safe, adequate, or appropriate services, treatment, and/or care. An interview was conducted with the Medical Director (MD) on [DATE] at 11:05 AM. The MD stated that he was aware of the situation involving Resident #1 and reviewed the case with the DON and Administrator. The MD stated that he knew Resident #1 had been asking to go to the hospital, had diarrhea throughout the shift and was later found unresponsive. The MD stated that he thought nursing was following Resident #1 during the shift. The MD stated that he was not sure that there was any delay in treatment but thinks that staff followed policies. The MD stated, "I didn't see that (Resident #1) was having any chest pain. Otherwise, if he was having chest pain, he wouldn't be able to transfer himself out of the wheelchair." The MD further stated, "I don't feel any neglect of care was done." During an interview with the DON on [DATE] at 9:05 AM, the DON stated that LPN #1, the ADON and the RNS failed to provide a complete assessment of Resident #1, although the ADON "did observe the resident and, in that respect, some semblance of an assessment was done." The DON stated that the AP should have been called at 4:00 PM on [DATE] when Resident #1 was asking to go to the hospital. The DON further stated that there was a delay in initiating CPR on Resident #1 because there was uncertainty regarding Resident #1's DNR status. However, when the surveyor asked whether there was evidence of actual neglect of Resident #1, the DON would not answer and remained silent. An interview was conducted with the Administrator on [DATE] at 11:00 AM. The Administrator stated that he was made aware of the situation with Resident #1 by the DON and directed the DON to immediately start an investigation. The Administrator stated that he spoke with residents to try to assure them that an investigation was being done and had a Quality Assurance meeting with the DON and Medical Director two days later to review policies. With regard to possible neglect of Resident #1 the Administrator stated, "It's a very hard call to make. I don't know everybody's story, so it's possible in a certain sense. I would have felt more comfortable if the doctor had been involved." Regarding the care of Resident #1 the Administrator further stated, "It wasn't aggressive enough." 10 NYCRR 415.27 (a-c)