Every finding on record at Granville Center for Rehabilitation and Nursing

Based on observation, record review, and interviews during a recertification and abbreviated (NY00346208 and NY00351484) survey, the facility did not ensure the provision of sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident throughout the facility. Specifically, 1) an analysis of the actual staffing schedule showed that on multiple occasions from 12/01/2024 to 12/18/2024, the facility was below the minimum levels required. 2) several nursing staff members reported a lack of sufficient staffing, and 3) multiple residents reported during interviews that the facility was short-staffed at times, and this resulted in call bells not being answered timely and residents not getting out of bed in time for appointments and therapy. This is evidenced by: Upon entrance to the facility on [DATE] there were 115 residents residing in 3 units. The Facility Assessment, which was conducted on 2/27/2024 and updated on 10/03/2024, documented the facility's staffing plan for direct residential care. The assessment documented that they were to have a certain minimum number of Certified Nurse Aides for the day, evening, and night shifts. The facility was to maintain daily average staffing hours equal to 3.5 hours of care per resident per day by a Certified Nurse Aide, Registered Professional Nurse, Licensed Practical Nurse, or Nurse Aide. Out of such 3.5 hours, no less than 2.2 hours of care per resident per day shall be provided by a Certified Nurse Aide. A review of staffing sheets provided by the facility from 12/01/2024 through 12/18/2024 documented the following: -12/01/2024: The facility had 26 Certified Nurse Aides scheduled for a total of 208 hours of direct care. For a census of 111 residents, the amount of direct care should have been 244.2 hours. -12/02/2024: The facility had 26 Certified Nurse Aides scheduled for a total of 208 hours of direct care. For a census of 113 residents, the amount of direct care should have been 248.6 hours. -12/03/2024: The facility had 28 Certified Nurse Aides scheduled for a total of 224 hours of direct care. For a census of 115 residents, the amount of direct care should have been 253 hours. -12/04/2024: The facility had 27 Certified Nurse Aides scheduled for a total of 216 hours of direct care. For a census of 115 residents, the amount of direct care should have been 253 hours. -12/05/2024: The facility had 24 Certified Nurse Aides scheduled for a total of 192 hours of direct care. For a census of 115 residents, the amount of direct care should have been 253 hours. -12/06/2024: The facility had 27 Certified Nurse Aides scheduled for a total of 216 hours of direct care. For a census of 117 residents, the amount of direct care should have been 257.4 hours. -12/07/2024: The facility had 28 Certified Nurse Aides scheduled for a total of 224 hours of direct care. For a census of 117 residents, the amount of direct care should have been 257.4 hours. -12/08/2024: The facility had 27 Certified Nurse Aides scheduled for a total of 216 hours of direct care. For a census of 117 residents, the amount of direct care should have been 257.4 hours. -12/09/2024: The facility had 28 Certified Nurse Aides scheduled for a total of 224 hours of direct care. For a census of 114 residents, the amount of direct care should have been 250.8 hours. -12/10/2024: The facility had 26 Certified Nurse Aides scheduled for a total of 208 hours of direct care. For a census of 115 residents, the amount of direct care should have been 253 hours. -12/11/2024: The facility had 24 Certified Nurse Aides scheduled for a total of 192 hours of direct care. For a census of 115 residents, the amount of direct care should have been 253 hours. -12/12/2024: The facility had 25 Certified Nurse Aides scheduled for a total of 200 hours of direct care. For a census of 113 residents, the amount of direct care should have been 248.6 hours. -12/13/2024: The facility had 22 Certified Nurse Aides scheduled for a total of 176 hours of direct care. For a census of 113 residents, the amount of direct care should have been 248.6 hours. -12/14/2024: The facility had 22 Certified Nurse Aides scheduled for a total of 176 hours of direct care. For a census of 114 residents, the amount of direct care should have been 250.8 hours. -12/15/2024: The facility had 26 Certified Nurse Aides scheduled for a total of 208 hours of direct care. For a census of 113 residents, the amount of direct care should have been 248.6 hours. -12/16/2024: The facility had 24 Certified Nurse Aides scheduled for a total of 192 hours of direct care. For a census of 114 residents, the amount of direct care should have been 250.8 hours. -12/17/2024: The facility had 22 Certified Nurse Aides scheduled for a total of 176 hours of direct care. For a census of 113 residents, the amount of direct care should have been 248.6 hours. -12/18/2024: The facility had 24 Certified Nurse Aides scheduled for a total of 192 hours of direct care. For a census of 114 residents, the amount of direct care should have been 250.8 hours. During an interview on 12/11/2024 at 1:47 PM, Resident #105 stated the facility was short on staff and sometimes the resident had to wait for a long time to get help. They stated that they could easily wait for over an hour on average depending on which staff person is working. During an interview on 12/12/2024 at 12:00 PM Resident #89 stated when they rang their call bell, they had to wait for 2 hours to be taken to the bathroom, and on several occasions, the staff did not attend to their bathroom needs, and would only come to assist them when they were doing their cares. Resident #89 also stated that they were late for their therapy session on several occasions because the staff got them out of bed late resulting in decreased time in therapy. During an interview on 12/12/2024 at 12:22 PM, Resident #80 stated that they always have to wait on staff to get care as they do not have enough people at times. They stated they could wait anywhere from 45 minutes to an hour at times for staff to come in to help. During an observation on 12/17/2024 at 1:35 PM, there were 3 rooms with call lights activated on the C unit. There were no staff members present in the unit. A family member came out to the main desk area to see if there were any staff present and voiced their displeasure that there was no one available. During an interview on 12/17/2024 at 2:22 PM Certified Nurse Aide #1 stated they needed to have more staff to perform all their duties. They stated that they feel very stressed and overworked due to the lack of staffing. Certified Nurse Aide #1 stated that they do multiple double shifts for the facility at least three times per week. They stated that there have been numerous times when they were unable to get the resident's afternoon care completed and had to either stay late to finish or turn the care over to the staff coming in during the evening. During an interview on 12/17/2024 at 2:48 PM Certified Nurse Aide #2 stated there were times it was impossible to get all the residents out of bed when the facility was short-staffed. They stated that they prioritized the residents who had therapy first when they were short-staffed. They stated they did double shifts for the facility two to three times per week. During an interview on 12/17/2024 at 3:22 PM Licensed Practical Nurse #2 stated that usually they feel there is enough staff, and everyone works together to provide the care for the residents. They stated that residents do wait an extended period for care during the evening (3 PM - 11 PM) shift because of staffing issues, especially between 6 PM - 9 PM. During a follow-up interview on 12/18/2024 at 9:45 AM Certified Nurse Aide #1 stated that they had only 2 aides for the day, and they were going to be very busy. They stated that they do not know the reason why they are extremely short-staffed for the day. During an interview on 12/18/2024 at 10:19 AM Registered Nurse #3 stated that staffing levels were an issue they were dealing with. On a regular day, they would have 3 Certified Nurse Aides and 2 Licensed Practical Nurses for the unit of 40 residents. They stated that the staffing levels are not ideal as they have numerous residents on the unit who require additional staffing for daily care. They stated that residents have waited extended periods due to aides taking care of other residents. They stated today they have only 2 aides for the unit and would help when needed. During an interview on 12/18/2024 at 11:05 AM Administrator #1 stated that staffing has been an issue, but they feel it is getting better however not ideal. They stated that they believe since they are in a remote location they do not have a pool of candidates to pick from. They stated that they had 6 Certified Nurse Aides leave in the past week due to different circumstances. They stated that they have a lot of agency and contract individuals working but they are trying to get more individuals locally to be employed by the agency. Administrator #1 stated that they believe that the facility is improving on its history, and they are getting more applicants. 10 New York Code Rules and Regulations 415.13(a)(1)(i-iii)

Based on interview and record review conducted during a recertification and abbreviated survey (Case # NY00346208), the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident ' s choices for 10 (Resident #s 365, 368, 112, 56, 29, 73, 109, 75, 18, and 89) of 10 residents reviewed for quality of care, which included residents in every unit of the facility. Specifically, the facility failed to place and read the purified protein derivative test for tuberculosis (an infectious disease) for Resident #365 and Resident #368; the facility failed to notify a provider when Resident #365 ' s blood sugar was 61; the facility failed to monitor the vital signs of Resident #368 when the resident was newly admitted to the facility. The facility failed to ensure that Resident #112 received treatment and care to prevent hospitalization , the facility administered 4300 milligrams of Tylenol in a 13-hour period, and the facility documented vital signs for Resident #112 after the resident discharged from the facility. The facility failed to obtain and document monthly vital signs according to provider orders for Residents #29, 89, and 73. This is evidenced by: Cross-referenced to F697: Pain Management The facility policy titled, Vital Signs and last revised 12/2020, documented that the facility would ensure vital signs were being monitored according to physician orders . and verify that there was a physician ' s order for frequency if regularly monitoring . document findings in the resident ' s medical record . alert the medical doctor of any findings outside of the resident ' s baseline. The facility policy titled, Tuberculosis - Residents and last revised 8/22/2024, documented that the facility shall conduct a baseline screen of residents for tuberculosis infection on admission including a tuberculosis skin test, also referred to as a purified protein derivative test. The results of the Tuberculin Skin Test must be read by a qualified nurse or healthcare practitioner (i.e., Registered Nurse) forty-eight (48) to seventy-two (72) hours after administration. Residents were not allowed to read or interpret their own Tuberculin Skin Test results. A. If the reaction to the first Tuberculin Skin Test is negative, administer a second Tuberculin Skin Test 1 to 3 weeks after the first test. 1. If the test reading/interpretation was not completed within 72 hours, the Tuberculin Skin Test must be repeated. Resident #365 Resident #365 was admitted with diagnoses of diabetes (an endocrine system dysfunction causing difficulty maintaining normal blood sugar levels), high cholesterol (high amounts of cholesterol in the blood which can cause limited blood flow), and depression (a mental health condition characterized by persistent feelings of sadness, hopelessness and loss of interest or pleasure in activities). The Minimum Data Set (an assessment tool) dated 11/14/2024 documented that the resident was cognitively intact, could understand others and could be understood by others. The Physician ' s Order dated 12/06/2024 stated that for blood sugar less than 70 to notify the medical doctor of the low blood sugar. Resident #368 Resident #368 was admitted with diagnoses of unspecified atrial fibrillation (abnormal heart rhythm), congestive heart failure (a condition where the heart muscle is weakened and cannot pump blood effectively), and hypertension (high blood pressure). The Minimum Data Set, dated dated dated [DATE] documented that the resident had intact cognitive ability, could be understood and understood others. The Medication Administration Record for 12/2024 documented the Purified Protein Derivative test was placed 12/11/2024 at 1:08 AM and was scheduled to be read on 12/12/2024. During an interview on 12/12/2024 at 12:13 PM, Director of Nursing #1 agreed it was not appropriate to read the test on 12/12/2024 and stated they would update the scheduled reading of the test and re-educate the staff. The Physician ' s Order dated 12/03/2024 stated vital signs (blood pressure, pulse, respirations per minute, temperature, and oxygen saturation) every shift for 30 days, then monthly every day shift every 1 month starting on the 1st [of every month] for 7 days for monitoring. The December 2024 Medication Administration Record/Treatment Administration Record documented the following duplicate vital signs: 12/07/2024 11 PM shift: not done 12/10/2024 3PM shift: blood pressure 123/73, temperature 97.2, pulse 84, respiration 18, oxygen saturation 98 percent 12/10/2024 11PM shift: blood pressure 123/73, temperature 97.2, pulse 84, respiration 18, oxygen saturation 98 percent Resident #112 Resident #112 was admitted to the facility with diagnoses of fracture of the lumbar vertebra (lower back bone), malignant neoplasm of the uterine adnexa (uterine cancer), and secondary malignant neoplasm of the bone (bone cancer). The resident was not at the facility long enough to have a Minimum Data Set (a resident assessment) completed. Resident #112 ' s Order Summary Report for September 2024 documented orders as follows: Begin Medication Regime When Available, ordered 9/19/2024. Acetaminophen extra strength oral tablet 500 milligram, give 2 tablets by mouth three times a day for pain, ordered 9/19/2024. Acetaminophen tablet 325 milligram, give 2 tablets by mouth every 6 hours as needed for pain (not to exceed 3 grams in 24 hours), ordered 9/19/2024. Resident #112 ' s Medication Administration Record for September 2024 documented the following medication administrations for pain: 9/19/2024 4:00 PM, Acetaminophen 1000 milligrams 9/19/2024 5:51 PM, Oxycodone 5 milligrams, 2 tablets given 9/19/2024 8:00 PM, Acetaminophen 1000 milligrams 9/20/2024 8:00 AM, Acetaminophen 1000 milligrams The facility administered a total of 4300 milligrams of Acetaminophen in 13 hours and 7 minutes, but the order was not to exceed 3000 milligrams in 24 hours. During an interview on 12/16/2024 at 10:45 AM, Family #2stated that Resident #112 was transported to the facility in the afternoon of 9/19/2024. Around 9:00 AM on 9/20/2024, Resident #112 called Family #2 and was in great distress. The resident stated they laid there without medication for pain, soiled clothing, and without food. Family #2 called 911 for transport back to the hospital. Resident #112 was in a great amount of pain and had been all night. Review of Resident #112 ' s vital signs revealed on 9/21/2024 at 2:33 AM a blood pressure of 139/79 was performed in the lying position on the right arm, the pulse was 83 beats per minute, 19 breaths per minute, and a temperature of 97.9; all of these vital signs were taken after the resident left the faciity on [DATE] around 11:00 AM and did not return to the facility. Resident #29 Resident #29 was admitted to the facility with the diagnoses of bipolar disorder (a mental health condition characterized by extreme shifts in mood, energy, and behavior), Parkinson ' s disease (a progressive neurological disorder that affects movement, balance, and coordination), and hypothyroidism (an abnormally low activity of the thyroid gland). The Minimum Data Set, dated dated dated [DATE] documented the resident was rarely/never understood, rarely/never understood others, and was severely cognitively impaired. The Physician ' s Order dated 9/6/2023 stated vital signs (blood pressure, pulse, respirations per minute, temperature, and oxygen saturation) to be obtained and recorded every month starting on the 1st for 7 days for monitoring. The September 2024 Medication Administration Record documented the following duplicate vital signs: 9/4/2024: Blood Pressure 122/78, Temperature 97.4, Pulse 76, Respirations 18, Oxygen Saturation 95 percent 9/5/2024: Blood Pressure 122/78, Temperature 97.4, Pulse 76, Respirations 18, Oxygen Saturation 95 percent 9/6/2024: Blood Pressure 122/78, Temperature 97.4, Pulse 76, Respirations 18, Oxygen Saturation 95 percent The October 2024 Medication Administration Record documented vital signs were obtained and recorded on 10/01/2024, 10/05/2024, and 10/06/2024. On 10/02/2024, 10/03/2024, 10/05/2024, and 10/07/2024 the response 9 was documented, The Medication Administration Record ' s Chart Codes documented 9 as Other/See Nurse ' s Notes. The November 2024 Medication Administration Record documented vital signs were obtained and recorded on 11/02/2024 and 11/03/2024. On 11/01/2024, 11/04/2024, 11/05/2024, and 11/06/2024 the response 9 was documented, The Medication Administration Record ' s Chart Codes documented 9 as Other/See Nurse ' s Notes. The December 2024 Medication Administration Record had no documentation of vital signs being obtained and recorded. On 12/01/2024-12/07/2024 the response 9 was documented. The Medication Administration Record ' s Chart Codes documented 9 as Other/See Nurse ' s Notes. Progress Notes dated 11/01/2024 through 12/13/2024 were reviewed. Progress Notes that correspond with the Medication Administration Record Chart Codes were reviewed. 11/01/2024 at 10:23 AM the Progress Note titled eMar - Medication Administration Note documented the order text Vital Signs Q shift (every shift) x 30 days then Monthly every day shift every 1 month starting on the 1st for 7 day(s) for Monitoring with no free text. 11/04/2024 at 11:39 AM the Progress Note titled eMar - Medication Administration Note documented the order text with no free text. 11/05/2024 at 10:54 AM the Progress Note titled eMar - Medication Administration Note documented the order text with no free text. 11/06/2024 at 11:00 AM the Progress Note titled eMar - Medication Administration Note documented the order text with no free text. 11/07/2024 at 10:25 AM the Progress Note titled eMar - Medication Administration Note documented the order text with no free text. 12/01/2024 at 11:34 AM the Progress Note titled eMar - Medication Administration Note documented the order text with no free text. 12/02/2024 at 8:58 AM the Progress Note titled eMar - Medication Administration Note documented the order text with no free text. 12/03/2024 at 10:28 AM the Progress Note titled eMar - Medication Administration Note documented the order text with no free text. 12/04/2024 at 11:14 AM the Progress Note titled eMar - Medication Administration Note documented the order text with no free text. 12/05/2024 at 9:06 AM the Progress Note titled eMar - Medication Administration Note documented the order text with no free text. 12/06/2024 at 7:31 AM the Progress Note titled eMar - Medication Administration Note documented the order text with no free text. 12/07/2024 at 1:17 PM the Progress Note titled eMar - Medication Administration Note documented the order text with no free text. During an interview on 12/13/2024 at 11:56 AM, Registered Nurse #2 stated the vital signs were to be documented on the Medication Administration Record. When asked to review the Medication Administration Record, Registered Nurse #2 stated they were unable to locate the documentation of Resident #29 ' s vital signs for December 2024 and located 2 documented vital signs for November 2024. They stated the vital signs were not done as ordered. 48413 Resident #89 Resident #89 was admitted to the facility with the diagnoses of cerebral infarction (a medical condition where blood flow to the brain is interrupted, leading to damage or death of brain tissue), displaced fracture of head of unspecified radius (fractured elbow), and hypertension (high blood pressure). The Minimum Data Set, dated dated dated [DATE] documented the resident was understood, could understand others, and was cognitively intact. The Physician ' s Order dated 2/23/2024 stated vital signs (blood pressure, pulse, respirations per minute, temperature, and oxygen saturation) to be obtained and recorded every month starting on the 1st for 7 days for monitoring. The June 2024 Medication Administration Record documented vital signs were obtained and recorded on 6/01/2024, 6/02/2024, 6/03/2024, 6/05/2024, and 6/06/2024. On 6/04/2024 and 6/07/2024 the response 9 was documented, The Medication Administration Record ' s Chart Codes documented 9 as Other/See Nurse ' s Notes. The November 2024 Medication Administration Record documented vital signs were obtained and recorded on 11/01/2024, 11/02/2024, 11/03/2024, 11/04/2024, and 11/06/2024. On 11/05/2024 the response 9 was documented, The Medication Administration Record ' s Chart Codes documented 9 as Other/See Nurse ' s Notes. There were no vital signs documented on the Medication Administration Record on 11/07/2024. The November 2024 Medication Administration Record documented the following duplicate vital signs: 11/01/2024: Blood Pressure 130/61, Temperature 97.9, Pulse 56, Respirations 18, Oxygen Saturation 93 percent 11/02/2024: Blood Pressure 130/61, Temperature 97.9, Pulse 56, Respirations 18, Oxygen Saturation 93 percent 11/03/2024: Blood Pressure 130/61, Temperature 97.9, Pulse 56, Respirations 18, Oxygen Saturation 93 percent 51742 Resident #73 Resident #73 was admitted to the facility with the diagnoses of acquired absence of right leg below the knee (right leg amputation below the knee), anemia (a condition characterized by a low levels of red blood cells), and depression (a mental health condition characterized by a persistent low mood, loss of interest or pleasure in activities). The Minimum Data Set, dated dated dated [DATE] documented the resident was able to be understood, could understand others, and was cognitively intact. The Medication Administration Record for December 2024 documented the following duplicate vital signs: 12/01/2024: Blood Pressure 110/66, Temperature 97.3, Pulse 72, Respirations 16, Oxygen Saturation 96 percent on room air 12/02/2024: Blood Pressure 110/66, Temperature 97.3, Pulse 72, Respirations 16, Oxygen Saturation 96 percent on room air 12/04/2024: Blood Pressure 118/68, Temperature 97.7, Pulse 78, Respirations 18, Oxygen Saturation 97 percent on room air 12/05/2024: Blood Pressure 118/68, Temperature 97.7, Pulse 78, Respirations 18, Oxygen Saturation 97 percent on room air 12/06/2024: Blood Pressure 118/68, Temperature 97.7, Pulse 78, Respirations 18, Oxygen Saturation 97 percent on room air During an interview on 12/17/2024 at 11:12 AM, Registered Nurse #1 stated a resident having the same vital signs several days in a row was odd. They stated that data such as vital signs should not be copied and pasted from one day to the next, but individual vital signs taken per the provider orders. 10 New York Code of Rules and Regulations 415.12

Based on observations, record reviews, and interviews during the recertification and abbreviated survey (Case # NY00355835), the facility did not ensure that food and drink were palatable and attractive for 4 (Resident #s 97, 75, 8, and 107) of 7 residents reviewed for palatable and attractive food and drink. Specifically, Residents #97, #75, #8 and #107 complained of food being cold, unattractive, and not palatable. Additionally, Resident # 97 and #75 lunch ticket did not match what the resident received during their lunch service on 12/17/2024. This is evidenced by: A facility policy titled Food and Nutrition Services dated 1/2024 documented that the facility would provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Resident # 107 Resident # 107 was admitted to the facility with diagnoses of peripheral vascular disease (a circulatory condition that occurs when blood vessels outside the brain and heart narrow, spasm, or become blocked), atherosclerotic heart disease (a condition where plaque builds up in the arteries of the heart), and hyperlipidemia (a condition where there are high levels of fats or lipids in the blood). The Minimum Data Set (an assessment tool) dated 9/25/2024, documented that the resident had intact cognitive ability, could be understood, and understood others. During an interview on 12/12/2024 at 1:05 PM, Resident #107 stated that the food is always cold and not very appealing or appetizing. Resident #107 stated that the trays for meals never arrive on the unit at a consistent time. Resident #107 was asked if the food was cold would staff reheat it for them and they stated that they do not bother as it would take a long time to get it back. During a follow-up interview on 12/17/2024 at 10:45 AM, Resident #107 was asked if the surveyor was allowed to take their lunch tray to be temperature and taste tested since they made a concern about the food temperature and taste. The resident was assured that they would receive a replacement tray immediately after theirs was taken. Resident #107 agreed to surrender their lunch tray for testing purposes. During an observation on 12/17/2024 at 12:08 PM the cart with lunch trays arrived on the C-unit by the front nurse's station desk. The lunch tray cart arrived at the resident's hall at 12:17 PM. Resident #107 lunch tray was obtained from Certified Nurse Aide at 12:24 PM and a new tray was obtained by Certified Nurse Aide and delivered at 12:28 PM. During an observation of Resident #107 lunch ticket, they were to receive 8 ounces of Beef Stroganoff, a half cup of Pasta Noodles, a side lettuce salad with dressing, half cup of Mixed Fruit Cobbler, 8 fluid ounces of 2% milk, 6 fluid ounces of Hot Tea, 8 fluid ounces of Water, 1 salt packet, 1 pepper packet, 2 sugar packets, and one half and half creamer. In a comparison of the lunch ticket and meal tray, the resident did not receive their Mixed Fruit Cobbler, milk, or water. During a test tray on 12/17/2024, temperature and taste were performed on Resident #107 ' s lunch. Pasta noodles were temped at 116.2 degrees Fahrenheit and tasted overcooked and sticky. The beef was temped at 114.4 degrees Fahrenheit and tasted as expected, beef was easily chewed and broken down. During a follow-up interview on 12/17/2024, Resident #107 was asked how their lunch was. They stated that it was just fine, and they ate it. When asked about the temperature of their lunch they stated that it was very warm stating that it just came from the kitchen and did not spend a long time on the delivery carts. During an interview on 12/17/2024 at 01:04 PM, Dietician #1 stated that they identify resident's preferences and place them into the facility system. They stated that the resident's meal tickets should be verified by the Certified Nurse Aides as they serve the tray to the resident. They stated that the individuals who are preparing the resident's trays in the kitchen should be verifying the tickets as well and checking again before the tray leaves the kitchen. Dietician #1 stated that they have a system for menus and they meet quarterly with residents to determine preferences. Resident # 97 Resident # 97 was admitted to the facility with diagnoses of dementia, protein-calorie malnutrition (lack of adequate food intake to maintain health), and history of falling. The Minimum Data Set, dated dated dated [DATE], documented that the resident had intact cognitive ability, could be understood, and understood others. During an interview on 12/11/2024 at 1:42 PM, Resident #97 stated the food was cold at times and could be better. A progress note dated 11/7/2024 at 8:03 AM documented that Resident #97 stated the food was visually unappealing to them; the Dietician discussed with Resident #97 that they had 6.9% weight loss in 30 days, which was significant. A provider progress note by Family Nurse Practitioner #1 dated 12/5/2024 documented the resident had some gradual weight loss over the past 30 days. They saw a dietician. They stated that they did not like the food, so they did not have much of an appetite. That's likely where the weight loss is stemming from. Please order nutritional shakes and see a dietician for fortified foods to add to their diet. Resident # 75 Resident # 75 was admitted to the facility with diagnoses of weakness, protein-calorie malnutrition (lack of adequate food intake to maintain health), and depression. The Minimum Data Set, dated dated dated [DATE], documented that the resident had intact cognitive ability, could be understood, and understood others. During an interview on 12/12/2024 at 11:33 AM, Resident #75 stated that no snacks were provided at night, the coffee and food was cold and did not taste good and the resident wanted more fresh fruit. Request to perform night observation to verify night snack availability denied by state agency management. During a follow-up interview on 12/17/2024 at 11:45 AM, Resident #75 was asked if the surveyor was allowed to take their lunch tray to be temperature and taste tested since they made a concern about the food temperature and taste. The resident was assured that they would receive a replacement tray immediately after theirs was taken. Resident #75 agreed to surrender their lunch tray for testing purposes. During an observation on 12/17/2024 at 12:08 PM, the cart with lunch trays arrived on the C-unit by the front nurse's station desk. Resident #75 ' s lunch tray was obtained from a Certified Nurse Aide at 12:15 PM and a new tray was requested, but the Certified Nurse Aide stated they were the only one on the hall and the request would cause other residents ' trays to be cold and delayed; surveyor requested replacement tray from the Administrator on the surveyor ' s way to the kitchen to request a replacement tray. During an observation of Resident #75 ' s lunch ticket, they were to receive 4 ounces of Beef Stroganoff, 2 ounces of beef gravy, a half cup of Pasta Noodles, a half cup of wax beans, half cup of Mixed Fruit Cobbler, 4 ounces of apple juice, two 6 fluid ounces of coffee, 8 fluid ounces of Water, 1 salt packet, 1 pepper packet. In a comparison of the lunch ticket and meal tray, the resident did not receive the second cup of coffee. During a test tray on 12/17/2024, temperature and taste were performed on Resident #75 ' s lunch. The beef stroganoff mixed with noodles was temped at 119.1 degrees Fahrenheit and the texture was acceptable but the beef lacked flavor and were warm but not hot and the noodles were without issues; the fruit cobbler was temped at 88.2 degrees Fahrenheit and was unpalatable; the wax beans were 112.0 degrees Fahrenheit and not tasted; the apple juice was 63.7 degrees Fahrenheit; and the water was temped at 58.8 degrees Fahrenheit. During a follow-up interview on 12/17/2024 at 12:53 PM, Resident #75 stated that the replacement tray arrived, but the food did not look appealing to the resident; staff entered to collect the tray and asked if Resident #75 would like an alternate meal and the resident stated that the food on the tray had ruined their appetite. The resident also voiced their frustration that multiple creamers were brought daily with the coffee and the resident drinks the coffee black and had informed multiple staff of that preference. Resident # 8 Resident #8 was admitted to the facility with diagnoses of weakness, need for assistance with personal care, and muscle weakness. The Minimum Data Set, dated dated dated [DATE], documented that the resident had intact cognitive ability, could be understood, and understood others. During an interview on 12/12/2024 at 11:33 AM, Resident #8 stated that they did not like oatmeal, but it was served to them most mornings; they further stated that the food on the ticket was not what was brought to the resident and that the food was constantly served cold. A facility grievance dated 11/10/2024 revealed a grievance related to late meal service which caused a resident to miss an activity; facility responded appropriately to address the concerns of this grievance to accommodate the specific resident. 10 New York Code of Rules and Regulations 415.14(d)(1)(2) 51742

Based on record reviews, and interviews during the recertification and abbreviated survey (Case # NY00355835), the facility did not ensure maintenance of acceptable parameters of nutritional status for 1 (Resident #97) of 3 residents reviewed for nutrition. Specifically, Resident #97 did not have weekly weights measured for monitoring of significant weight loss as ordered by the dietician for the weeks of 11/25/2024 and 12/09/2024. This is evidenced by: Cross-referenced to F804: Nutritive Value/Appearance, Palatable/Prefer Temp A facility policy titled, Weight Management, with a current revision dated of 3/01/2024, documented that the resident's weight shall be obtained within twenty-four hours of admission, weekly for four weeks, then monthly thereafter and more frequently as clinically indicated for the residents, and documented in the clinical record. It further documented that the registered dietician will review the resident weights monthly, with a significant unplanned weight change and as needed. Parameters for evaluating the significance of unplanned and undesired weight is as follows: 1 month - 5 percent weight change is significant, greater than 5 percent is severe. 3 months - 7.5 percent weight change is significant, greater than 7.5 percent is severe. 6 months - 10 percent weight change is significant, greater than 10 percent is severe. Resident # 97 was admitted to the facility with diagnoses of dementia (a degenerative neurological condition causing memory problems), protein-calorie malnutrition (lack of adequate food intake to maintain health), and history of falling. The Minimum Data Set (an assessment tool) dated 8/09/2024, documented that the resident had intact cognitive ability, could be understood, and understood others. Review of Resident #97 ' s Care Plan revealed a focus of nutritional problem or potential nutritional problem related to malnutrition diagnosis, low weight for age; variable intakes since admission; dementia diagnosis; dislike of facility food with declining alterative options; and unintentional weight loss (initiated 8/19/2024). There was a goal of receiving adequate nutrition and hydration without unplanned significant weight changes (initiated 8/19/2024) and maintain stable weight with minimal change of 3 percent by next review (initiated 11/07/2024). Interventions/tasks documented were follow weights as ordered weekly weights until stable (initiated 8/19/2024), identify and honor food preferences, and monitor meal and fluid consumption records. Resident #97 ' s December 2024 Medication Administration Record and Treatment Administration Record revealed an order for Weigh on Admission/readmission x1, then weekly x 4, then monthly every day shift every 1 month(s) starting on the 1st for 1 day(s). Monitor Weight (Must customize weekly weight to shift and day specified for your facility and remove these directions) Monthly Weights must be obtained by the 7th of each month -Start Date- 10/01/2024 0700. Record review of active orders showed no order for weekly weights. Record review revealed that on 08/14/2024, the resident weighed 119 lbs. On 12/04/2024, the resident weighed 107 pounds, which was a -10.08 percent Loss. During an interview on 12/11/2024 at 1:42 PM, Resident #97 stated the food was cold at times and could be better. A Dietary Weight Change Progress note dated 11/07/2024 at 8:03 AM documented a weight warning, with the resident ' s weight on 11/05/2024 being 107.8 pounds which was 6.9 percent over 30 days and was significant weight loss. Resident stated the food was unappealing to them; dietician added supplement shake to increase intake. In addition, the Dietician documented the plan of care included monitor weights weekly for four weeks. A Dietary Weight Change Progress note dated 11/13/2024 at 9:53 AM documented the resident ' s weight was 107.6 pounds on 11/11/2024; the plan of care documented weekly weights were ordered due to significant weight loss over 30 days and to continue weekly weighs and supplement. A Provider Progress note on 11/18/2024 documented that Family Nurse Practitioner #1 saw Resident #97 due to a chief complaint of periodic dizziness; blood work was ordered, extra fluids were ordered every shift, blood pressure and pulse reviewed were taken 10/03/2024. Weight loss was not addressed according to the provider note. A provider progress note dated 12/05/2024 by Family Nurse Practitioner #1 documented, resident has had some gradual weight loss over the past 30 days. The resident saw a dietician. They stated that they do not like the food, so they do not have much of an appetite. That is likely where the weight loss is stemming from. Please order nutritional shakes and see a dietician for fortified foods to add to their diet. A Dietary Weight Change Note dated 12/05/2024 at 9:27 AM documented a weight warning and showed the resident ' s weight on 12/04/2024 was 107.4 pounds; the resident was consuming on average 50-75 percent of meals; the resident told the dietician the sandwiches provided had stale bread so the resident could not eat them and the resident did not like the taste of many items on the menu. The Dietician noted to continue weekly weights. A Rehabilitation Referral Progress note dated 12/17/2024 at 9:49 AM documented that Resident #97 was unable to get in and out of bed and the resident felt they were requiring more assistance; the most recent weight was documented as 107.4 pounds on 12/04/2024. Record review of weights revealed the following weights for Resident #97: 8/06/2024 - 114.64 pounds 8/14/2024 - 119.0 pounds 8/19/2024 - 119.0 pounds 8/28/2024 - 118.2 pounds 9/01/2024 - 116.2 pounds 10/02/2024 - 115.6 pounds 11/04/2024 - 107.8 - struck out by Dietician and comment re-weighed on 11/8/2024 11/08/2024 - 112 pounds 11/11/2024 - 107.6 pounds 11/19/2024 - 108.6 pounds 12/01/2024 - 105.4 - struck out and comment re-weighed on 12/02/2024 12/02/2024 - 105.0 - struck out and comment re-weighed by Dietician 12/05/2024 12/04/2024 - 107.4 pounds No weights were found for the week of 11/25/2024, 12/09/24, 12/16/24 During an interview on 12/17/2024 at 10:54 AM, Registered Nurse #3 stated that the Dietician would send an email every Monday that listed which residents required weekly weights, when the dietician was not out on leave. Registered Nurse #3 checked their emails and did not find an email dated 12/09/24 and could not find weights for resident for 11/25/24 nor 12/09/24. 10 New York Code Rules and Regulations 415.12(c)(2)

Based on interviews and record review conducted during the recertification survey, the facility did not provide proper treatment and assistive devices to maintain the vision ability for 1 (Resident #70) of 2 residents reviewed for communication. Specifically, for Resident #70, the facility did not ensure the resident, who had impaired vision, was provided with an optometry consultation to be evaluated for vision aids. This is evidenced by: Resident #70: Resident #70 was admitted to the facility with the diagnoses of chronic obstructive pulmonary disease (a long-term breathing problem), hypertension (high blood pressure), and seizures (sudden, uncontrolled electrical discharges in the brain that can cause temporary changes in movement and consciousness). The Minimum Data Set (an assessment tool) dated 11/21/2024, documented the resident was understood, able to understand others, and was cognitively intact. The Minimum Data Set documented the resident had impaired vision and used corrective lenses. The Policy and Procedure titled, Physician - Consultations, dated 8/2019, stated it was the policy of the organization to ensure all residents receive medical care in a timely manner. The Consult Form dated 3/07/2023 documented the resident had been examined by an optometrist. The form documented the next follow up should be scheduled for 3/2024. Review of the medical record showed no further optometry consults were documented for the resident or a comprehensive care plan developed for the resident regarding their vision. During an interview on 12/11/2024 at 1:03 PM, Resident #70 stated they would like to see the eye doctor. During an interview on 12/17/2024 at 11:12 AM, Registered Nurse #1 stated the resident should see the optometrist every 6-12 months. They stated they would forward any recommendations to Medical Records #1 to schedule follow-up appointments. During an interview on 12/18/2024 at 10:04 AM, Medical Records #1 stated they receive an email from the nurse managers to schedule appointments. They stated they keep a list of the doctors that come to the facility (dental, optometry, podiatry) and give that list of residents to be seen to the doctors. 10 New York Codes, Rules, and Regulations 415.12(2)(b)

Based on interview and record review during a recertification survey, the facility failed to ensure pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents ' goals and preferences for 1 (Resident #112) of 1 residents reviewed for pain management. Specifically, the facility failed to administer Resident #112 ' s pain medication in a manner that managed the resident ' s pain and which resulted in the resident expressing their pain was 10 out of 10, and Family Member #2 calling 911 to have Resident #112 sent to the hospital for care. This is evidenced by: A facility policy titled Medication Administration - Documentation, last revised 1/2019, documented that when administering medications, documentation must include, as a minimum, a. Name and strength of the drug; b. Dosage; c. Method of administration; d. Date and time of administration; e. Reason(s) why a medication was withheld, not administered, or refused; and f. Signature and title of the person administering the medication. A facility policy titled, Pain Management last revised 3/2020, documented that the facility would determine appropriate intervention to manage pain and side effects, review interdisciplinary assessments and documentation, include the resident and family in determining the resident ' s pain goal and acceptable level of pain, identify the potential cause(s) for resident pain, evaluate alleviating and/or exacerbating factors. Appropriate interventions may include pharmacologic as well as non-pharmacologic interventions. Document pain management interventions. Evaluate effectiveness of pain management intervention(s) within 30-60 minutes. Notify physician if interventions are not effective in achieving resident comfort and/or functional goals and re-assess resident status as indicated including, but not limited to level of pain, side effect management, effectiveness of interventions and need for increasing/decreasing amount of medication due to tolerance or side effects. Resident #112 was admitted to the facility with diagnoses of fracture of the lumbar vertebra (lower back bone), malignant neoplasm of the uterine adnexa (uterine cancer), and secondary malignant neoplasm of the bone (bone cancer). The resident was not at the facility long enough to have a Minimum Data Set (a resident assessment) completed. The discharge summary from the hospital, dated 09/19/2024, documented that Resident #112 suffered a compression fracture to the lumbar vertebra #1 (lower back fracture) which required intravenous narcotics, thenan increase in the resident ' s oral narcotics until the pain was controlled. The hospital discharge summary documented Resident #112 should continue to take ropinirole 0.25 milligram (medication for restless leg syndrome which causes uncontrollable spasms of the legs) tab oral daily at bedtime. Additionally, the hospital summary documented that Resident #112 use a diclofenac 1.3 percent patch every 12 hours, acetaminophen (Tylenol extra strength) 500 milligram tab, take 1000 milligrams oral 3 times per day, and oxycodone 5 milligram tab every 4 hours as needed for pain not to exceed 40 milligrams per day. Specifically, the hospital summary documented the following parameters for oxycodone administration: 5-10 milligrams: give 5 milligrams (1 tab) for pain level 3-5 and 10 milligrams for pain level 6-10. Resident #112 ' s Comprehensive Care Plan for alteration in comfort due to cancer and fracture, documented a goal of Resident was able to verbalize pain and request pain medications as needed. Interventions/tasks documented included: to administer medications as ordered Notify physician is interventions were unsuccessful or is current complaint was a significant change from residents past experience of pain Report to Nurse resident complaints of pain or requests for pain treatment Resident was able to verbalize pain and request pain medications as needed. Resident #112 ' s Comprehensive Care Plan for Fracture/Joint Replacement: Alteration in physical function related to fracture dated 09/19/2024 documented a goal of resident will be free of complications from fracture. The documented Interventions/Tasks included giving medications as ordered and monitor for increased signs or symptoms of pain ad notify provider of any change. A Physician order dated 09/19/2024 documented that the resident needed a pain evaluation every shift and to have the pain recorded on a 0-10 scale. Resident #112 ' s Order Summary Report for September 2024 documented orders as follows: Acetaminophen extra strength oral tablet 500 milligrams, give 2 tablets by mouth three times a day for pain, ordered 9/19/2024. Acetaminophen tablet 325 milligrams, give 2 tablets by mouth every 6 hours as needed for pain (not to exceed 3 grams in 24 hours), ordered 9/19/2024. Oxycodone 5 milligrams, give 1 tablet by mouth every 4 hours as needed for pain, ordered 9/19/2024. Oxycodone 5 milligrams, give 2 tablets by mouth every 4 hours as needed for pain, ordered 9/19/2024. Oxycodone 5 milligrams, give 2 tablets by mouth one time only for pain for 1 day, ordered 9/19/2024. Ropinirole .25 milligrams, give 1 tablet by mouth at bedtime for restless legs, ordered 9/19/2024. No order for diclofenac 1.3 percent patch every 12 hours was found on the order summary for Resident #112. During an interview on 12/16/2024 at 10:45 AM, Family Member #2 stated that Resident #112 was initially admitted to the facility from the hospital because this facility was the only one with a bed open and Resident #112 needed some rehab before they could return home; the resident was transported in the afternoon of 09/19/2024. Around 9:00 AM on 09/20/2024, Resident #112 called Family Member #2 and was in great distress. The resident stated to them they had laid in their bed without medication for pain, had soiled clothing, and did not have food. Family Member #2 stated that when they heard this, they called 911 so the resident could be transported back to the hospital. A nursing note dated 09/20/2024 at 10:00 AM, documented that Family Member #2 came to speak with the staff regarding the resident ' s condition. Family Member #2 stated they had called 911 and informed the dispatch that Resident #112 needed to be transferred back to the hospital. When asked what was going on Family Member #2 stated Resident #112 was in pain. Staff educated Family Member #2 on the resident ' s current meds including meds that had been administered. Offered to call the provider to review pain and alternate pain relief. Family Member #2 declined and continued to state, I think its better the resident goes back to the hospital. Provider made aware. During an interview on 12/16/2024 at 1:01 PM, Emergency Medical Technician #1 stated the family met the ambulance outside when they arrived at the facility; the family requested transport for Resident #112 back to the hospital. Emergency Medical Technician #1 stated it was a while ago and from what they recalled, the resident had increased pain, and the facility gave the resident pain medication right before or when the ambulance arrived on 09/20/2024. Resident #112 ' s Medication Administration Record for September 2024 documented the following medication administrations for pain: 09/19/2024 4:00 PM, Acetaminophen 1000 milligrams. 09/19/2024 5:51 PM, oxycodone 5 milligrams, 2 tablets given. 09/19/2024 8:00 PM, Acetaminophen 1000 milligrams. 09/20/2024 8:00 AM, Acetaminophen 1000 milligrams. 09/19/2024 10:36 PM, Acetaminophen 650 milligrams for 10 out of 10 pain. 09/20/2024 5:07 AM, Acetaminophen 650 milligrams for 5 out of 10 pain. Total of 4300 milligrams of acetaminophen in 13 hours and 7 minutes, order was not to exceed 3000 milligrams in 24 hours. The narcotic log for Resident #112 documented the following: 09/19/2024 5:46 PM oxycodone 5 milligrams, 2 tablets were administered. 9/20/2024 10:41 AM oxycodone 5 milligrams, 2 tablets were administered (this administration was not documented in the Medication Administration Record). Resident #112 ' s September 2024 progress notes documented: 09/19/2024 10:36 PM 325 milligram acetaminophen, 2 tablets given as needed for pain, not to exceed 3 grams in 24 hours given by Registered Nurse #4. 09/20/2024 1:34 AM documented by Registered Nurse #5 that the as needed administration of Tylenol at 10:36 PM was effective and the follow-up pain scale was 0; this was not documented within 30 minutes-60 minutes required by the facility policy. 09/20/2024 5:07 AM Registered Nurse #5 documented that 325 milligrams acetaminophen, 2 tablets were given as needed for pain, not to exceed 3 grams in 24 hours. 09/20/2024 6:11 AM Registered Nurse #5 documented that the as needed administration of acetaminophen had a follow-up pain scale of 2. 09/20/2024 10:10 AM the Director of Nursing documented that Family #2 spoke to them and had called 911 to transport Resident #112 back to the hospital because the resident was in pain. 09/20/2024 11:22 AM Registered Nurse #6 documented that prior to leaving, Resident #112 was given their due medications and was still complaining of pain and restless legs and was given oxycodone (which was not documented in the medication administration record), and vital signs were taken with a blood pressure of 147/65 and pulse rate of 80 beats per minute. Record review of Resident #112 ' s vital signs revealed that on 09/19/2024 at 10:36 PM, Registered Nurse #4 recorded that Resident #112 verbalized their pain at a 10 out of 10. Record review of the 09/2024 Medication Administration Record revealed that Registered Nurse #4 administered 650 milligrams of Tylenol when Resident #112 communicated they were experiencing 10 out of 10 for pain. The emergency room summary for admitted [DATE] and discharge date of [DATE] documented the following: The chief complaint was restless leg. The hospital administered ropinirole, which resolved the leg symptoms. Later that evening, the patient requested a dose of oxycodone, which was given. The resident rested comfortably the rest of the evening. During an interview on 12/18/2024 at 9:10 AM, Director of Nursing #1 stated that staff administered Tylenol in response to Resident #112 stating they were in pain. When asked if that was appropriate intervention for a 10 out of 10 pain that was verbalized by the resident, Director of Nursing #1 did not answer. Director of Nursing #1 stated that Resident #112 should have verbally requested oxycodone because the order was written as needed. On 12/18/2024 at 10:24 AM, surveyor attempt to contact Registered Nurse #4 was unsuccessful. 10 New York Codes Rules and Regulations 415.12

Based on observations, record review, and interviews conducted during the Recertification Survey, the facility did not ensure that it provided or obtained emergency dental services to meet the needs of each resident for 1 (Resident #75) of 1 resident reviewed for Dental Services. Specifically, Resident #75 had broken a front tooth the week of 12/02/2024 and had not been seen by the dentist. This is evidenced by: The facility policy titled, Dental Services, last revision date 9/2019, documented both routine and emergency dental services were available to meet the oral needs of each resident. Resident #75 had diagnoses which included hypertension (high blood pressure), chronic obstructive pulmonary disease (a condition involving constriction of the airways and difficulty breathing), and depression (a mental health condition characterized by a persistent low mood, loss of interest or pleasure in activities). The Minimum Data Set (a resident assessment tool) dated 8/14/2024 documented Resident #75 was able to be understood by others and could understand others, had mild cognitive impairment, and had no mouth or facial pain, or difficulty chewing. Resident had obvious cavities and broken natural teeth. On 12/12/2024 at 11:33 AM, Resident #75 was observed in their room and their top front teeth were broken. During an interview 12/12/2024 at 11:33 AM, Resident #75 stated they had broken their teeth 2 weeks ago and they had not seen the dentist yet and continued to have slight pain. During an interview on 12/18/2024 at 10:55 AM, Licensed Practical Nurse #1 stated they would give the information to the Finance Director #1, who was responsible for setting up dental appointments. During an interview on 12/18/2024 at 10:55 AM, Finance Director #1 stated that Resident #75 had seen the dentist on 6/20/2024, but that they would add Resident #75 to the list to see the dentist on their next visit. 10 New York Code Rules and Regulations 415.17(b)(1)(2)

Based on record review and interviews during an abbreviated survey (Case # NY00278217), the facility did not provide needed care and services that are resident centered and in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for 1 (Resident #5) out of 11 residents reviewed. Specifically, the facility did not ensure the resident was assessed and that the physician was notified when Resident #5, a resident prescribed an anticoagulant (blood thinning) medication, developed a nosebleed. The resident was not assessed by nursing staff when the nosebleed occurred; the resident then called for emergency services and was subsequently admitted to the hospital for treatment. This is evidenced by: The Policy and Procedure titled, Change in Condition Notification, dated August 2019, read in pertinent part that it was the policy of the facility to monitor residents for changes in their condition, to respond appropriately to those changes and then notify the physician. The Policy and Procedure titled, Anticoagulation Therapy, dated March 2019, read in pertinent part that nursing staff and the physician should monitor for possible complications in individuals who were being anticoagulated and were to manage related problems. The physician should identify where risk factors constituted contraindications to anticoagulation. Resident #5 Resident #5 was admitted to the facility on [DATE] with diagnoses which included repeated falls, atherosclerotic heart disease of native coronary artery and ischemic cardiomyopathy (the heart's decreased ability to pump blood properly, due to heart muscle damage brought upon by restricted or reduced blood flow). The Minimum Data Set (an assessment tool) dated 6/04/2021 documented the resident could be understood and could understand others with intact cognition for decisions of daily living. A Physician Order dated 6/04/2021 documented warfarin sodium tablet (blood thinning medication) three milligram tablet by mouth at bedtime for treating/preventing blood blots. Review of the Comprehensive Care Plan, initiated on 6/9/2021, revealed there was no comprehensive plan for nursing care in place for the resident. A Nursing Progress Note dated 6/20/2021 at 8:49 AM documented the resident was sent to the hospital that morning of 6/20/2021 due to calling 911 on their own authority. The nurse documented they were unaware of an emergency with the resident. The nurse documented they first became aware of the nosebleed at 3:30 AM but wasn't overly alarmed as the resident had been the hospital multiple times since admitting to the facility and had been on anticoagulation since they admitted . The nurse documented they offered the resident a prescribed nasal decongestant, which the resident declined, and then told the resident to keep pressure on it. The note read that at approximately 6:45 AM, the nurse was informed by an unexpected visit from the police that the resident had called 911 asking for an ambulance transport, before they could do anything about the situation. A Nursing Progress Note dated 6/20/2021 at 2:24 PM documented that the hospital Nurse Practitioner reported that the resident was going to be staying overnight at the hospital and would most likely be seen by the Ear, Nose and Throat physician to see if there might have been something going on inside of their right nostril causing nose bleeds. Review of the resident record revealed no documentation of the resident previously experiencing a nosebleed at the facility. During an interview on 12/12/2023 at 2:26 PM, Licensed Practical Nurse Unit Manager #4 stated when a resident had a change in condition, the resident should be assessed, and the physician and resident's family notified. They stated they would follow through with any new orders given by the physician or to have the resident sent out to the hospital. During an interview on 12/13/2023 at 9:57 AM, Licensed Practical Nurse #5 stated that if a resident who was prescribed anticoagulant medication had a nosebleed, they would try to stop the bleeding, clean the resident up, check the resident's vital signs, and call the physician. They further stated they would let the physician know the resident was prescribed anticoagulant medication and then take orders from the physician. They stated the physician should be notified right away when a resident on anticoagulant medication experienced bleeding. During an interview on 12/18/2023 at 1:12 PM, the Director of Nursing stated they vaguely recalled the resident but did not recall that they were ever informed of the resident calling 911 and going to the hospital. They stated that the resident had a diagnosis of nosebleeds when they admitted to the facility. Upon review of the resident's record, they stated the resident was not documented have had any other nose bleeds while at the facility. The Director of Nursing stated the resident was prescribed anticoagulant medication. They further stated the physician should be notified if a resident was prescribed anticoagulant medication and had nosebleed so that the physician could make the decision on whether the anticoagulant medication should be withheld, or any other treatment provided. They stated the resident's comprehensive care plan should include monitoring for side effects of anticoagulant medication use such as bleeding. The Director of Nursing stated, upon review of the resident's care plan, that it appeared the activities staff and dietary department had completed their portions of the resident care plan, however, the nursing care plan was not completed and could not be reviewed. During an email correspondence on 12/19/2023 at 12:27 PM, the Nursing Home Administrator documented that a comprehensive nursing care plan was not put in place due to the resident having been sent out to the hospital after they were admitted . They stated the resident had not been in the facility for seven consecutive days in order to complete a comprehensive care plan. They documented a baseline care plan was completed for the resident. 10 NYCRR 415.12

Based on record reviews and interviews during an abbreviated survey (Case # NY00271568), the facility did not ensure it implemented the comprehensive care plan consistent with resident rights for 1 (Resident #2) of 8 residents reviewed. Specifically, the facility did not ensure the intervention for the use of floor mats as documented on Resident #2's comprehensive care plan (CCP) for At Risk to Fall was implemented by facility staff resulting in a fractured right upper arm from a fall out of bed. This resulted in actual harm to Resident #2 that was not immediate jeopardy. This is evidenced by: The Policy and Procedure titled, Care Plans- Comprehensive documented a comprehensive, person-centered care plan is developed and implemented for each resident. Each resident's care plan will be consistent with the resident's right to receive the services and/or items included in the care plan. Resident #2 was admitted to the facility with diagnoses of dementia, a cerebral vascular accident (damage to the brain from interruption of its blood supply), and diabetes. The Minimum Data Set (MDS-an assessment tool) dated 2/2/2021, documented the resident had moderate cognitive impairment, could be understood, and could understand others. The untimed facility Investigation Form dated 2/15/2021, documented the investigation concluded the resident rolled out of bed at approximately 6:45 AM. Certified Nurse Aide (CNA) #1 heard resident yelling and immediately responded to the resident's room where they found the resident on the floor lying on their right side next to their bed yelling in pain. CNA #1 called for the nurse who responded and assessed the resident. There were right upper extremity abnormalities and increased pain. The resident was sent to the emergency room (ER) for evaluation and was diagnosed with a right humerus (bone in upper arm) fracture. The investigation concluded the root cause of the incident was a care plan violation because the floor mats were not in place (next to the sides of the resident's bed). The Comprehensive Care Plan (CCP) for At Risk for Falls dated 4/3/2020, documented to place bilateral floor mats (1 mat on each side of the bed). The CCP for At Risk for Falls dated 2/15/2021, documented a perimeter mattress (a mattress that raised sides at the foot and head used to prevent falls out of bed) was placed on Resident #2's bed. The CNA Kardex (the CNA care plan) dated 1/6/2023, documented the resident was to have bilateral floormats in place. A Nursing Clinical Evaluation Note dated 2/15/2021 at 10:13 AM, documented Registered Nurse (RN) #1 was informed that the resident was lying on the floor next to their bed. Resident #2's assessment showed considerable discomfort to the right upper arm/shoulder. The Nurse Practitioner (NP) #1 was notified and ordered the resident to be sent to the ER for x-ray and evaluation. A Tele-Health Physician Progress note dated 2/15/2021 at 7:04 AM, documented the resident was seen by the NP #1 after staff found the resident on the floor at 6:45 AM. The resident reported excruciating pain to their right upper arm. The resident was unable to provide details about the fall and would not allow RN #1 to assess their extremity. The resident was to be transferred to the emergency room for a STAT (immediate) x-ray of the humerus. The Radiology Report dated 2/15/2021, documented the x-ray showed a fracture of the right humerus. The facility Admission note dated 2/15/2021 at 2:31 PM, documented the resident returned from the hospital diagnosed with a right humerus fracture. On 1/10 at 10:54 AM, 1/17 at 12 PM, and 1/18/2023 at 11:59 AM, messages were left CNA #1 requesting a call back with no response. During an interview on 1/3/2023 at 10:47 AM, CNA #2 stated they knew what kind of care the residents needed by looking at their Kardex. CNA #2 stated they looked at the Kardex every day and every time they entered a resident's room to provide care just in case there had been a change. During an interview on 1/3/2023 10:54 AM, CNA #3 stated they knew what kind of care to provide a resident by looking at their Kardex. CNA #3 stated they looked at the Kardex every day and when they were given report that there was a change. During an interview on 1/3/2023 at 11:02 AM, Licensed Practical Nurse (LPN) #1 stated they could look in the computer and on the resident's Kardex for the care they needed. LPN #1 stated staff should look at the Kardex every time they provided care to residents. During an interview on 1/3/2023 at 11:05 AM, Resident #2 stated they broke their right arm when they fell out of bed onto the floor. Resident #2 recalled there was no mat on the floor when they fell . Resident #2 stated staff put a mat down after their fall and now they had a mat on each side of their bed. Resident #2 stated they still had some discomfort if they laid on their right shoulder. During an interview on 1/3/2023 at 1:28 PM, the Director of Nursing (DON) stated Resident #2 fell out of bed on 2/15/2021. CNA #1, who was working with another resident at the time, heard the Resident #2 yelling and went to their room. They found Resident #2 on the floor and called for RN #1 who came and assessed the resident. The DON stated RN #1 contacted the on-call provider, and a telehealth visit was made with the resident. An order was provided to send Resident #2 to the hospital for an x-ray of their right arm. Resident #2 returned from the hospital with a diagnosis of a right humerus fracture. The DON stated the resident was supposed to have floor mats by their bed, but they were not in use at the time of the incident. The DON stated the CNAs were supposed to be looking at the residents care cards at the beginning of their shift. Changes in the care plan were verbally communicated to nurses and CNA by the Unit Managers. During an interview on 1/6/2023 at 10:32 AM, RN #1 stated they recalled Resident #2. RN #1 stated they were called to the Resident #2's room and when they entered the room, they thought there was a floor mat on one side of their bed but recalled there was not a floor mat on the side of the bed the resident fell out of. During an interview on 1/23/2023 at 11:01 AM, the Medical Director (MD) stated Resident #2 was diagnosed with osteoporosis in 12/2019. Resident #2 was not under treatment for it. Osteoporosis can affect any bones in the body, especially femur, vertebrae, ribs, and humerus. The MD stated Resident #2 had history of osteoporotic fractures. In a resident like this, Resident #2 was likely to have had a fracture even if the floor mat was in place. The resident was frail, debilitated, and had many comorbidities. F600- Past noncompliance Based on the following corrective actions taken, there was sufficient evidence the facility corrected the noncompliance and was in substantial compliance for this specific regulatory requirement at the time of this survey: -Completed a full house audit to determine which residents were to have mats on the floor beside their beds. The blank Fall Devices Audit Tool provided included the date, name of auditor, names of residents and the following criteria: 1. Does resident have fall device used as an intervention? 2. Does the care plan reflect the fall intervention? 3. Is the fall device in place? 4. Is the device functioning properly? -To ensure the deficient practice will not recur, Unit Managers and/or Supervisor will audit those residents who are care planed for floor mats for compliance weekly for 4 weeks. Outcome of the audits will be present during monthly Quality Assurance (QA) meeting. -Nursing staff were in-serviced on 2/18/2021 for Review of Kardex presented by the DON. The attendance record and teaching material were provided. -Specific to CNA #1, the alleged perpetrator, they were immediately removed from the schedule pending outcome of the investigation, disciplinary action was implemented for them, and CNA #1 was educated individually on following the care plan and use of residents' Kardex for resident specific interventions. 10 NYCRR 415.11(c)(1)

Based on record reviews and interviews during an abbreviated survey (Case #s NY00271205, NY00271568, NY00272306, and #NY00278116), the facility did not ensure that all alleged violations involving abuse, and neglect are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse/neglect/or mistreatment or result in serious bodily injury for 4 residents (Resident #s 1, 2, 7, and 8) of 8 residents reviewed for abuse reporting. Specifically, the facility did not ensure it reported allegations of abuse/neglect/mistreatment for Resident #1 who reported they had been hit and fell , Resident #2 who had a fall with a fractured arm that the facility reported as a care plan violation, and Resident #7 who was witnessed to be verbally abused by Certified Nurse Aide (CNA) #1 within 2 hours of each occurrence. This was evidenced by: The Policy and Procedure titled, Abuse dated 2/2019, documented to notify the local law enforcement and appropriate State Agency (s) immediately (no later than 2 hours after allegation/identification of allegation). Resident #1: Resident #1 was admitted to the facility with diagnoses of schizoaffective disorder, history of traumatic brain injury, and chest pain. The Minimum Data Set (MDS- an assessment tool) dated 7/1/2021, documented the resident was cognitively intact, could be understood, and could understand others. An untimed Facility Grievance Form dated 6/28/2021, documented on 6/26/2021, Resident #1 called 911 and reported to police someone had hit them and they fell out of bed. The resident became increasingly accusatory and continued to state someone had hit them and they fell . The NYS Department of Health (DOH) Nursing Home Incident Form documented the incident occurred on 6/26/2021 at 6:00 PM. The form was submitted to DOH on 6/28/2021 at 5:34 PM. Resident #2: Resident #2 was admitted to the facility with diagnoses of dementia, stroke, and diabetes. The MDS dated [DATE], documented the resident had moderate cognitive impairment, could be understood, and could understand others. The untimed facility Investigation Form dated 2/15/2021, documented the incident that involved Resident #2 was a fall with injury and care plan violation. The resident sustained a fractured right arm. The DOH Nursing Home Incident Form documented the incident occurred on 2/15/2021 at 6:45 AM. The form was submitted to DOH on 2/15/2021 at 12:57 PM. Resident #7: Resident #7 was admitted to the facility with diagnoses of Alzheimer's disease, dementia with behavioral disturbance, and delusional disorder. The MDS dated [DATE], documented the resident had severe cognitive impairment, was usually understood, and could usually understand others. The untimed facility Investigation Form dated 3/2/2021, documented CNA #1 assisted Resident #7 into the library at 5:45 PM on 3/1//2021 and was overheard by the Activities Director (who was in their office adjacent to the library with their door closed) yell at the resident to sit your ass down, then yelled at the resident to shut up and go to sleep, and Who the hell do you think you are? The DOH Nursing Home Incident Form documented the incident occurred on 3/1/2021 at 5:45 PM. The form was submitted to DOH on 3/2/2021 at 11:44 AM. Interviews: During an interview on 1/5/2023 at 11:16 AM, the Director of Nursing (DON) stated abuse was to be reported within 24 hours if there was no injury, and within 2 hours if injury occurred. During an interview on 1/5/2023 at 2:06 PM, the Administrator (ADM) stated reportable incidents needed to be reported to the DON within 24 hours, or if the incident involved serious injury, within 2 hours. 10 NYCRR 415.4(6)

Based on record review and interviews during an abbreviated survey (Case #s NY00271205, NY00271568, NY00272306, and #NY00278116), the facility did not ensure the resident has the right to be free from abuse. The facility must not use verbal abuse for 1 (Resident #7) of 8 residents reviewed for abuse. Specifically, the facility did not ensure Resident #7 was free from verbal abuse when Certified Nursing Assistant #1 (CNA) was overheard by the Activities Director (AD) yelling at the resident using abusive language. Additionally, the Administrator (ADM) witnessed CNA #1 swearing in front of residents seated around the nurses' station. This was evidence by: The Policy and Procedure titled Abuse dated 2/2019, documented the facility prohibits the mistreatment, neglect, and abuse of residents by anyone including staff. It defined verbal abuse as disparaging and derogatory terms willfully spoken to the resident, or within their hearing distance to describe the resident, regardless of their ability to comprehend. Resident #7: Resident #7 was admitted to the facility with diagnoses of Alzheimer's disease, dementia with behavioral disturbance, and delusional disorders. The Minimum Data Set (MDS-an assessment tool) dated 2/21/2021, documented the resident had severe cognitive impairment, was usually understood, and could usually understand others. The Investigation Form dated 3/2/2021, documented CNA #1 assisted resident into the library at 5:45 PM, and was overheard by the Activities Director, who was in their office adjacent to the library with their door closed, yell at Resident #7 to Sit your ass down, then yelled at the resident to Shut up and go to sleep, and Who the hell do you think you are? The Comprehensive Care Plan (CCP) initiated 10/16/2020 for At Risk for Being a Victim, documented the resident was at risk due to inability to understand their surroundings, related to dementia and dependence on others for activities of daily living. The CCP initiated 11/3/2020 for At Risk for Abuse Related to Behaviors and Dementia, documented to investigate all allegations of abuse and neglect promptly, to provide support, and ensure the resident is free from abuse. A General Progress Note dated 3/2/2021 at 10:25 AM, documented the resident was in a pleasant mood and conversing per their baseline. Staff were to continue to monitor for any changes in behaviors. During an interview on 1/5/2021 at 1:37 PM, the AD, stated they recalled Resident #7. They stated they were in their office (on 3/1/2021), which was located in the library, with the door shut. CNA #1 brought Resident #7 into the library and CNA #1 did not know the AD was in their office while the CNA #1 was yelling at the resident. The AD stated they opened their door and when the CNA #1 saw them, they darted out of the library. The AD had no idea where they went. The AD stated they did not recognize CNA #1 because they did not usually work that late. The AD stated they asked staff who the CNA #1 was, and once they found out, they went straight to the Administrator's office to report the incident. The AD stated CNA #1's tone of voice was loud, angry, and they were screaming when they asked the resident Who the hell do you think you are? During an interview on 1/5/2021 at 2:06 PM, the ADM stated the AD immediately reported what they had heard and saw regarding the (3/1/2021) incident to them. The ADM went to the unit where CNA #1 was working, but CNA #1 was not on the unit at the time. They waited for them to return. The ADM stated they had no idea where CNA #1 was, but when CNA #1 returned to the unit, they told them they were suspended because of an allegation of verbal abuse pending outcome of an investigation. The ADM stated CNA #1 did not leave, so they told them a second time they were suspended and had to leave the building. The ADM stated then CNA #1 tried to call their employment agency, so they had to tell CNA #1 a 3rd time they were suspended and to leave the building. The ADM stated CNA #1 was mouthy and started swearing in front of the residents. The ADM stated they told CNA #1 they could not use that language in front of residents. They needed to tell CNA #1 a minimum of 3 times to leave. The ADM stated they stayed with CNA #1 the entire time and they escorted them out of the building. 10 NYCRR 415.4(b)(1)(i) x

Based on record review and interview during a recertification and abbreviated surveys conducted 9/19/2022 to 9/23/2022, the facility did not ensure residents were provided a safe, clean, comfortable, and homelike environment on 3 of 3 units observed. Specifically, on Unit A, a strong, stale urine odor was noticed throughout the unit each day of the survey and resident rooms lacked a homelike environment in the absence of personalized items and decor. On Unit B the floors and ceiling tiles were soiled, and on Unit C the laminate trim was peeling away from the wall in a resident room. Additionally, the facility did not ensure that appropriate dishware was consistently utilized in accordance with facility policy on the B-wing nursing unit on 9/19/2022 and in the main dining area on 9/21/2022. This is evidenced by: A facility policy titled, Home Like Environment created 9/19/2022 documented Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. Procedure: The facility staff and management shall maximize, to the extent possible, the characteristics of the facility. That reflect a personalized homelike setting. These characteristics include. A. Cleanliness and order. C. Inviting colors and decor. D. Personalized furniture and room arrangements. E. Pleasant, neutral scents. The facility staff and management shall minimize, to the extent possible, the characteristics of the facility that reflect a depersonalized, institutional setting. These characteristics include: B. Institutional odors. Unit A: During observations on 09/19/22 at 10:37 AM and 02:21 PM, a strong, stale urine odor was noted immediately upon entering the unit. The odor was perceived to be the same throughout the unit. During observations on 09/20/22 at 9:39 AM and 2:48 PM, the odor noted on previous day was significantly stronger throughout the unit, with added intensity near the Unit desk. During observations on 09/21/22 at 8:41 AM and 3:08 PM, the odor noted on previous days remained throughout Unit A. During observations on 09/21/22 at 9:51 AM and again on 09/22/22 at 10:29 AM, the floors were soiled with dirt including in corners and next to walls in the A-Unit Assisted Dining Room and a ceiling tile was stained in resident room #A-11. During observations on 09/22/22 at 9:44 AM and 1:25 PM, the odor noted on previous days remained throughout Unit A, perceived as intense as it was during 09/19/22 (day 1 of survey) observation. During an observation on 09/23/22 10:34 AM, in resident room A-11 the walls were unembellished, and surfaces were without decorative items except for one small basket of artificial flowers in the window, not visible to the resident in the bed on the door side of the room. In resident rooms A-20 and A-36 the walls were unembellished, and surfaces were without decorative items. During an interview on 09/19/2022 at 3:34 PM, the Maintenance Director stated that about 2 weeks ago a new ventilation unit was ordered for the long hall on the A-unit and is waiting for the weather to clear to install the unit. During an interview on 09/20/22 at 09:13 AM, Resident #36 reported they keep the door closed to try to keep out the odor. States staff say there's nothing they can do about it. During an interview on 09/23/22 at 10:18 AM, Resident #20 stated that the A-wing unit smelled like urine and feces most of the time. They noticed that it smelled particularly worse when they had been off the unit and returned, for example, when they return from therapy. They stated that in the past they have mentioned to staff that the unit smelled bad, but staff had told them that it happens and it is a nursing home. During an interview on 09/23/22 at 10:21 AM, Housekeeper #1 reported they had noticed the odor a few weeks ago and have tried to get rid of it but can't. Believes it is coming from some of the mattresses that hold the odor and possibly the floor wax. Has discussed with supervisor, not sure if they are doing anything about it. During an interview on 09/23/22 at 1:05 PM, the Housekeeping Supervisor reported they have known about the odor problem for over a month maybe closer to two months. Believes part of the problem was the air circulator that was replaced by maintenance on Tuesday. The Housekeeping staff try very hard to eliminate the odor including extra cleaning of rooms and items that are known to be urinated on frequently, but it's not enough. When asked if they thought the facility had provided an environment free of institutional odor, the Housekeeping Supervisor stated, no, not even half of the time. During an interview on 09/23/22 1:20 PM, the Social Worker Director (SWD) stated residents and family are encouraged to bring personal items, however they do not know who's responsible for telling them that. The SWD does not know if the facility provides anything for those that have no family to bring items in, and stated it might be Activities' responsibility. During an interview on 09/23/22 at 1:28 PM, the Activities Director reported they did not regularly discuss with residents or family about bringing personal items into the facility and did not know if it was an Activity or Social Work Department responsibility. During an interview on 09/23/22 at 1:30 PM, Activities Aid #2 stated there was information in the welcome pack about bringing in personal items. They also stated, if a resident has no family to bring items in the facility could provide decorative items for their room if they ask, it is not done routinely though. During an interview on 09/23/22 at 1:56 PM, the Administrator stated they were not aware of the odor on Unit A until Monday when a surveyor asked about it. There was an exhaust fan that was not functioning, and it was repaired on Wednesday. There is also a resident on the unit that refuses to bath and that may be part of the problem. We will try to figure out where the odor is coming from and correct. The Administrator also stated they would expect activities to let them know if a resident needed anything, including decorative items for their room. They were not aware of rooms with no decorative items. During an interview on 09/23/22 at 2:26 PM, the Maintenance Director stated they have been working on the exhaust units to correct the odor problem. In the past 6 weeks they have replaced two of three units. Unit B: During observations on 09/21/22 at 9:51 AM and again on 09/22/22 at 10:29 AM, the floors were soiled with dirt including in corners and next to walls in resident rooms #B-25, #B-26, #B-31, #B-37, and #B-38. Unit C: During observations on 09/21/22 at 9:51 AM and again on 09/22/22 at 10:29 AM, the laminate trim was peeling from the wall in resident room #C-8. During interviews on 09/23/22 at 10:33 AM, the Administrator, Maintenance Director, and Director of Housekeeping and Laundry stated that stripping and waxing the floors on the B-wing was slowed due to the pandemic and issues with staffing, it is being discussed within the facility to finished stripping the floors as soon as possible, an alternate product may need regarding gluing the laminate trim, and the facility will be audited for stained ceiling tiles. The Administrator stated that the rooms identified will be the initial focus and priority. The Policy and Procedure (P&P) titled Meal Tray Pass, revised 1/2020, documented trays for room service would be set up in the dietary department, and dishes would be utilized unless otherwise ordered by the physician. During an observation on 9/19/2022 at 12:57 PM, 13 unpassed trays were observed on the B-unit dining cart. All 13 trays contained a bowl of orange gelatin served in a disposable paper bowls. During an observation on 9/21/2022 at 11:55 AM, cinnamon apples were served in disposable paper bowls to 17 residents in the main dining area. During an observation on 9/22/2022 at 9:14 AM, 5 resident meal trays on the B-wing dining cart contained 30 milliliter (mL) clear medicine cups that were filled with a white liquid. During an interview on 9/22/2022 at 9:14 AM, Licensed Practical Nurse (LPN) #2 stated that the white liquid in the 5 plastic medicine cups on the B-wing dining cart was [MEDICATION(S)]. Staff were using the medicine cups, because the facility ran out of coffee creamers, and yesterday, they ran out of half and half, so this was what was being provided to the residents. During an interview on 9/22/2022 at 9:18 AM, Registered Nurse (RN) #1 stated that yesterday the facility ran out of coffee creamers, so they began providing residents half and half in 30 mL medication cups at mealtime. Since the facility was out of half and half today, the staff were serving [MEDICATION(S)] to the residents in the medication cups at mealtime. During an interview on 9/23/2022 at 10:51 AM, Licensed Practical Nurse Unit Manager (LPNUM) #1 stated that according to the facility's meal tray pass policy, ceramic/plastic dishes should be used for all residents unless a physician's order documented otherwise. They were not aware of any reason that disposable cardboard bowls should have been utilized for large groups of residents during a meal pass. During an interview on 9/23/2022 at 11:22 AM, the Food Service Director (FSD) #1 stated that ceramic plates, 6 oz. non-disposable tumblers, and 9 oz. non-disposable bowls should be used for food service at each meal, unless a resident had alternative orders from the physician. FSD #1 stated that the orange gelatin and cinnamon apples observed on 9/19/2022 and 9/21/2022 respectively, should have been served in non-disposable bowls instead of the disposable cardboard bowls they were served in. They also stated that the directive to use medication cups to distribute half and half and [MEDICATION(S)] on 9/21/2022 and 9/22/2022 respectively did not come from the kitchen; they assumed that the half and half and [MEDICATION(S)] was going to be added directly to the coffee in one of the carafes that were sent to the unit. Using the medication cups to distribute the half and half and [MEDICATION(S)] was probably not the best way to ensure a homelike environment for the residents. During an interview on 9/23/2022 at 12:25 PM, the Director of Nursing (DON) stated that when the facility ran out of coffee creamers and half and half, staff should have implemented an alternative solution rather than using medication cups to distribute these fluids to ensure a homelike environment was maintained for the residents. 10 NYCRR 415.5(h)

Based on observation and interviews during the recertification survey dated 09/19/22 through 09/23/2022, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety in the main kitchen and two (2) of 3 nourishment areas. Specifically, in the main kitchen, one #10 can of tomato sauce found in the common stock had a V-shaped dent; the pressure gauge servicing the automatic dishwashing machine was broken; the faucet servicing the 2-compartment sink was leaking. Additionally, multiple surfaces and equipment in the main kitchen and unit areas were soiled with food particles, splatters and grime. This is evidenced as follows: The main kitchen and unit kitchenettes were inspected on 09/19/22 at 11:30 AM. In the main kitchen, one #10 can of tomato sauce found in the common stock had a V-shaped dent; the pressure gauge servicing the automatic dishwashing machine was broken; the faucet servicing the 2-compartment sink was leaking; and the microwave oven, can opener holder, door gaskets and bottom inside of the roll-in refrigerator, kitchen floor fan, kitchen doors, ceiling above the cooking line, exhaust hood above the dishwashing machine, wall fan left of the dishwashing machine, dishwashing machine room floor including the floor below the dishwashing machine, fire extinguishers, and mop and bucket were soiled with food particles, splatters, or grime. And the floor in the A-Unit nourishment area, and the cabinet below the sink in the C-Unit nourishment area were soiled with food particles. During an interview on 09/19/22 at 12:57 PM, the Food Service Director stated that worker orders will be submitted for the dishwashing machine pressure gauge, faucet leak, and ceiling tiles; and a cleaning list will be developed in general and for the items found. During an interview on 09/20/22 at 1:24 PM, the Administrator stated that the items found in the kitchen and nourishment areas will be addressed. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1.32, 14-1.110, 14-1.115, 14-1.170

Based on record review and interviews during the recertification survey, the facility did not ensure there was immediate notification of the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status for 1 (Resident #108) of 5 residents reviewed for notification of change. Specifically, for Resident #108, the facility did not ensure the physician was notified immediately after a change in mental status was identified on the morning of 7/21/2022. This was evidenced by: Resident #108: Resident #108 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - an assessment tool) dated 5/19/2022, documented the resident had severely impaired cognition, could usually understand others, could usually make themselves understood, and had no signs or symptoms of a swallowing disorder. The Policy and Procedure (P&P) titled Notifications, dated 4/2019, documented the facility must notify the resident's physician immediately when there was a significant decline in the resident's physical, mental, or psychosocial status. Immediately shall mean as soon as possible. The Comprehensive Care Plan (CCP) titled Activities of Daily Living (ADLs) reviewed 5/23/2022, documented Resident #108 was supervision with setup help for eating. A change in condition note dated 7/21/2022 at 1:21 PM, documented Resident #108 had experienced a change in condition of altered mental status evidenced by increased confusion, needing more assistance with ADLs, general weakness, and decreased mobility. A nursing note dated 7/21/2022 at 2:59 PM, documented Resident #108 had increased lethargy in the morning and was brought to the feeding assist room for breakfast. Attempts to feed the resident resulted in the food rolling out of the resident's mouth. The resident remained at their table until 12:30 PM, at which time they were observed to be unresponsive with drool pouring out of their mouth. The resident received three sternal rubs, with no response; a faint pulse rate was felt. The Nurse Practitioner (NP) was notified, and the resident was sent to the hospital. During an interview on 09/22/2022 at 2:41 PM, Registered Nurse (RN) #1 stated that during breakfast on 7/21/2022, approximately 8:30 AM, Resident #108 appeared lethargic, and food was falling out of their mouth when staff attempted to feed them; this was new for the resident. After breakfast, the resident's mental status still appeared to be diminished from their baseline and they were still not acting like themselves. Later in the afternoon, the resident became unresponsive. The Nurse Practitioner (NP) was notified, and the resident was sent to the hospital. RN #1 stated the facility policy regarding physician notification was that if a resident had a change in condition, including a change in mental status, the provider should be informed immediately. They stated when Resident #108's change in mental status was identified at breakfast on 7/21/2022, they did not notify the physician. The NP was not notified of Resident #108's change in condition until the resident was unresponsive around lunchtime. During an interview on 09/22/2022 at 4:01 PM, Licensed Practical Nurse (LPN) #1 stated they were assigned to Resident 108's unit on 7/21/2022. Around lunchtime on that day, the resident was minimally responsive, which was a change in their mental status from their baseline. Staff informed them the resident had been that way since breakfast, and they reported this to the resident's nurse (LPN #2) and the nurse manager (RN #1). Shortly afterwards, the NP arrived on the unit, and the resident was sent to the hospital. During an interview on 09/23/2022 at 8:09 AM, LPN #2 stated they were assigned to Resident #108 on 7/21/2022, and they had not seen Resident #108 so lethargic that they were unable to keep food in their mouth like they were in the morning of 7/21/2022; that was new and a change in mental status for the resident. When the change of condition was identified during breakfast, the physician was not notified immediately. Around lunchtime, the NP was notified after the resident was unresponsive, and they were sent to the hospital. During an interview on 09/23/2022 at 12:25 PM, the Director of Nursing (DON) stated when a change in condition was identified, the resident needed to be assessed and the physician notified. When the change in condition involved a change in mental status, the physician needed to be notified immediately. The DON stated that on 7/21/2022, when nursing identified the change in Resident #108's mental status at breakfast, the physician should have been contacted immediately. 10 NYCRR 415.3(e)(2)(ii)(b)

Based on record review and interview during the recertification survey, the facility did not ensure that a Level 1 Screen was completed prior to admission to the nursing home for 1 (Resident #35) of 19 residents reviewed for pre-admission screening. Specifically, for Resident #35, the facility did not complete a Level 1 Screen prior to the resident's admission to the facility. This is evidenced by: Resident #35: Resident #35 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - an assessment tool) dated 8/5/2022, documented the resident had severe cognitive impairment and was rarely/never able to make needs known. A Policy and Procedure titled PASRR/SCREENS dated 12/2019 documented, every admission to the facility would have a completed Level 1 Screen prior to admission to ensure the resident was appropriate for admission to the facility. Upon admission, the social worker would be responsible to ensure the completed Level 1 Screen (and Level 2 PASRR if required) was in the medical record. On 9/20/2022, the resident's medical record did not include a Level 1 Screen. During an interview on 9/23/2022 at 2:50 PM, the Director of Nursing (DON) stated after searching for the Level 1 Screen for Resident #35, the facility was unable to locate the document. During an interview on 9/23/2022 at 2:51 PM, Social Worker (SW) #5, stated the corporate admissions team reviewed all screens prior to accepting residents for admission and the Level 1 Screen should have been included with the admission paperwork from the hospital. SW #5 stated on 4/13/2022 and again on 8/25/2022, they had requested that corporate admissions staff provide a copy of Resident #35's Level 1 Screen to be placed in the resident's medical record. SW #5 stated they had not received a copy of the Level 1 Screen and could not verify it was completed. 10 NYCRR415.11(e)

Based on observation and interviews during the recertification survey, the facility did not ensure food that accommodated resident allergies, intolerances, and preferences, or appealing options of similar nutritive value were provided for 2 (Resident #'s 20, and 42) of 3 residents reviewed for food. Specifically, for Resident #20, the facility did not ensure that all the items on the resident's meal ticket, or appealing options of similar nutritive value were provided on 9/20/2022 and 9/23/2022 and for Resident #42, the facility did not ensure that all the items on the resident's meal ticket, or appealing options of similar nutritive value were provided on 9/23/2022. This was evidenced by: Resident #20: Resident #20 was admitted to the facility with diagnoses of chronic heart failure, [CONDITION(S)], and depression. The Minimum Data Set (MDS - an assessment tool) dated 7/15/2022, documented the resident was cognitively intact, able to make themselves understood, and able to understand others. During an interview on 9/20/2020 at 9:03 AM, Resident #20 stated they did not always receive what was on their meal ticket at mealtime. When this occurred, they were usually told that the kitchen was out of items that were not provided. They stated they typically did not receive items that were on their meal ticket approximately three times a week. Resident #20's meal ticket dated 9/20/2022, documented for one banana to be provided with breakfast. The breakfast meal tray did not include a banana, and no substitution was present. During an interview on 09/22/22 at 9:18 AM, Registered Nurse (RN) #1 stated that they received complaints from residents regarding incorrect items on their meal trays a few times a day, and that it was always different residents each day with issues. When residents were missing items on their ticket, they would call the kitchen. Usually, the kitchen told them that they were out of items that they were calling about. Resident #20's meal ticket dated 9/23/2022, documented for one banana to be provided with breakfast. The breakfast meal tray did not include a banana, and no substitution was present. During an interview on 9/23/2022 at 11:22 AM, the Food Service Director (FSD) stated that when items were missing from meal trays or unavailable on resident meal trays, an alternative item needed to be sent. Resident #20 should have had alternative items sent on their tray for the bananas that were not provided on 9/20/2022 and 9/23/2022. Resident #42: Resident #42 was admitted to the facility with diagnoses of diabetes, [CONDITION(S)], and [CONDITION(S)]. The MDS dated [DATE], documented the resident was moderately cognitively impaired, able to make themselves understood, and able to understand others. Resident #42's meal ticket dated 9/23/2022, documented for corn flakes, moistened with milk, to be provided with breakfast. The breakfast meal tray did not include corn flakes, and no substitution was present. During an observation and interview on 9/23/2022 at 8:55 AM, Resident #42 was eating their breakfast. Their meal ticket documented for corn flakes; there were no corn flakes on the meal tray, and the resident stated they did not receive them. Resident #42 stated they would have liked to have received the corn flakes, but what was on their tray was all that was provided to them for breakfast. During an interview on 9/23/2022 at 11:22 AM, the FSD stated prior to going to the floors, meal trays were spot checked for accuracy. When errors were identified on the meal tickets, they needed to be corrected and all the remaining trays needed to then be checked for accuracy before they were sent to the units. 10 NYCRR 415.14(d)(4)

Based on record review and interviews during an abbreviated survey (Case #NY 033), the facility did not ensure the resident has the right to be free from abuse and neglect for 1 (Resident #1) of 5 residents reviewed for abuse and neglect. Specifically, for Resident #1, who has a loss of sensation in both their hands due to diabetes, the facility did not ensure that staff reviewed the resident's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Subsequently, Resident #1 sustained a thermal injury with partial thickness [CONDITION(S)] to the 2nd, 3rd, and 4th fingers on both hands and the development of gangrene. This resulted in actual harm that is not Immediate Jeopardy. This is evidenced by: Resident #1: Resident #1 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-an assessment tool) dated 4/1/2022, documented the resident was cognitively intact, could be understood, and could understand others. The Policy and Procedure (P&P) titled, Orders dated 10/12/2021, documented that Rehabilitation Therapists would request and receive MD (medical doctor) orders per facility policy prior to initiating treatment. The P&P titled, Hydrocollator Pack dated 10/12/2021, documented a hydrocollator pack was moist heat that could be administered by Physical or Occupational Therapists after careful consideration of the contraindications (reason(s) a person should not receive a particular treatment because it could be harmful) and MD orders have been obtained. The treatment was contraindicated over an area with no sensation. Precautions for use included sensory impairment, for example diabetes, [CONDITION(S)], and [CONDITION(S)] (reduced blood flow). The Comprehensive Care Plan (CCP) for Resident #1 for Impaired Skin Integrity r/t Burn Injury dated 4/28/2022, included documentation for staff to apply treatment per MD orders and to evaluate the wounds for infection, necrosis (death of tissue; can be caused by injury), eschar (a dry, dark scab), and gangrene (type of tissue death caused by a lack of blood supply) and to notify the MD as indicated. The Occupational Therapy (OT) Recertification, Progress Report and Updated Therapy Plan for the certification period of 4/19/2022- 5/15/2022 documented the following treatment approaches: Therapeutic exercises, group therapeutic procedure, OT evaluation; moderate complexity, therapeutic activities, self-care management, community/work reintegration, and wheelchair management training. Review of the MD orders from 3/24/2022- 4/29/2022 did not include an MD order for Occupational Therapy to provide moist heat treatments to Resident #1. A Nurse's Note dated 4/26/2022 at 5:24 PM, documented the resident had heat treatment from OT around 10:00 AM, and has swelling around the right index and middle fingertips. A Nurse's Note dated 4/26/2022 at 9:42 PM, documented the top of the index finger and middle finger of the left hand presented with swelling and blisters. The resident states no pain around the area. There was no documentation of any action taken that evening. A Skin Monitoring Note dated 4/27/2022 at 6:34 AM, documented the resident had an open blister on the index finger of the right hand, another blister on the middle finger, and on the left hand, blisters on the index finger and middle finger. The resident denied pain and stated they had [CONDITION(S)]. The Initial Event Documentation dated 4/27/2022 at 6:27 AM, documented nursing became aware of the blisters at 6:00 AM. It documented the blister on the right index finger had ruptured, causing the resident to lose their fingernail. An MD order dated 4/28/2022, documented to cleanse bilateral fingertip blisters and open areas with normal saline, apply [MEDICATION(S)] cream to all open areas and wrap with a dry sterile dressing two times a day. Apply skin prep to and a dry sterile dressing to intact blisters two times a day. A Narrative assessment dated [DATE] at 10:27 AM, documented the Registered Nurse (RN) was notified by the overnight nurse at 7:00 AM that the resident had blisters on their fingertips and a right index finger blister had ruptured, taking the fingernail with it. The overnight nurse rendered care and the fingers were currently wrapped. At 11:15 AM, the resident's fingers were assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Measurements were obtained of all areas. Blisters were noted on fingers of both hands. Skin prep (protects the skin) was applied to all intact blisters. The resident tolerated well and had no complaints of pain or emotional concerns. The resident had [CONDITION(S)] with no sensation to touch. An untimed physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had heat therapy in which the MD was told warm towels were used for the resident's carpal tunnel. The MD documented the blistered areas did not look infected. Sensation was absent in all of the areas, and also absent in their palms. The MD's impression was right and left second, third, and fourth distal fingers; rule out third degree [CONDITION(S)] with blisters. Right second distal finger de-gloved/denuded (the top layers of skin and tissue were torn away from underlying tissue), and the resident lost the fingernail. The MD ordered [MEDICATION(S)] Cream twice daily to open areas to the blisters. An untimed Encounter Note dated 4/29/2022, documented the resident was seen by the Nurse Practitioner (NP). The resident had full thickness [CONDITION(S)] (2 full layers of skin are destroyed and the burn may go into the innermost layer of skin) on their 2nd and 3rd fingers of the right hand. The resident was started on [MEDICATION(S)] (an antibiotic) 250 milligrams (mg) three times a day for 7 days for the possible start of an infection. No signs of distress were noted. An emergency room (ER) Physician Note dated 5/2/2022 at 10:56 PM, documented the resident presented for evaluation of [CONDITION(S)] to their fingertips. The resident was sent to the ER because of concern about their right index finger and some color changes to the finger. The skin examination documented partial thickness [CONDITION(S)] to the 2nd, 3rd, and 4th fingers on both hands, with the most significant [CONDITION(S)] on the right index and middle fingers. There was loss of the first layer of skin to the right middle finger, and the tip of the index finger appeared necrotic (presence of dead tissue). It documented the resident's wounds were debrided (removal of dead tissue from a wound), particularly the middle right finger. The right index finger did not require debridement. Antibiotic ointment and a dressing were applied to both fingers. The MD documented they had some concern about the viability (ability to heal) of the fingertip of the right index finger. The MD documented they would refer the resident to vascular surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An untimed physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . On MD examination, the resident had necrosis (dead tissue) of the right fingertip and eschar on the 2nd finger which was missing its nail. The right 3rd fingertip had minimal darkened area. The blisters on the left hand were healing and there were no signs or symptoms of infection. The MD documented the resident had right and left 2nd, 3rd, and 4th fingertip [CONDITION(S)]; 2nd (partial thickness- [CONDITION(S)] with blisters), and 3rd (full thickness) degree [CONDITION(S)] with blisters. The right 2nd fingertip was de-gloved/denuded with the nail gone and was debrided in theER on [DATE]. It documented to continue with [MEDICATION(S)] cream and continue the [MEDICATION(S)] for 7 more days. The untimed Vascular Consult Note dated 5/13/2022, documented the resident was receiving occupational therapy (OT) for their carpal tunnel syndrome. The resident was treated with a heating pad and subsequently developed blisters and now had gangrenous (dead tissue) changes of their fingers. The areas appeared without infection. The blood flow appeared normal into the resident's hands, and hopefully the wounds would heal without further issues. The MD documented they assessed gangrene of fingers of both hands. During an interview on 7/14/2022 at 2:41 PM, the Interim Therapy Supervisor (ITS) stated a moist heat pack was used on the resident (on 4/26/2022). Several hours afterward it was discovered the resident had a blistered appearance to their fingertips. The ITS stated the protocol the Physical Therapist (PT) or Occupational Therapist (OT) should follow to implement a treatment would be to complete an assessment of the resident and review their records for contraindications to the treatment. If it was determined the treatment would be beneficial to the resident, an MD order would be obtained, and the treatment would be added to the resident's plan of care. The Physical Therapy Assistants (PTA) and Certified Occupational Therapist Assistants (COTA) did not do that because it was not within their scope of practice. Prior to treatment with moist heat the resident was supposed to be evaluated each time. As long as the MD order was in place, and it was in the resident's plan of care, a COTA could provide moist heat treatments. There was not an MD order for moist heat treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The ITS stated precise communication did not occur between the COTA and the OT about the approach for treatment with a moist heat pack to determine if it was appropriate for the plan of care. During an interview on 7/14/2022 at 3:24 PM, the OT stated they and the COTA had discussed doing splinting and other range of motion (ROM) techniques for increased functionality of the resident's hands for activities of daily living (ADL). The OT stated the COTA did not discuss using moist heat on the resident's hands and there was no MD order to use it. The OT stated prior to using moist heat, they would ensure there were signed MD orders for moist heat treatment prior to use and they would check the hydrocollator (a thermostatically controlled water bath for warming cloth heat packs) to ensure the moist heat packs were at the appropriate temperature. A log was kept next to the hydrocollator to document the temperature checks. The OT stated prior to therapy, the resident's skin should be inspected to ensure there were no wounds or reddened areas before placing the heat pack. When assessing to determine if moist heat was indicated, one of the most important things was to determine if the resident had sensation in the area. A resident would not be able to tell if the heat pack was too hot if they had sensory impairment. The OT stated Resident #1 had impaired sensation due to carpal tunnel syndrome and diabetes, both of which can cause [CONDITION(S)]. The OT stated moist heat was a valid treatment to increase ROM, but not without a signed MD clarification order and not without checking the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 7/15/2022 at 9:47 AM, the COTA stated they used moist heat (on 4/26/2022) with Resident #1 because they had stiffness in their fingers, and they had an ADL goal for getting dressed. The stiffness was limiting their ability to dress themselves. The COTA stated they put 6 layers of toweling between the resident's skin and the moist heat pack. The COTA checked the resident's skin 5 minutes into treatment, and again at the end of treatment and there were no skin issues. The resident voiced no complaints during the treatment. The treatment lasted for 9 minutes. The COTA stated later in the afternoon they took the resident hand splints to try because the resident was complaining of stiffness. They put the splints on the resident's hands to see how they fit and to see if the resident could tolerate wearing them at night. The COTA stated they were focused on fitting the splints and did not notice how the skin on the resident's hands looked. The COTA stated they did not personally check the water temperature in the hydrocollator prior to providing the moist heat treatment to the resident and could not recall if they specifically looked at the hydrocollator temperature log on 4/26/2022. They stated a Rehabilitation Therapy Aide was assigned the task of checking the water temperature in the hydrocollator on a daily basis. The COTA stated an MD order was needed for moist heat treatment. There was not an MD order. They had discussed treatment options with their Supervising OT but did not specifically discuss using moist heat as a treatment. They at the time, they thought the treatment would be beneficial to the resident but should have looked at the OT evaluation prior to treatment to see if moist heat was on the resident's plan of care. The COTA stated that was the mistake they made. They also should have been more diligent about communicating with their Supervising OT. During an interview on 7/15/2022 at 12:31 PM, the resident's MD stated the presentation of the resident's blisters was consistent with [CONDITION(S)]. The resident had carpal tunnel syndrome and it impaired the resident's sensory awareness (ability to feel sensations). The MD stated an infection started and the resident was treated with an antibiotic. The MD stated would be best practice for PT/OT to discuss moist heat therapy with the MD prior to implementing it, especially in a resident with sensory impairment or neurological deficits. During an interview on 7/15/2022 at 1:59 PM, the Medical Director (Med. Dir.) stated the incident was reported to them on this date and they did a brief record review. The Med. Dir. stated the resident was in rehabilitation and sustained [CONDITION(S)] on their fingers from treatment. The Med. Dir. stated all treatments required a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 7/19/2022 at 8:27 AM, the Director of Nursing (DON) stated they covered the clinical aspect of the investigation. The DON stated they looked at possible environmental causes for the resident's [CONDITION(S)], other than the moist heat therapy the resident had received and there were no other environmental causes found to contribute to the [CONDITION(S)]. The DON stated the resident's vascular MD classified the injuries as [CONDITION(S)] because of the resident's carpal tunnel syndrome and [CONDITION(S)] that both resulted in the resident having decreased sensation. The DON stated there was supposed to be an MD order for moist heat therapy, but there was no order specific to OT for moist heat therapy to be used on the resident. During an interview on 7/19/2022 at 2:27 PM, the Administrator stated they saw Resident #1 the next morning (4/27/2022) following the incident. The resident had not realized they had blisters on their fingers until someone pointed it out to them. The Administrator stated they investigated possible environmental causes for the blisters, but none were found. The Administrator stated there was not an MD order for the moist heat therapy and they would have expected there to be one. The Administrator stated the water temperature in the hydrocollator was supposed to be checked daily, but since the (4/26/2022) incident, the water temperature was to be checked three times a day and before each use. The Administrator stated the Rehabilitation Tech or designee was responsible for the hydrocollator water temperature checks and the Therapy Director was responsible for the quality assurance reviews to ensure the hydrocollator checks were being done. The quality assurance reviews were not reported to the Administrator. The Administrator stated there was intensive education provided by Corporate for all therapy staff regarding P&P for use of the hydrocollator. The Administrator stated the hydrocollator was immediately taken out of service following the (4/26/2022) incident, and once it was placed back in service, the water temperature was tested for 14 days before it was put back into use. 10 NYCRR 415.4(b)(1)(i) F600- Past noncompliance Based on the following corrective actions taken, there was sufficient evidence the facility corrected the noncompliance and was in substantial compliance for this specific regulatory requirement at the time of this survey: -Completed a full house audit to determine which residents were receiving moist heat therapy and to determine if orders were in place for the therapy, it was in the resident's plan of care and the hydrocollator temperature log was up to date. -The hydrocollator was pulled from use and inspected by a medical equipment company to ensure there was no malfunction. The hydrocollator passed inspection. -Educated all therapy staff regarding the hydrocollator use, orders, plan of care, supervision of Therapist Assistant, scope of practice, and modes of therapy service delivery. -Developed and implemented a plan to ensure the water temperature in the hydrocollator was checked three times a day and prior to moist heat therapy being provided to a resident.

Based on record review and interviews during an abbreviated survey (Case #NY 662), the facility did not ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, were reported immediately, but not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility for 1 (Resident #7) 3 residents reviewed for abuse and neglect . Specifically, allegations of physician-ordered wound care not being provided to Resident #7's wounds were not reported to the Administrator by staff who were aware of the allegations. This is evidenced by: The Policy and Procedure (P&P) titled Abuse last revised 02/19, documented neglect was defined as the failure to provide services necessary to avoid physical harm, mental anguish or mental illness. Once an allegation of abuse was made, the supervisor who initially received the report must inform the Administrator/Director of Nursing (DON) immediately. Resident #7 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (an assessment tool) dated 4/1/22, documented the resident had mild cognitive impairment. Medical Doctor Orders dated April 2022 for Resident #7 documented: A start date of 1/14/22 documented that every Day shift was to: - The right second toe tip was to be cleansed with Normal Saline (NS), painted with [MEDICATION(S)] (a solution used to treat or prevent infections) and covered with a dry protective dressing (DPD). - The left lateral fifth metatarsal (the long bones in the foot that connect the ankle to the toes) was to be cleansed with NS, [MEDICATION(S)] applied and covered with a DPD. - The right fifth metatarsal was to be cleansed with NS, [MEDICATION(S)] applied and covered with a DPD. - The right third toe tip was to be cleansed with NS, [MEDICATION(S)] applied and covered with a DPD. A start date of 2/19/22 documented that every Day shift was to: - The left lateral mid foot, left lateral heel, and the left lateral malleolus (the bony protuberance on either side of the ankle), were to be cleansed with acetic acid solution, rinsed with NS, skin prep peri-wound (tissue surrounding a wound), [MEDICATION(S)] (wound gel used to treat acute and chronic wounds) was to be applied to the wound base and covered with a 4X4 gauze and a pad and wrapped lightly with Kerlix (a bandage roll providing wicking action, aeration and absorbency). - The right lateral mid foot, right lateral heel, right lateral leg and the right lateral malleolus, were to be cleansed with acetic acid solution, rinsed with NS, skin prep peri-wound, [MEDICATION(S)] was to be applied to the wound base and covered with a 4X4 gauze and abdominal pad and wrap lightly with Kerlix. During an interview on 4/19/22 at 12:20 PM, Resident #7 stated they were supposed to have wound care completed to both feet every day but the wound care was not completed daily. The resident also stated that they had made staff aware when wound care was not provided. During an interview on 4/20/22 at 9:38 AM, Licensed Practical Nurse (LPN) #10 stated Resident #7 had complained to them about wound care not being completed by LPN #8 several times over the previous 2 months. LPN #10 stated they were able to confirm wound care was not completed on several occasions as the resident's dressings were labeled (initialed and dated) as completed two days prior to the times Resident #7 complained. LPN #10 stated they informed LPN Unit Manager (LPNUM) #9 each time this was identified. During an interview on 4/20/22 at 11:00 AM, LPNUM #9 stated they were aware of Resident #7's complaints of wound care not being completed by LPN #8 on several occasions since becoming the unit manager in November 2021. They had been told by several staff members that LPN #8 was signing for wound care and did not complete the task. LPNUM #9 stated they were aware Resident #7's dressings were signed for on more than one occasion by LPN #8 and that the dressings had not been changed. Staff had confirmed dressing changes were not completed the previous day, as the date and initials of a nurse 2 days prior was still in place on the dressings. LPNUM #9 stated they did not notify the DON and Administrator each time wound care/ treatment was signed for but not completed, and that they should have notified them. During an interview on 4/20/22 at 1:55 PM, the DON stated that, after a surveyor interviewed LPNUM #9 , LPNUM #9 told them that wound care was signed for by LPN #8 for Resident #7 and not completed on several occasions. The DON stated they, or the Administrator, should have been made aware that the wound care had been signed for and not completed, but they had not been. 10 NYCRR 415.4(b)(2)

Based on observation and staff interview during an Abbreviated Survey (Case #NY 553) completed on 04/22/22, the facility failed to provide adequate supervision for 1 (Resident #2) of 10 residents reviewed for accidents. Specifically, after Resident #2, who had severely impaired cognition, exited the facility through a delayed egress door on 03/31/22 at 2:34 AM, facility staff did not perform a headcount or [MEDICATION(S)] to identify if residents were missing after the delayed egress alarm sounded. This was evidenced by: Resident #2 was admitted to the facility with diagnoses of [CONDITION(S)], dementia and anxiety disorder. The Minimum Data Set (MDS, an assessment tool) dated 3/08/2022, documented the resident could sometimes be understood and could sometimes understand others and had severely impaired cognition. The facility's Elopement-Missing Resident Policy dated, 01/2020 documented that staff were to initiate a Code Gray at the time a resident was determined to be missing. The policy did not include guidelines for staff to follow when the security doors alarmed. The facility's Procedure to Follow When Door Alarm is Activated Policy documented staff were not to silence the alarm until staff ensured that a resident has not eloped The policy did not document the procedure for determining if a resident had eloped. The Comprehensive Care Plan (CCP) initiated on 1/06/2022, documented Resident #2 was at risk for wandering related to cognitive impairment/decline, a desire to leave the facility unattended, exit seeking behavior, and wandering behavior. The CCP also documented the resident was risk for elopement. Interventions included: Staff were to distract the resident from wandering by offering pleasant diversions, attempt to identify pattern to target interventions, initiate psychiatric evaluation, and provide a wander guard. Delayed egress hardware prevents a door from being opened from the egress side for a period of 15 seconds. This type of device is used in nursing homes to prevent elopement and maintain a safe exit discharge. An Elopement Risk Evaluation dated 1/11/2022, documented Resident #2 was at a high risk for wandering related to being fully ambulatory, aimless wanderings, voiced desire to leave, and previous attempts to elope. The facility documented the resident was assigned a wander guard to prevent elopement. An elopement investigation dated 04/04/2022, documented Resident #2 entered the therapy room through a C-Unit hallway door that housekeeping staff left unlocked, and exited the facility at 03/31/2022 at 2:34 AM through the delayed egress door in the room. The alarm sounded and nursing staff responded to, and silenced, the alarm after not observing activity by the therapy room door. The staff member did not determine if a resident was missing or initiate a resident head count before silencing the alarm. At 2:51 AM Resident #2 triggered the alarm on the outside door of the B-Unit and nursing staff identified that Resident #2 was trying to re-enter the facility. During an interview on 04/19/2022 at 1:30 PM the Director of Maintenance stated that the doors to the outside of the facility in the therapy room and at the end of each resident unit were delayed egress doors, and alarmed when the panic bar was engaged. After the panic bar was engaged for 15 seconds, the locking mechanism released. Once the alarm sounded, staff had to manually turn off the alarm by entering a code into a key pad. During an interview on 04/21/2022 at 2:00 PM the DON stated that the security door policy or the elopement policy did not include a procedure for how staff should response when a delayed egress door was alarmed, and the in-service that was given to staff after Resident #2's elopement did not include a staff response for ensuring that a resident did not elope. Additionally, the DON stated that the facility did not update the elopement policy after the investigation of the Resident #2's elopement. During an interview on 04/21/2022 at 11:35 AM the Administrator stated Registered Nurse #1 should have conducted a head count after the delayed egress door alarm sounded in the therapy room. 10 NYCRR 483.25(d)

Based on record review and interviews during an abbreviated survey (NY 498), the facility did not ensure residents were seen by a physician at least every 30 days for the first 90 days after admission for 1 (Resident #1) of 8 residents reviewed. Specifically, Resident #129 was not seen by the physician until 64 days after admission to the facility. This is evidenced by: Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (an assessment tool) dated 7/7/2021, documented the resident had moderate cognitive impairment, could be understood, and could usually understand others. The Policy and Procedure titled Physician Visits dated 5/2019, documented the physician was to visit their residents at least once every 30 days for the first 90 days following the resident's admission. A Progress Note dated 9/2/2021 at 4:48 PM, documented the physician saw Resident #1 because the resident reported they felt like they had a stroke 2 days prior and felt themselves going out. The MD documented the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 4/13/2022 at 2:40 PM the Director of Nursing (DON) stated their record keeping system saved anything documented into the Electronic Medical Record (EMR). The DON stated they spoke with the liaison from the medical provider contract company to ask them to follow up on obtaining Resident #1's MD notes, and when the liaison called back, they stated they were unable to locate any documentation other than what the facility already had. The DON stated they were not able to locate documentation for the resident's admission history and physical or an MD visit for the resident until the Progress Note dated 9/2/2021. During an interview on 4/21/2022 at 4:26 PM, the MD stated they did not do a History and Physical for Resident #1. The MD stated they had seen the resident for an acute illness but could not recall the date. 10 NYCRR 415.15(b)(2)(ii)

Based on record review and interviews during an abbreviated survey (Case # NY 561), the facility did not ensure a resident's right to be free from abuse for 1 (Resident #1) of 7 residents reviewed for abuse. Specifically, the facility did not ensure Resident #1, who had severe cognitive impairment, was free from sexual abuse when she was assaulted by Resident #2 who had moderately impaired cognition. Due to the resident's severe cognitive impairment and inability to express her feelings, it was determined that actual psychosocial harm occurred as a result of the assault, using the reasonable person concept referenced in the Centers for Medicare and Medicaid Services Psychosocial Outcome Severity Guide. This is evidenced by: The Policy and Procedure (P&P) titled Abuse Policy last revised 1/2019, documented the facility prohibited mistreatment, neglect, and abuse of residents. Abuse could include verbal, mental, sexual, emotional or physical abuse. The P&P documented sexual abuse was defined as including humiliation, harassment, coercion, or assault (an intentional act by one person that creates an apprehension in another of an offensive contact). Resident #1: Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - an assessment tool) dated 8/17/18, documented the resident sometimes made themself understood, was sometimes understood others, and his/her cognitive skills for daily decision making were severely impaired. The Comprehensive Care Plan (CCP) for Impaired Cognitive Function, initiated on 7/4/17, documented Resident #1 had impaired thought processes related to [MEDICAL CONDITION]. The CCP for Communication Problem, last reviewed 6/5/18, documented Resident #1 had difficulty communicating with others due to dementia. Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. The MDS dated [DATE], documented Resident #2 had moderately impaired cognition, could understand and could be understood. An Incident Report dated 10/7/18 at 8:00 PM, documented two Certified Nurse Aide's (CNA #s 1 and 2) saw Resident #2 with his/her hand down the pajama shirt of Resident #1, rubbing the right breast and between the legs of Resident #1. The Incident Report documented Resident #1 did not have upper body undergarments on and that Resident #1 was unable to respond to a statement regarding the incident. Additionally, the facility concluded on the Incident Report that Resident #1 did not consent to being touched by Resident #2. A written statement dated 10/7/18 by CNA #1, documented the CNA observed Resident #2 was sitting next to Resident #1 with his/her hand in Resident #1's shirt and rubbing Resident #1's breast. A Nursing Clinical Evaluation Progress note dated 10/7/19 at 9:20 PM by Registered Nurse Supervisor (RNS) #1, documented 2 CNA's reported that Resident #2 had his hand down the pajama shirt of Resident #1, was rubbing the right breast and between the legs of Resident #1 while Resident #1 was sitting quietly in a reclining chair. A Social Services Note dated 10/9/19 at 8:26 AM by the Director of Social Work (SW), documented Resident #1 was not able to follow the content of the interview conversation and could not recall the incident. The Facility Investigative Review Form dated 10/9/18, documented investigative findings that the hand of Resident #2 was in the shirt and between the legs of Resident #1 and that Resident #1 was unable to comprehend any of the questions from the Director of Social Services. Resident #2 recalled the incident and immediately stated, I'm sorry, it was all my fault, and acknowledged the behavior was inappropriate and wrong. Resident #2 stated that he/she would never do it again. During an interview on 11/5/19 at 1:00 pm, SW stated Resident #2 had the cognitive ability to understand what he/she had done, and that Resident #2 was embarrassed after the incident. Resident #1 had extensive cognitive impairment since admission to the facility, and did not appear to recall the incident. During an interview on 11/5/19 at 2:25 PM, RNS #1 stated Resident #1 was not able to speak for his/herself and was unable to be interviewed due to severe cognitive impairment. RNS #1 stated that she felt a reasonable person would have been upset by the incident. During an interview on 10/6/19 at 2:00 PM, the Director of Nursing stated Resident #1 was unable to consent permission for Resident #2 to rub his/her breast due to severely impaired cognition and was therefore touched inappropriately. During an interview on 11/7/19 at 12:30 PM, CNA #2 stated she observed Resident #2's hand under the shirt of, and rubbing Resident #1's breast and in the area between the thighs. CNA #2 stated Resident #2 immediately apologized, and that Resident #1 did not have the ability to call out for help due to cognitive impairment. During an interview on 11/7/19 at 4:50 PM, Resident #1's representative stated that, prior to developing cognitive impairment from [MEDICAL CONDITION], Resident #1 would have been very upset or even horrified of the incident with Resident #2. 10 NYCRR 415.4 (b)(1)(i)

Based on observation, record review, and resident and staff interview during an extended recertification survey, the facility failed to ensure that all allegations of abuse neglect and mistreatment were reported, and all incidents were thoroughly investigated, to protect residents from abuse, for five (5) (#s 15, 18, 37, 39, and #43) of twelve (12) residents reviewed for abuse and neglect. Specifically, for Resident #15, the facility failed to ensure that an allegation of sexual abuse was investigated and that the resident was protected from further abuse. For Resident #37 the facility did not ensure that an alleged sexual abuse by another resident, was reported immediately to the appropriate person in the facility, and for Resident #43, the facility did not report to the New York State Department of Health, an incident involving abuse, neglect, and mistreatment by a Certified Nursing Assistant (CNA). Additionally, the facility did not conduct the minimum required background checks prior to hiring employees. Specifically, the State nurse aid registry check and a NY State Department of Education Office of the Professions (OP) check was not conducted for two (2) of four (4) new employees reviewed. This resulted in no actual harm with the potential for more that minimal harm that is Immediate Jeopardy and substandard Quality of Care. This was evidenced by: Resident #15: The facility failed to ensure that an allegation of sexual abuse was investigated and the resident protected from further abuse. The resident was admitted to the nursing home on 11/6/12 with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident as having moderately impaired cognitive skills for daily decision making and long and short-term memory deficits. It documented that the resident was usually understood and was usually understood by others. During an observation on 11/6/14 at 3:30 pm, Resident #15 was ambulating in the hall near the unit dining area. Resident #20 approached Resident #15 in his wheelchair, grabbed her around the waist and pulled her into his lap. The resident was still holding her walker and yelling, "No stop" and trying to wiggle out of Resident #20's grasp when staff intervened and separated the residents. As staff were separating the residents, Resident # 20 was yelling, "I want her on my lap". There was no documented evidence in the resident # 15's medial record of any interactions between her and Resident #20 until the event witnessed by the surveyor on 11/6/14 at 3:30 pm. There was no documented evidence of an incident report for any occurrence between Resident # 15 and Resident # 20 prior to 11/6/14. There was no documented evidence in the Comprehensive Care Plan of resident # 15 of interventions to protect this resident, who was a victim of sexual abuse, from unwanted sexual advances. During an interview on 11/6/14 at 4:00 pm Registered Nurse Manager (RNM) #1 who did not know that surveyor witnessed the interaction between Residents #20 and #15, stated that, at 3:30 pm Resident # 20 attempted to pull Resident #15 into his lap but staff intervened before any physical contact occurred between the residents. When surveyor advised RNM #1 that the incident was witnessed by the surveyor and there was not only, contact, but that staff had to release the resident from the grasp of Resident #20, RNM #1 stated, "Obviously I did not see that", and that he (RNM # 1) was unaware of any similar behaviors by Resident # 20. During an interview on 11/7/14 at 1:15 pm, CNA #11 stated that while she was at work during the 3:00 - 11:00 pm shift sometime this week, she heard from a CNA and a nurse that Resident #20 had tried to go up Resident #15's night gown when the resident was walking in the hall. During an interview on 11/8/14 at 10:45 am RNS #1 stated that she was not aware of any incidents with any resident except Resident #108, and that resident was moved to a different unit. During an interview on 11/8/14 at 12.00 pm, CNA #2 stated that she had resident # 15 on her assignment on 11/6/14 during the 3:00 pm - 11:00 pm shift. CNA #2 stated that when she returned from break that evening she was told by the nurse that Resident #20 was trying to put his hand up the resident # 15's night gown when she was in the hall. During an interview on 11/8/14 at 2:30 pm Licensed Practical Nurse (LPN) #3 stated that on 11/5/14 he responded to residents yelling, "stop, stop, help". LPN #3 stated that the resident was not saying anything but other residents were yelling , stating that Resident #20 put his hands up Resident # 15's night gown. LPN #3 stated that he reported to RNS (registered nurse supervisor) #1 and about one hour after the nurse witnessed RNS #1 call the Director of Nursing and report the incident. LPN #3 stated that he did not document the incident or start an incident report because, "he did not know if he should". LPN #3 further stated that Resident #20 was not placed on 1:1 or placed in an area to be monitored and RNS #1 gave no direction on what to do. Resident #37: The facility did not ensure that an alleged incident involving mistreatment and/or abuse, was reported immediately to the administrator. This resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE], documented that the resident was cognitively intact, and was able to make herself understood, and able to understand others. During an interview on 11/7/14 at 9:10 am, Licensed Practical Nurse (LPN) #1 stated that she had heard that Resident #20 had climbed into bed with Resident #39 and had inappropriately touched Resident #37. During an interview on 11/7/14 at 9:40 am, RNM #1 stated that he was "extremely concerned" with Resident #20's behaviors toward other residents, and had reported his concerns to the Director of Nursing (DON). He also stated that he was not aware that Resident #20 had been in this resident's bed, and if staff knew about that, they should have completed and Incident and Accident Report, and reported it to a supervisor. During an interview on 11/7/14 at 9:45 am, Resident #37 stated that one night recently, she awoke in the middle of the night and Resident #20 was lying on top of her. She could not reach her call bell, so she began yelling and rolled over knocking Resident #20 to the floor. Resident #20 went to her roommate's bed (Resident #39). Resident #39 began yelling and a staff member removed Resident #20 from the room. During an interview on 11/7/14 at 9:45 am, Resident #39 stated that Resident #20 attempted to get in bed with her, so she yelled and a staff member removed him from the room. During an interview on 11/7/14 at 10:15 am, the DON stated that she was not aware of an allegation that Resident #20 had been in Resident # 37's bed. If staff knew about that allegation, they should have completed and Incident and Accident Report, and reported it to a supervisor. She also stated that she was aware that Resident #20 had frequent inappropriate behaviors towards staff, but was not aware of resident-to-resident incidents involving Resident #20. During an interview on 11/7/14 at 2:07 pm, the Administrator stated that she was aware that Resident #20 had frequent inappropriate behaviors towards staff, but was not aware of resident-to-resident incidents involving Resident #20. She also stated that staff should have completed an Incident and Accident Report on any allegations of abuse or mistreatment. During an interview on 11/7/14 at 2:20 pm, LPN #6 stated that staff were in the hallway talking to Resident #20 about his inappropriate behavior. Resident #37 was present and stated that a couple weeks prior, Resident #20 had climbed into bed with her. LPN #6 stated that she, "did not take it seriously, because it was the first time she heard that". She also stated that she had previously removed Resident #20 from the rooms of Residents #15 and #21. During an interview on 11/7/14 at 3:15 pm, CNA #10 stated that she had heard that Resident #20 had gotten into this resident's room. Resident #37 told her she did not want Resident #20 in her room again. During an interview on 11/7/14 at 3:45 pm, LPN #2 stated that on 10/5/14, Resident #20 was in this resident's room, attempting to kiss a female resident in that room. He removed Resident #20 from that room and escorted him back to his room. During an interview on 11/8/14 at 11:10 am, CNA #1 stated that approximately one month ago, during change of shift rounds with the night CNAs, they reported that Resident #20 had been found in Resident #37's bed. She stated that a nurse must have been aware because that same morning a Velcro banner was placed on the door to Resident #37's room. She stated that the Velcro banners were placed by a nurse or a nurse manager. She also stated that Resident #37 was "frantic" about Resident #20 being in her bed. Additionally, at that same time, Resident #39 told her that Resident #20 tried to get in her bed with her, and she screamed. CNA #1 stated that she had reported these allegations to LPN #6, but no one got back to her, so she did not know if anything had been done about it. During an interview on 11/8/14 at 2:30 pm, LPN #3 stated that,"weeks ago," he heard Resident #37 telling another resident that Resident #20 had climbed into bed with her. He stated that he did not report this because Resident #20 already had an alarmed banner on his door. He also stated that, at night, Resident #20 went room-to-room, "being inappropriate." The Policy and Procedure for Abuse/Behavior dated 7/2013, documented that any person, with knowledge of or reason to believe that a resident had been a victim of abuse or mistreatment, was to immediately report to their immediate manager/supervisor, and that the manager/supervisor was to report to the DON and/or the Director of Social Work. Resident #43: The facility did not report an incident involving abuse, neglect, and/or mistreatment to the New York State Department of Health (DOH) within 5 working days of the incident. This resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE], documented that the resident had moderately impaired cognition, was able to understand others and was able to make herself understood. A Resident/Family Grievance Report dated 9/2/14, documented that a staff member removed the resident's wheelchair from her bedside, and moved it across the room. When the resident needed to use the toilet, the staff member told her that she had, "been going all night." Another Resident/Family Grievance Report dated 9/2/14, and attached to the above noted Report, documented that a staff member was mean and rude to the resident, and that she, "pees too much," and told the resident she was taking her to the bathroom. The resident told the staff member that she did not have to go, but the resident was taken anyway. After returning to bed, the staff member placed the wheelchair at the end of the bed so the resident could not reach it, and told the resident that if she fell it would be her own fault. The staff member also told the resident that her roommate wanted to move because she was noisy and kept her up. A written statement attached to the Grievance Report, signed by evening Registered Nurse Supervisor (RNS) #1, documented that on that evening, she heard Certified Nursing Assistant (CNA) #12 complain that this resident was in and out of the bathroom, "dozens of times." The section of the Resident/Family Grievance Report dated 9/2/14, entitled "Resolution," documented that CNA#12 had been terminated. The Report was signed by the DON and the Administrator. During an interview on 11/5/14 at 3:20 pm, the DON reviewed the Resident/Family Grievance Report dated 9/2/14, and stated that she had not seen the second Report or the attached statements. She stated that this was verbal abuse and it was not reported to the DOH because she did not know the extent of the incident. The DON also stated that the Social Worker must have gathered the additional information, and did not show it to her. During an interview on 11/6/14 at 10:47 am, the Director of Social Work stated that Licensed Practical Nurse Manager (LPNM) #1 took the resident's daughter's statement, and RNS #1's statement, then informed her of the events. She stated that this was a very serious situation, so she immediately reported it to the DON. The determination was that CNA #12 grew tired of assisting the resident to the toilet and took the resident's wheel chair away. She stated that she did not recognize this as abuse because abuse was physical, such as hitting or pushing. During an interview on 11/6/14 at 10:57 am, LPNM #1 stated that she heard about the incident on the morning of 9/2/14, and that it had been discovered that this was an agency CNA. LPNM #1 stated that the CNA's treatment of [REDACTED]. The Policy and Procedure for Abuse/Behavior dated 7/2013, documented that psychological or emotional abuse included tactics such as harassment, insults and intimidation. All staff were to report incidents of resident abuse, or suspected abuse to their immediate manager/supervisor. The Director of Nursing and/or the Director of Social Work were to report any alleged or suspected case of abuse/mistreatment to the Department of Health. Finding #1: The facility did not conduct the minimum required background checks prior to hiring employees. The personnel file for Employee #1, an LPN hired on 07/31/2014, was reviewed on 11/04/2014. This record review revealed that the facility had conducted both a Nurse Aid Registry (NAR) check and an OP check for this employee on 09/01/2014, 32 days after hiring. The personnel file for Employee #2, a Occupational Therapy Assistant hired on 07/22/2014, was reviewed on 11/04/2014. This record review revealed that the facility had conducted an OP check for this employee on 07/23/2014, the day after hiring. The Human Resources Director stated in an interview conducted on 11/05/2014 at 9:00 AM that Employee #1 worked here before, and the Nurse's Aide Registry (NAR) check and OP check for Employee #1 was conducted on 09/01/2014, after hiring, but before her first day at work on 09/08/2014. Additionally, the Human Resources Director stated that Employee #2 had worked with residents for one day before knowing that she was employed. The facility checklist Hire Policy: All Applicants Will Complete All Requirements Listed was reviewed on 11/05/2014. Under the section Pre-Employment Requirements (H.R.) is an item for " Verification of License-Online." The facility did not have a written policy specific to NAR checks or OP checks. 10NYCRR 415.4(b)(1)(ii)

Based on record review, resident and staff interview during an extended recertification survey, the facility did not ensure that each resident received adequate supervision for two (2) ( #'s 5 & 20 ) of seven (7) residents reviewed for a need for increased supervision. Specifically, the facility failed to ensure Resident #5 received adequate supervision to ensure that the oxygen tank did not run empty. Additionally,the facility failed to ensure Resident #20 received adequate supervision after displaying inappropriate sexual behavior toward female residents. This resulted in Immediate Jeopardy to resident health and safety and Substandard Quality of Care. This was evidenced by: Resident # 20 The resident was admitted to the nursing home on 9/5/14 with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident as having moderately impaired cognitive skills for daily decision making and short and long term memory deficits. It documented that the resident understood and was usually understood by others. A Comprehensive Care Plan dated for "behavioral symptoms" dated 9/5/14 documented that the resident was grabbing at staff, asking for sex, and masturbating. On 9/8/14 it documented that the resident was not to be left alone with other residents, and on 9/11/14 it documented that the resident was to have an alarmed stop banner at his door. During an observation on 11/6/14 at approximately 11:30 am Resident #20 approached the state surveyor who was sitting in the common area across from the nursing station. Resident #20 rubbed the surveyor's upper thigh and lateral buttocks and asked, "Are you wearing panties." An Activity Aide (AA) who was present for the interaction, stated, "this is what we have to deal with all the time", but did not immediately remove the resident from the interaction with the surveyor. When the AA did remove the resident she just took him away from the surveyor but left him in the common area. During an observation on 11/6/14 at 3:30 pm, the resident was ambulating in the hall near the unit dining area when the resident grabbed Resident #15 around the waist and pulled her into his lap. Resident #15 was still holding onto her walker and yelling, "No stop" and trying to wiggle out of Resident #20's grasp, when staff intervened and separated the residents. As staff were separating the resident's, Resident #20 was yelling, "I want her on my lap." During an observation on 11/6/14 at 4:00 pm the resident was in his room standing next to his bed with the privacy curtain pulled around the resident's bed. There was no bed or chair alarm sounding and the the alarmed Velcro banner was not across his doorway. The resident moved the curtain out of his way and was ambulating independently toward the door to his room. He was holding onto his groin and speaking inappropriately staff had not intervened until the resident came out into the hall. An admission progress note dated 9/5/14 at 11:25 am documented that the hospital nurse stated that the resident was "touchy, feely". It documented that they were advised that the resident would grope at and attempt to kiss the staff. A progress note dated 9/5/14 at 2:38 pm documented that the resident was currently attempting to grab staff, and stated that he wanted "sex" and was masturbating. It documented that the resident undressed and refused to get redressed. A progress note dated 9/8/14 at 6:08 am documented that the resident was wheeling up and down the halls in his wheel chair. It documented that the resident was found up and walking in the hall and attempting to go into other residents' rooms. A progress note dated 9/24/14 at 4:54 pm the Social Worker documented that she discussed the need to change the resident's room due to room mate issues. There was no further information. A progress note dated 10/5/14 at 2:00 am by the Licensed Practical Nurse (LPN) #2 documented that resident wandering in another female resident's room and found trying to kiss her. An unsigned physician rounding worksheet dated 10/9/14 documented that the resident was having very sexualized behaviors toward other female patients and staff. A progress note dated 10/11/14 at 10:09 pm by LPN #3 documented that the resident was moving around in his wheelchair all over the unit and to other wings. It documented that he was caught going into other rooms and was redirected back out into the hall. A progress note dated 10/24/14 at 1:56 pm the Registered Nurse Manager (RNM) documented ongoing incidents of the resident making sexualized comments to staff in addition, one potential episode of similar activity towards another resident. He was placed in a stationary chair with a Velcro belt to reduce the risk of an incident. A progress note dated 10/26/14 at 3:06 pm the RNM documented that a meeting was held with the family to discuss the resident's sexual behaviors and that he had tried to hug a female resident. A progress note dated 11/1/14 at 9:34 pm documented that the resident had increased sexually aggressive verbal and physical behaviors toward staff. It documented that the resident slapped staff who had tried to redirect him away from other resident's rooms. A progress note dated 11/4/14 at 2:33 pm documented that the resident continued to make sexually inappropriate gestures and verbal suggestions to female staff. It documented that he spent much of the day in his wheelchair self propelled in hall. During interviews on 11/7/14 CNA #'s 1, 2, 3, 8, 9, 10, and #11, all stated that they were aware of sexually inappropriate behaviors by the resident directed to female residents and that the resident was moved from the A unit to the B unit after inappropriately touching a family member of his roommate. During an interview on 11/7/14 at approximately 10:40 am RNM #1 stated he did not recall the incident on 10/5/14 and he did not recall telephoning LPN #2 to get information about the incident. RNM #1 stated that he was aware of an incident with resident # 108 but that she sought Resident #20 out not the other way around. Additionally he stated that he thought there may have been an incident with him trying to get in Resident #16's room. During an interview on 11/7/14 at 11:15 am the DON stated that she did not know which resident, the note of 10/5/14 at 2:00 am referred to. The DON stated that there was no follow up because there was no actual contact, and that "the nurse must have intervened." During an interview on 11/7/14 at 1:15 pm the AA stated that the resident was sexually inappropriate but was old and did not know what he was doing. During an interview on 11/7/14 at 3:30 pm LPN #4 stated that she was told by Resident #37 that the resident climbed into her bed. LPN #4 stated that the resident said it in front of numerous staff members at the nursing station including the Registered Nursing Supervisor (RNS) and she thought the RNS took care of it. During an interview on 11/7/14 at 3:45 pm, Agency LPN #2, who on 10/5/14 at 2:00 am, documented that Resident #20 wandered in another female resident's room and found trying to kiss her, stated that he did not recall the resident's name that he was referring to in the note. LPN #2 stated that he responded to the female resident yelling and took the resident # 20 from her room, and put him back in his room. LPN #2 further stated that he was contacted the next day by the RNM #1 asking him questions about what had occurred. During an interview on 11/8/14 at 10:05 am the RNM #1 stated that he was the person who wrote the physician rounding worksheet dated 10/9/14, that documented that Resident # 20 was having very sexualized behaviors toward other female patients and staff, but did not recall which female resident's that the note referred to. During an interview on 11/8/14 at 2:30 pm LPN #3 stated that the resident was very active and liked to roam around the facility. LPN #3 stated that the resident had an alarm on his bed and chair because he liked to get up and walk. LPN #3 stated that on 11/6/14 he responded to residents in the common area yelling, "stop, stop, help". LPN #3 stated that Resident #15 was not saying anything but the other residents were yelling, stating that Resident #20 put his hands up Resident #15's night gown. LPN #3 stated that he reported to RNS #1, but she gave no direction as to what to do. LPN #3 stated that nothing different was done with Resident #20; he was not placed on 1:1 or placed in an area to be closely monitored. Resident #5 The facility did not ensure this resident received adequate supervision to ensure that the oxygen tank did not run empty. The undated Policy and Procedure (P&P) for Oxygen Use documented that residents who used oxygen were to be monitored by the unit nurse to determine effectiveness of the treatment, and use was to be documented on the Medication Administration Record. This resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE], documented that the resident had moderately impaired cognition, was able to understand others and was able to make herself understood. A physician's orders [REDACTED]. The Medication Administration Record dated 11/2014, documented that the resident was to continuously receive 3 liters of oxygen by a nasal cannula. It documented oxygen saturation values once per shift from 11/1/14 - 11/6/14 and that the oxygen saturation levels ranged between 93% - 98%. During an observation on 11/5/14 at 1:30 pm, this resident was in her wheelchair in the unit hallway. The nasal cannula was in her nose. The oxygen tank was in the "on" position, and the volume meter read empty. The resident did not appear to be in respiratory distress. An LPN came to the resident, then retrieved a new oxygen tank. During an interview on 11/5/14 at 1:30 pm, this resident stated that she was not getting oxygen in her nose at that time. She stated that she was slightly short of breath, but did not feel she was in distress. During an observation on 11/7/14 at 8:10 am the resident was wheeling herself from the direction of the main dining room. When she reached the nurses station, she stated to the surveyor, "I wheeled myself all that way." An empty portable oxygen tank was noted on the back of the resident's chair, and the nasal cannula was out of the resident's nose. During an interview on 11/7/14 at 7:20 am, the Director of Nursing (DON) stated that at that time, the facility did not have a systematic way to ensure oxygen tanks did not run empty. She stated that staff knew to keep an eye on the tanks, and that the tanks were to be checked before the resident left the facility for an appointment. During an interview on 11/7/14 at 8:10 am, the Food Service Director (FSD), who was standing in the vicinity, stated that the resident often removed her oxygen. The FSD then walked away toward the unit dining area. During an observation on 11/7/14 at 9:00 am, this resident was in her wheel chair in the unit hallway. The oxygen tank was empty and LPN #6 replaced the resident's nasal cannula, and stated, "Oh, your tank is empty". The LPN then replaced the tank. During an interview on 11/7/14 at 11:35 am, an LPN stated that this resident's oxygen tank was, "quite often empty". When the tank ran empty, the resident was often short of breath, sweaty and red in the face. Finding #1 On 11/4/14 at 9:30 am upon entering the facility an inspection of Unit A revealed the soiled utility room door was unlocked and was able to be open without using the door lock security device mechanism. The unlocked soiled utility room contained an open unlocked cabinet which contained a container of germicide (Dial a Therm) with the warning of keep out of the reach of children, multiple plastic ties in a plastic bag, 2 containers of liquid cleaner , a glass vase with multiple batteries in the vase. On the floor of the soiled utility room was a red plastic sharps container approximately three quarters full with multiple razors. On 11/05/14 at 1:00 pm the soiled utility door was observed unlocked and the door was able to be opened without the use of the door lock security device mechanism. On 11/06/14 at 8:20 am the soiled utility door was obeserved unlocked and was able to be opened without the use of the door lock security device mechanism. On 11/07/14 at 8:45 am the soiled utility door was observed unlocked and was able to be opened without the use of the door lock security device mechanism. During an interview on 11/07/14 at 8:50 am the maintenance director stated that the soiled utility room door should be locked and not just opened without using the door lock security device mechanism. During an interview at 11/07/14 at 9:15 am a CNA when asked if the soiled utility room door should be locked she said that this door should be locked and should not open without the door lock security device mechanism being used. During an interview at 11/07/14 at 9:20 am the LPN was asked to open the soiled utility room door and she was able to do so without using the door lock security device mechanism. The LPN stated that this door should be locked. 10 NYCRR 415.12(h)(2)

Based on interview and record review during an extended recertification survey, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for five (#15, 18, 20, 37, 39) of twelve (12) resident's reviewed for abuse, neglect, and mistreatment. Specifically, a male resident with moderate cognitive impairment, had inappopriate sexual behaviors directed toward female residents since 9/2014. These incidents were reported to nursing staff, but were not identified as sexual abuse. Investigations did not occur, effective care plan interventions were not put into place, and increased supervision was not provided. Female residents expressed fear and safety concerns. This resulted in Immediate Jeopardy to resident health and safety. This was evidenced by: Refer to Resident Behavior and Facility Practices - F 225 Investigate/Report Allegations/individuals, Scope and Severity - K Refer to Quality of Care- F 323, Free of Accident Hazards/Supervision/Devices, Scope and Severity- K During an interview on 11/7/14 at 10:15 am, the Director of Nursing (DON) stated that she was not aware of an allegation that Resident #20 had been in other residents beds. If staff knew about that allegation, they should have completed and Incident and Accident Report, and reported it to a supervisor. She also stated that she was aware that Resident #20 had frequent inappropriate behaviors towards staff, but was not aware of resident-to-resident incidents involving Resident #20. During an interview on 11/7/14 at 2:07 pm, the Administrator stated that she was aware that Resident #20 had frequent inappropriate behaviors towards staff, but was not aware of resident-to-resident incidents involving Resident #20. She also stated that staff should have completed an Incident and Accident Report on any allegations of abuse or mistreatment, and that the nurse manager, and the DON should have been notified. During an interview on 11/7/14 at 4:20 pm the Medical Doctor (MD) stated that he was aware of some inappropriate behaviors between Resident #20 and Resident #108, prior to Resident #108 being moved to another unit. The MD stated, however, that he was not aware that Resident #108 was sitting in the lap of Resident #20, or inappropriate touching occurred, but he should have been. He was also not aware of any incidents involving other female residents. Additionally the MD stated that there were enough incidences to say that Resident #20's behavior was a pattern. 10NYCRR415.26

Based on record review and staff interviews during an abbreviated survey (Case # NY 313), the facility did not ensure that the physician was immediately informed when there was a significant change in the resident's physical status for 1 (# 1) of 2 residents reviewed. Specifically, the facility did not to notify the physician when Resident #1 experienced increased heart rates. The resident had a [MEDICAL CONDITION] and expired. This resulted in actual harm that was not immediate jeopardy. This is evidenced by: Resident #1: The resident was readmitted to the facility on [DATE] went out to the hospital for a right total hip replacement in ,[DATE] and returned to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident with no cognitive impairment. A progress noted dated [DATE] at 2:40pm by the nurse documented the resident's admission pulse as 85 beats per minute (b/m) and a note at 10:38pm the pulse was documented as 83 b/m. A problem focused progress noted dated [DATE] at 3:30pm by the physician documented under chief complaints that the resident was being seen because the nurse was concerned about wound drainage from the hip incision. Under impression and problem list it documented episodic low blood pressure which is symptomatic. A physician order [REDACTED]. A "clinical monitoring detail report" for radial pulse on [DATE] documented that at 8:22am the resident had a pulse rate of 136 b/m, at 11:40am 126 b/m, at 5:16pm 142 b/m, and 138 b/m. There was no documented evidence in the medical record that these pulse rates were reported to the physician. A progress note and 24 hour report dated [DATE] at 2:06pm by the Licensed Practical Nurse ( LPN) documented that the resident complained of shortness of breath (SOB) at 7:05am and improvement was noted after nebulizer treatment and documented the resident ' s oxygen saturation at 91% It documented pulse rates of 126b/m and 142 b/m. There was no documented evidence that the pulse rate or the resident ' s SOB was reported to the physician or that a Registered Nurse (RN) assessment took place. A progress noted dated [DATE] at 4:36pm by an agency LPN documented a pulse rate of 142 b/m and that she would continue to monitor. There was no documented evidence that the increased pulse was reported to the MD. The next progress note and 24hour report entry was on [DATE] at 4:36am by the RN supervisor which documented that the resident was found by the LPN at 4:00am without respirations and a code blue and cardio pulmononary resuscitation was initiated. During an interview on [DATE] at 10:45am the 7:00am - 3:00pm LPN stated that she did not recall if she reported the resident ' s increased pulse rates that occurred during her shift to the doctor. During an interview on [DATE] at 4:30pm the agency LPN stated that she did not notify the physician of the elevated pulse. During an interview on [DATE] at approximately 10:30 am the RN supervisor stated she was not aware that the resident had been having increased pulse rates on [DATE] prior to his [MEDICAL CONDITION]. During an interview on [DATE] at 9:30am the Medical Director stated that he was not aware that the resident had a spike in his pulses on [DATE] and that staff should have contacted the physician with this "acute" change in condition. During an interview on [DATE] at 10:30am the resident ' s physician stated that the pulse spike was an acute change in condition and that after reviewing the vital signs that the resident was having spikes in his pulse starting on [DATE] and staff should have known to report this. He further stated that he was not aware of the resident ' s change in condition and was not on call but that the physician should have been notified of spike in the pulses and an assessment should have been done. During an interview on [DATE] at 4:30pm the agency LPN stated that she did not notify the physician of the elevated pulse. 10 NYCRR 415.3(e)(2)(ii)(b)

Based on record review and interview the facility did not ensure that it maintained acceptable parameters of nutritional status, such as body weight, for one (#9)of two residents reviewed during an abbreviated survey (#NY 643). Specifically: Resident was admitted to the facility with anasarca (General swelling, or massive [MEDICAL CONDITION]), weights were not completed according to policy, physician was not notified of weight loss and reweights were not done and a significant weight loss was not assessed timely. The resident was not monitored for increase or decrease in [MEDICAL CONDITION]/swelling. The resident experienced a 17.8% weight loss in 18 days and then expired. This resulted in actual harm that is not immediate jeopardy. This is evidenced by: Policy & Procedure (P&P) entitled Weight Policy and Procedure and undated, documented: each resident will be weighed within 24 hours from admission; weight will be documented in the electronic medical record (EMR), for consistency weekly weights should be recorded on the same day each week; new admissions will be weighed a minimum of weekly for 4 weeks and monthly thereafter; the Dietician and Interdisciplinary team (IDT) will assess each admission for a period of 4 weeks to determine nutritional intervention or weight monitoring. Resident risk review documented: residents at risk for significant weight loss/gain or have actual weight loss/gain will be assessed by the IDT; all weight variance of 5% or more in 30 days, 7.5 5 in 90 days will be reported to the physician (MD) and responsible party. Weight record documented: the Dietitian will document in her notes if the loss/gain is significant and the percentage of loss/gain. Notification of the MD and responsible party of the weight change will be done by person designated by Director of Nursing (DON). Any recommendations must be given to the MD. Obtaining weights documented: daily, weekly, monthly weights and reweights will be completed by nursing team member designated by the DON for this task; weights will be recorded in the EMR; Weights will be reviewed by the Nurse Manager (NM) and/or Dietician; Certified Nurse Aides (CNA) will record weights on the weight worksheet; residents over 100 pounds (lb) will be reweighed if the weight variance is 5 lbs or more; reweights are to be done in the presence of a licensed nurse and must be obtained within 48 hours. Resident # 9: The Resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident had long and short-term memory problems and was moderately impaired in decision making according to the Minimum Data Set ((MDS) dated [DATE]. Resident expired in the facility on [DATE]. Hospital History & Physical dated [DATE] documented Resident was admitted to the hospital on [DATE] with chief complaint documented as right leg pain and falls. This [AGE] year old female with a history of chronic lower extremity [MEDICAL CONDITIONS] on chronic [MEDICATION NAME] anticoagulation, transitional cell bladder [MEDICAL CONDITION] status [REDACTED]. Hospital Discharge Summary dated [DATE] documented admission [DIAGNOSES REDACTED]. Chronic left hip pain likely from arthritis, and supratherapeutic international normalized ratio (INR). Discharge medications included; aspirin 325 milligrams (mg) daily (qd), increase [MEDICATION NAME] (diuretic) to 60 mg two times per day (bid), [MEDICATION NAME] (treat high cholesterol), [MEDICATION NAME] ([MEDICAL CONDITION] hormone), [MEDICATION NAME] (treat high blood pressure), Potassium (supplement), and [MEDICATION NAME] (treat pain). Procedure in hospital Cat Scan of chest without contrast showing chest wall and breast anasarca, bilateral pleural effusions and mild interstitial fluid that may represent mild [MEDICAL CONDITION]. No acute [MEDICAL CONDITION] infiltrates. The resident had an echocardiogram that revealed global hypokinesis, systolic [MEDICAL CONDITION]. Was started on IV [MEDICATION NAME] and was aggressively [MEDICATION NAME]. However, for several days, did not tolerate diuresis given blood pressures. Comprehensive Care Plan (CCP) entitled Nutritional Status and dated as effective [DATE] documented, Diet ground, nectar liquids, no bread, no added salt (NAS) low fat, low cholesterol, 1.5 liter fluid restriction. Weight 165.8 lb. weight goal 160 plus or minus 5%. Interventions include, monitor weight weekly effective [DATE], daily weights effective [DATE], record meal consumption daily effective [DATE], 1200 cc (fluid) diet effective [DATE]. Documented under notes and dated [DATE] and created by Dietician, status [REDACTED]. May need to consider discussion of alternate feedings with family. CCP entitled Potential for Dehydration due to recent illness, fluid restriction 1500 cc daily dated as effective [DATE]. Interventions included monitor fluid intake daily, monitor moistness of mucous membranes as needed. CCP entitled Medical [DIAGNOSES REDACTED]. Interventions included administer medications and treatments as ordered, monitor for changes and advise MD of changes. CCP entitled Alteration in Renal Function, End Stage [MEDICAL CONDITION] CKD stage 4 and dated as effective [DATE] with interventions that included, observe for signs and symptoms of [MEDICAL CONDITION] i.e. [MEDICAL CONDITION], congestion. monitor for weight changes/fluctuations, inform dietician and MD. Record intake and output and inform MD of any problems/abnormalities. Physician orders [REDACTED]. Computer weight trend dated [DATE] documented Resident's weight as 168.9 lbs. Initial Nutrition Evaluation dated [DATE] at 10:14 am and signed by Registered Dietician (RD) documented for diagnosis; [MEDICAL CONDITION]/anasarca, dementia, [MEDICAL CONDITION], hypertension (HTN), [MEDICAL CONDITION] (OA), [MEDICAL CONDITION] and [MEDICAL CONDITION]. Documented for Diet order; no added salt diet (NAS), low cholesterol, 1.5 liter fluid restriction. Documented for lab results dated [DATE]; BUN-64 (normal-,[DATE]), creatinine-2.3 ( normal-0XXX,[DATE].3), GFR-21 (>60), potassium-4.6 (normal-3XXX,[DATE]), sodium 139 (normal-,[DATE]). Weight was documented 165.8 labs. Problems influencing nutrition were documented as fluid overload, constipation risk and moderate risk for pressure sores. Note weight is down today from hospital weights due to diuresis-she still has fluid on board-need to monitor labs for dehydration. Note potassium also on board. Plan/Goals: weight goal 160 +/- 5%, 1200 cc fluids from dietary. Physician history and physical on [DATE], dictated at 10:15 am, entered into computer on [DATE], and signed by MD # 2 documented, the patient was admitted with right leg pain and recurrent falling at home. She did have anasarca and swelling on admission, her BNP (diagnose and treat [MEDICAL CONDITION]) was elevated to 1632 (BNP levels above 900 pg/mL indicate severe heart failure). Chest X-ray showed cardiomegaly and mild interstitial [MEDICAL CONDITION]. The patient was given [MEDICATION NAME] IV, the patient is on [MEDICATION NAME] 60 mg twice daily on transfer. She continues to have some [MEDICAL CONDITION]. While in the hospital her TSH ([MEDICAL CONDITION]-stimulating hormone) was slightly elevated and [MEDICATION NAME] was increased slightly. Her BUN-50, creatinine-2.0, GFR-25 on [DATE]. Documented on examination: blood pressure (BP) ,[DATE], pulse 80 irregular, there is no weight available yet, the patient is obese. Extremities 2+, 3+ [MEDICAL CONDITION] bilaterally. Documented plan: continue treatment for [REDACTED]. Check a BNP in the future. Physician orders [REDACTED]. Computer weight trend dated [DATE] documented Resident's weight as 164.6 lbs (2.5% loss). Nursing progress note dated [DATE] (Friday) at 6:06 pm documented critical value called in from lab, BUN 102, creatinine 2.8, GFR 17.071. Physician Assistant (PA) in the facility updated new orders to discontinue [MEDICATION NAME] and obtain labs on Monday BNP, BMP and have MD # 3 assess resident with change of condition and if patient condition changes call on call for possibly send to hospital is " +2 [MEDICAL CONDITION] patient awake vague at times base line disoriented-will continue to observe weights reviewed. Computer weight trend dated [DATE] documented Resident's weight as 164.0 lbs (2.9% loss). There was no evidence of nursing or medical progress notes on [DATE]. Nursing progress note on [DATE] at 1:16 am documented [MEDICATION NAME] given for increased agitation. At 4:32 am no effect from [MEDICATION NAME], resident yelling out most of shift, water given in sips at a time due to "RF". Tylenol given for complaints of leg pain, results pending. There was no evidence of nursing or medical progress notes on the day or evening shift of [DATE] or for [DATE]. Nursing progress note on [DATE] at 5:03 pm documented Resident found on floor unwitnessed fall, found lying on left side. Complaining of pain, large hematoma. Call to MD, OK to send to hospital. At 11:26 pm returned from the hospital, vital signs done by Licensed Practical Nurse (LPN). Cat Scan negative for intracranial injury. Nursing progress note dated [DATE] at 12:47 pm documented call placed to MD # 3 and updated regarding resident recent fall and yelling out. Resident increase in behaviors not changing with [MEDICATION NAME], possibly could be pain related, order for [MEDICATION NAME]. Dietary Progress note dated [DATE] at 3:43 pm documented, by mouth (po) average at 43%, fluids 780 cc. Note labs [DATE] included BUN 102, creatinine 2.8, GFR 17, potassium 4.8. MD discontinued her [MEDICATION NAME]. Weight is down 1.8 # (lbs) since admission. Note resident complaining of thirst, can offer canned fruit between meals to help with this. Computer weight trend dated [DATE] documented Resident's weight as 151.1 lbs (10.5% loss). Physician orders [REDACTED]. There is no progress note in regards to this order or reason for. There was no evidence of progress notes documenting about the 10.5% weight loss or [MEDICAL CONDITION] on [DATE] or [DATE]. Computer weight trend dated [DATE] documented Resident's weight as 138.7 lbs (17.8%). Speech Therapy progress note dated [DATE] at 3:30 pm documented recommends diet change to ground solids and nectar liquids. Patient must be upright at 90 degree angle for all po intake, and 1:1 assist during meals for initiation of intake and safety. Nursing and dietary notified of this change. Progress note dated [DATE] at 5:20 am documented resident's CNA called out for the nurse and resident was found on the floor. Resident had hit head and had moderate bleeding. At 6:12 am Resident was transferred to hospital. There was no evidence of progress notes documenting about the 17.8% weight loss or [MEDICAL CONDITION] on [DATE] or [DATE]. There was no progress note documenting the Residents return from the hospital. Hospital Discharge Summary dated [DATE] at 1:27 pm documented diagnosis, fall, Urinary Tract Infection [MEDICAL CONDITIONS] Fibrillation, Hypertension, [MEDICAL CONDITION], and chronic bilateral lower extremity [MEDICAL CONDITION]. Cat scan of the face showed acute nasal bone fracture. Nursing progress note dated [DATE] at 6:56 pm documented unable to administer [MEDICATION NAME] at 6:00 pm due to not here from pharmacy. Order received from RPA to begin when arrives from pharmacy. Dietary progress note dated [DATE] at 4:23 pm documented status [REDACTED]. Labs [DATE] included glucose 141, BUN 102, creatinine 2.8, GFR 17, diet is ground with nectar liquids now, with 1.5 liter fluid restriction. Weight is down 29.1% since admission- some of the weight loss is likely due to diuresis but po has overall been poor. She continues on 60 mg [MEDICATION NAME] twice daily. This weight was taken before her last trip to hospital, she may have been somewhat dehydrated at that point. There were no new labs. Need to monitor hydration, weight is less than goal set on admission but do not know baseline weight and [MEDICAL CONDITION] was present on original admission. She is on [MEDICATION NAME] for extra protein due to low protein levels. Speech Therapy treatment note dated [DATE] at 4:57 pm documented the patient seen in her room for initial evaluaiton and treatment. She recently returned from hospital after a recent fall. She was very difficult to arouse to alert state. Speech to see patient 5x/week for 4 weeks. Computer weight trend dated [DATE] documented Resident's weight as 140.9 lbs (16.5% loss. physician progress notes [REDACTED]. Weight 140.9 lbs on [DATE]. Massive facial bruising involving big hematoma on the forehead. [MEDICAL CONDITION], lungs clear to auscultation (cta) with few bibasilar crackles. Extremities no cyanosis, clubbing, [MEDICAL CONDITION] is positive. Labs from a couple of days ago showed GFR of 28, with hypopotassium 3.1. Impression and problems, lack of source of nutrition with poor gag reflex/high risk for aspiration, dehydration with worsening [MEDICAL CONDITION], resolving proteus UTI, [MEDICAL CONDITION], the patient with continued [MEDICAL CONDITION] (to lower extremities). Management and plan, she is out of her intravenous (IV) source, could not complete her IV antibiotic course for UTI. Patient has no source of feeding anymore. We called HCP again to update the situation and discussed the end of life options. I talked to HCP who just wants to keep her comfortable. Full comfort care orders entered by RN. There was no mention in this note that Resident had a 16.5% weight loss since admission on [DATE]. Nursing progress note dated [DATE] MD # 1 placed call to HCP to discuss advanced directives and change in her status condition and HCP stated she would like to start comfort care and stop all essential medications and make her comfortable. Nursing progress note dated [DATE] at 11:18 am documented called to see resident. No signs of life, absent for vital signs, pupils dilated and fixed. Call to sister for notification. During an interview on [DATE] at 1:20 pm the Dietician stated that a new admission with the [DIAGNOSES REDACTED]. Dietician remembered the Resident # 9 was not a good eater which contributed to the weight loss. Dietician would notify the Nurse Manager of any weight losses and she is presently sending this information to the DON being there are no nurse managers at this time. During an interview via telephone on [DATE] at 10:30 am Dietician stated that there was a concern with Resident # 9 renal function. The [MEDICATION NAME] had been discontinued at one point and she was not eating well. Dietician did not remember if she told anyone about the weight loss but everyone knew the Resident was not eating well. Dietician never received a computer alert for greater than 5 % weight loss, stated probably because she was not in the facility for thirty days. During an interview on [DATE] at 10:30 am the Speech Therapist stated the first day Resident #9 was admitted she was alert and oriented and conversing. She stated the very next day she picked her up as she had already started to decline and was not doing well with meals. She stated she was not made aware of Resident #9's weight loss. She further stated the physician should have been made aware. During an interview on [DATE] at 11:00 am Physician #2 stated he was not aware of Resident #9's weight loss and it was definitely a concern. During an interview on [DATE] at 12:55 pm the ADON stated she was not aware of Resident #9's weight loss. She stated that staff should be looking at the previous weight when weighing residents to make a comparison and identify any weight loss or gain. During an interview on [DATE] at 11:15 am the Director of Nurses stated that the CNAs would weigh the resident and let the nurse know what the weight was. He stated the CNA and nurse should be looking at the previous weight, but they do not do that. He stated the Dietician would review the weights and notify nursing of any weight loss. He stated he was not aware of Resident #9's weight loss, but he should have been made aware, as well as the physician. 10 NYCRR 415.12 (i)(1)

Based on medical record review and staff interview the facility did not ensure that a resident who displays mental or psychosocial adjustment difficulty receives appropriate treatment and services to correct the assessed problem for two of 2 resident's (#s 9 and 11) reviewed during an abbreviated survey #(NY 643). Specifically, for Resident # 9 who stated she wanted to kill herself on the night of admission [DATE], then stated she wanted to kill herself on [DATE] during the night shift and lunged from her wheel chair and sustained facial fracture, the nursing staff failed to respond to the statement according to the facility policy and procedure (P&P). Additionally, the resident sustained [REDACTED]. Resident #9 expired on [DATE]. Resident #11, with a history of suicidal ideation, on [DATE] after [MEDICAL TREATMENT] she made a statement that she wanted to die. Upon return to the facility, the Social Worker (SW) was made aware of her comment but did not appropriately assess the resident. Furthermore, the physician was not made aware for further follow up. This was actual harm for Resident #9 and no actual harm for Resident #11 with the potential for more than minimal harm. The Policy and Procedure (P&P) entitled Suicide/Homicide Precautions documented it is the policy of the facility to take reasonable actions and implement interventions in the event a resident expresses [MEDICAL CONDITION]. The purpose is to determine a thorough evaluation whether or not the resident is at risk for suicide and to take precautions to prevent resident injury or injury to others. Procedure documented that staff shall report any resident threats of suicide immediately to the Nurse Supervisor/ Charge Nurse and they shall immediately assess the situation and notify the Charge Nurse/ Supervisor and/or the Director of Nursing (DON). Nursing will immediately contact the attending physician. If the SW is on duty, advise the physician that the SW will interview the resident and follow-up with recommendations to the physician in a timely manner upon the conclusion of the interview. Document all actions taken in Nurses Notes. Notify Administration-DON and Administrator. A Suicide Risk Scale/ Assessment Tool was attached indicating the following: <10= No risk at this time, ,[DATE]= Low risk, ,[DATE]= Moderate risk, ,[DATE]= High risk. Resident # 9: The Resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident had long and short-term memory problems, had moderately impaired decision making and was understood and was able to understand according to the Minimum Data Set ((MDS) dated [DATE]. The MDS also assessed the resident was aware she was in a nursing home. The [DATE] MDS Section D Mood assessed the resident stated wishes for death or attempts to harm self as the symptoms did not occur. Nursing progress note dated [DATE] at 4:54 am documented at 3:00 am Resident #9 was over heard saying "I want to kill myself". Resident exhibits very bizarre behavior i.e., very restless in bed yelling strange babbling nonsense. The resident stated she had no plan to harm herself and stated she always says "dumb" things like that. The on call Physician Assistant (PA) was contacted, no new orders received as resident had no plan to harm herself. Resident was placed on 15 minute checks. Social Service progress note dated [DATE] at 4:12 pm documented Resident made a statement to staff that she wanted to kill herself. The resident does not have a plan. Family was called Nurse Manager will notify physician (MD). Care plan in place. Comprehensive Care Plan (CCP) dated [DATE] and entitled Mood State documented, Anxiety, made a statement she wanted to die upon arrival. Agitated and yelling at night. The CCP entitled Nutritional Status and dated as effective [DATE] documented, Diet ground, nectar liquids, no bread, no added salt (NAS) low fat, low cholesterol, 1.5 liter fluid restriction. Weight 165.8 lb. weight goal 160 plus or minus 5%. Interventions include, monitor weight weekly effective [DATE], daily weights effective [DATE], record meal consumption daily effective [DATE], 1200 cc diet effective [DATE]. Documented under notes and dated [DATE] and created by Dietician, status [REDACTED]. May need to consider discussion of alternate feedings with family. The CCP entitled Potential for Dehydration due to recent illness, fluid restriction 1500 cc daily dated as effective [DATE]. Interventions included monitor fluid intake daily, monitor moistness of mucous membranes as needed. Computer weight trend dated [DATE] documented Resident's weight as 164.6 lbs (2.5% loss). Computer weight trend dated [DATE] documented Resident's weight as 164.0 lbs (2.9% loss). There was no evidence of nursing or medical progress notes on [DATE]. Physician, Admission History & Physical written by MD # 2, dated [DATE] at 11:10 pm documented, patient was admitted with right leg pain and recurrent falling at home. The staff called me yesterday saying the patient is quite agitated and screaming. There is no history of any agitation at the hospital. The staff feels the patient has Dementia. Review of systems, unattainable from the patient. She has no complaints. She is being evaluated by physical therapy. She appears weak. For her agitation-continue [MEDICATION NAME] as needed. She is currently lethargic and received it last night, but her screaming has subsided. We will get a CT (computed tomography) of the head because of the [MEDICAL CONDITION] for the weakness and confusion. There was no mention of the Resident making the statement of wanting to kill herself. Dietary Progress note dated [DATE] at 3:43 pm documented, MD discontinued her [MEDICATION NAME] and weight is down 1.8 # (lbs) since admission. Note resident complaining of thirst, can offer canned fruit between meals to help with this. Computer weight trend dated [DATE] documented Resident's weight as 151.1 lbs (10.5% loss). There was no evidence of progress notes documenting about the 10.5% weight loss or [MEDICAL CONDITION] on [DATE] or [DATE]. Computer weight trend dated [DATE] documented Resident's weight as 138.7 lbs (17.8%). Speech Therapy progress note dated [DATE] at 3:30 pm documented recommends diet change to ground solids and nectar liquids. Patient must be upright at 90 degree angle for all po intake, and 1:1 assist during meals for initiation of intake and safety. Nursing and dietary notified of this change. There was no evidence of progress notes documenting about the 17.8% weight loss or [MEDICAL CONDITION] on [DATE] or [DATE]. Nursing progress note dated [DATE] at 5:20 am and signed by Registered Nurse Supervisor (RNS) documented CNA called out for nurse and Resident was found on the floor, resident had hit her head and resident had blood in moderate amounts, coming from her nose. Temperature-97.2, pulse-109, respirations-20, blood pressure (BP) ,[DATE], 02 Saturation not obtainable. The Director of Nursing (DON) was called and stated; OK to send resident to hospital. 911 called. Ice pack applied to head. Bleeding has subsided slightly. Nursing progress note dated [DATE] at 6:12 am and signed by RNS documented Resident was transferred to hospital at 5:45 am with 3 assistants. Epitaxis had subsided slightly, and resident had no other distress noted. MD called and message left on answering service. Ambulance service transferred resident on stretcher as per protocol. There was no documentation in regards to Resident anxiety, being medicated for anxiety or making statements of wanting to kill herself prior to the fall on [DATE], or notification to the MD. There was no facility written transfer form of communication to the hospital, indicating the residents anxiety and/or statements of wanting to kill herself prior to the fall. There was no documented evidence that a Suicide Risk Scale/ Assessment Tool was completed prior to the fall. Incident/Accident Report (I&A) dated [DATE] at 4:55 am documented Resident # 9 jumped/lunged out of wheelchair during trip to bathroom, falling onto the floor, hitting head and causing bright red bleeding. Location was noted as resident's room and at bedside. Type of injury was noted laceration, epitaxis. Documented for how did incident/injury occur, Resident had tranquilizer with no effect, remained restless and jumped (lunged) out of wheelchair, falling to the floor. Investigative Report by the Administrator, dated [DATE] documented the following interview: CNA assigned to the Resident stated that resident was agitated all night long. She stated the resident did not feel good. Resident was trying to choke herself with her hands, put her hand down her throat, and banging her head on the overbed table. Resident stated she wanted to kill herself. CNA informed the LPN and RNS of resident statements; LPN stated she was notified by CNA that resident had stated she wanted to kill herself approximately ,[DATE]:00 am. LPN spoke with Resident and Resident did not reiterate her remarks. Resident did not want to be in her room and CNA brought her back out to the hallway. LPN never witnessed resident banging her head on over bed table; RNS stated she was aware of the resident's statement regarding suicidal ideation and stated she did not call the doctor. RNS looked at the medications ordered and directed the LPN to give [MEDICATION NAME]. CNA did not relay the behaviors the resident was having to her. The investigation conclusion documented, based on the facility investigation there was no credible evidence to support resident abuse, neglect or mistreatment. There were no care plan violations. Facility determined that the RNS did not assess resident when medication was not effective in managing behaviors. RNS did not follow facility protocol regarding exhibiting suicidal ideation. Hospital Discharge Summary dated [DATE] at 1:27 pm documented admission diagnosis, unwitnessed fall, possibly secondary to [MEDICAL CONDITION]. Cat Scan of the face showed acute nasal bone fracture. There was no documentation indicating hospital was made aware of the anxiety and/or suicidal statements prior to fall. There is no progress note indicating the Resident's arrival back to the facility. There was no documented evidence that a Suicide Risk Scale/ Assessment Tool was completed upon return from the hospital. There was no evidence of documentation from any discipline, that Resident was evaluated upon her return from the hospital for suicidal statements. Dietary progress note dated [DATE] at 4:23 pm documented status [REDACTED]. , diet is ground with nectar liquids now, 1.5 liter fluid restriction. Weight is down 29.1% since admission- some is likely diuresis but po has overall been poor. She continues on 60 mg [MEDICATION NAME]. This weight was taken before her last trip to hospital, she may have been somewhat dehydrated at that point. There were no new labs. Need to monitor hydration, weight is less than goal set on admission but do not know baseline weight and [MEDICAL CONDITION] was present on original admission. She is on [MEDICATION NAME] for extra protein due to low protein levels. Speech Therapy treatment note dated [DATE] at 4:57 pm documented the patient seen in her room for initial evaluation and treatment. She recently returned from hospital after a recent fall. She was very difficult to arouse to alert state. Speech to see patient 5 x/week for 4 weeks. Computer weight trend dated [DATE] documented Resident's weight as 140.9 lbs (16.5% loss. Social Service note dated [DATE] at 4:11 pm documented, care plan meeting today. Social service, activities, dietary, nursing and administrator present. Resident's sister attended via phone. She received an update from nursing concerning general condition, [DIAGNOSES REDACTED]. There was no mention of Resident stating she wanted to kill herself on [DATE] prior to her fall. physician progress notes [REDACTED]. Weight 140.9 lbs on [DATE]. Massive facial bruising involving big hematoma on the forehead. [MEDICAL CONDITION], lungs clear to auscultation (cta) with few bibasilar crackles. Extremities no cyanosis, clubbing, [MEDICAL CONDITION] is positive. Labs from a couple of days ago showed GFR of 28, with hypopotassium 3.1. Impression and problems, lack of source of nutrition with poor gag reflex/high risk for aspiration, dehydration with worsening [MEDICAL CONDITION], resolving proteus UTI, [MEDICAL CONDITION], the patient with continued [MEDICAL CONDITION]. Management and plan, she is out of her intravenous (IV) source, could not complete her IV antibiotic course for UTI. Patient has no source of feeding anymore. We called HCP again to update the situation and discussed the end of life options. I talked to HCP who just wants to keep her comfortable. Full comfort care orders entered by RN. There was no mention in this note that Resident had a 16.5% weight loss since admission on [DATE]. Nursing progress note dated [DATE] at 11:18 am documented called to see resident, no signs of life, absent for vital signs, pupils dilated and fixed. Call to resident's sister. During an interview on [DATE] at 1:20 pm the Dietician stated that a new admission with the [DIAGNOSES REDACTED]. Dietician remembered Resident # 9 was not a good eater which contributed to the weight loss. Dietician would notify the Nurse Manager of any weight losses and she is presently sending this information to the DON. During an interview via telephone on [DATE] at 10:30 am Dietician stated that there was a concern with Resident # 9 renal function. The [MEDICATION NAME] had been discontinued at one point and she was not eating well. Dietician did not remember if she told anyone about the weight loss but everyone knew the Resident was not eating well. Dietician never received a computer alert for greater than 5 % weight loss, stated probably because she was not in the facility for thirty days. During an interview on [DATE] at 10:30 am the Speech Therapist stated the first day Resident #9 was admitted she was alert and oriented and conversing. She stated the very next day she picked her up as she had already started to decline and was not doing well with meals. She stated she was not made aware of Resident #9's weight loss. She further stated the physician should have been made aware. During an interview on [DATE] at 11:00 am the Assistant Administrator stated that following the [DATE] fall on the next day the CNA was asked to come in and do a reenactment of the incident. CNA stated to Assistant Administrator, Administrator, and DON that she was trying all night long to convince the Supervisor and nurse that the Resident was making the statement that she wanted to die. During an interview on [DATE] at 12:10 pm the Director of Social Work (DSW) stated that she was aware of Resident # 9 making the statement to kill herself on admission and had done a risk assessment and care plan at that time. DSW was not made aware of Resident # 9 making the same type of statements on the night of [DATE] prior to the fall. DSW would have assessed the Resident and monitored on a regular basis until stable. During an interview on [DATE] at 12:15 pm the Social Worker (SW)stated she was aware of the fall on [DATE] but was not told about the statements of wanting to kill herself. SW would have been looking more closely at the Resident and her behaviors if she had known. During an interview on [DATE] at 10:00 am CNA # 1 stated on [DATE] she was assigned as a 1:1 to Resident # 9. CNA # 1 stated that sometime between the hours of 1:00 am and 2:00 am she was sitting in front of the Resident with the tray table between them. The Resident complained of breathing problems and the LPN # 3 came in and checked her, gave her some water and then left. About an hour later the Resident became anxious and agitated, grabbing and saying I want to die, calling CNA # 1 Mommy. Stated I'm going to kill myself, tried to grab her own neck, put her hand in her mouth and tried to bang her head on the table. CNA stated that this behavior went on for about 3 minutes. CNA # 1 called for help and the LPN # 3 came and helped to bring the Resident out to the nurse station. CNA # 1 stated she told the LPN # 3 of this behavior and the Supervisor and neither one of them talked to the Resident. The Supervisor told the LPN # 3 to give a medication, LPN # 3 stated the [MEDICATION NAME] does nothing for her, but the LPN orientee gave it. CNA # 1 stated that she saw the DON at 7:00 am and told him about the behavior of Resident # 9 that night. Later in the night after the CNA # 1 returned from her break the LPN orientee had put the Resident into bed. CNA # 1 was sitting on the side of the bed when the Resident # 9 attempted to get up from the opposite side of the bed. CNA # 1 went over to that side and assisted the Resident into her wheelchair. CNA # 1 then turned to hit the alarm button on the bed alarm and the Resident went forward from the chair to the floor. CNA # 1 did not see the beginning of the fall but saw the Resident going forward to the floor. She then screamed and called for help, Resident was bleeding and the LPN responded first . During an interview on [DATE] at 10:15 am LPN # 3 stated Resident # 9 had been anxious since her admission. LPN # 3 stated that CNA # 1 told her around 2:00 am that the Resident wanted to kill herself. LPN # 3 stated the Resident's room was fairly close to the nursing station and the CNA # 1 and Resident # 9 had not been out of her sight for very long. LPN # 3 stated that CNA # 1 did not want to stay in the room alone with the Resident and LPN # 3 found it hard to believe that the Resident said she wanted to kill herself. LPN # 3 stated she knew the P&P for suicidal statements and that the Supervisor needed to be notified. LPN # 3 stated that the Supervisor told her to given the [MEDICATION NAME] when she was told about the behaviors of stating she wanted to kill herself. During an interview on [DATE] at 12:55 pm the ADON stated she was not aware that Resident #9 had made previous comments about wanting to kill herself or that she was making those comments on [DATE]. She further stated the Registered Nurse Supervisor should have acted on that immediately. During an interview on [DATE] at 11:15 am the DON stated there was no evidence that staff made the hospital aware that Resident #9 had been making comments that she wanted to kill herself on [DATE]. During an interview on [DATE] at 10:30 am Physician #1 stated that he is in the facility twice a month and only saw Resident #9 once. He stated when he saw the resident he was told that she was declining and the health care proxy (HCP) wanted the resident to be placed on comfort care. He stated he did not really know the resident, however she was not eating well and her condition was going downhill. He stated he was unaware of the resident's psychological issues, and therefore respected the family's decision and placed the resident on comfort care. He stated as he was unaware of the psychological concerns, he did not see the need to pursue anything else (psychological services). Resident #11 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented the resident had moderately impaired cognition. The Comprehensive Care Plan (CCP) entitled Suicide Precautions dated [DATE] documented the resident had a history of [REDACTED]. Interventions documented on the CCP as of [DATE] included contact MD immediately when statements are made, psychiatry and psychology services as needed, remove all lethal means of self injury, use plastic utensils and dishes, if suicidal ideation is noted contact Administration, DON, MD, Social Work, and health care proxy (HCP). Interventions documented on the CCP as of [DATE] included resident to remain on one on one while awake and fifteen minute checks while asleep (Not a new intervention). The Individual Plan Report (a document used by staff to know what care the resident required) undated, documented use two caregivers at all times due to resident's false accusations when one on one not in progress. It also documented under alarms "bed alarm and clip while in chair *15 minute checks*". It did not document the other interventions mentioned on the resident's Suicide Precautions CCP. The Hospital [MEDICAL TREATMENT] Chronic Monitor Sheet dated [DATE] documented the resident's [MEDICAL TREATMENT] treatment began at 7:00 am. At 7:30 am it documented "patient agitated sitting with aide and son." At 8:00 am it documented "tx (treatment) ended. Pt (patient) yelling she wants to come off machine and that she refuses to stay here for 3 hrs. Very agitated. Very abusive to nurse aide. Abusive to son." In the Nurses Note dated [DATE] at 3:48 pm LPN #1 documented resident returned from [MEDICAL TREATMENT] around 9:30 am. Agitated/rough morning at [MEDICAL TREATMENT] per comments in report log. Toileted several times when returned, in and out of bed several times, in wheelchair assisted under supervision to her choice destinations. Pain medication given for discomfort. Assisted with meals as she allows, poor appetite with snacks provided. "BS" monitored. The Social Services Note dated [DATE] at 4:11 pm documented the resident made comments at [MEDICAL TREATMENT] that she just wanted to die. Her family and an aide from the facility were present. Resident returned from [MEDICAL TREATMENT] early. She had no recollection of the comments that she made and denied any suicidal ideation. There was no documented evidence that a Suicide Risk Scale/ Assessment Tool was completed. There was no documented evidence that nursing or the physician were made aware of the resident's comment. During an interview on [DATE] at 9:05 am the Social Worker stated the resident had been on a one on one for quite some time as she was falling out of bed and had agitated behaviors. She stated the resident did not have a history of suicidal ideation as far as she knew. She stated after [MEDICAL TREATMENT] on [DATE] the resident returned, and it was reported to her by the driver that the resident stated she was done and did not want to live anymore. She stated she spoke to the resident, but did not complete a Suicide Risk Scale/ Assessment Tool because the resident did not have intent. She stated she talked to the DON regarding the incident and would have expected nursing to let the physician know about the resident's comment, as she does not contact the physician. During an interview on [DATE] at 9:35 am the Director of Social Services stated that a resident stating they wanted to die was not an uncommon statement in a nursing home and it was a "gray area." She stated a comment such as this would prompt the Social Worker or Nursing to complete a Suicide Risk Scale/ Assessment Tool. She stated if a resident was noted to fall under high risk they would be placed on a one on one or 15 minute checks. She further stated nursing would be responsible for calling the physician, making them aware of the circumstances, and letting the physician decide if any further intervention is needed. During an interview on [DATE] at 11:45 am LPN #1 stated she was not aware that the resident had any history of suicidal ideation. She stated she was not aware of the comment made by the resident on [DATE]. She stated if she had been aware she would have notified the Social Worker and DON and completed the Suicide Risk Scale/ Assessment Tool. She further stated either the Social Worker or DON would then notify the physician. During an interview on [DATE] at 12:10 pm the DON said the resident required a one on one as she would throw herself on the floor. He was not aware that the resident had any history of suicidal ideation. He stated he was not made aware of the comment made by the resident on [DATE] that she was done and did not want to live anymore. He stated he would expect staff to complete a Suicide Risk Scale/ Assessment Tool as well as an Incident/Accident Report. He further stated whether the resident was scored as a high risk or not, he would expect the physician to be made aware. 10NYCRR 415.12(f)(1)

Based on observation, record review, and staff interviews during an abbreviated survey (Complaint #NY 508), the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one (# 5) of one resident reviewed for pain. Specifically, Resident # 5 who is edentulous (without teeth) complained of jaw pain and did not receive the as needed ( prn ) pain medication until the pain reached moderate to severe levels. There was no standing orders for pain medication to be given, to control the resident's pain for approximately sixteen days into having the pain. Policy & Procedure (P&P) entitled Pain dated October 2010 documented, the Nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. The staff and physician (MD) will identify the nature and severity of pain. The MD will help identify causes of pain. Part of the medical assessment, the physician will help identify the extent to which underlying causes of pain can be addressed or reversed. The MD will perform or order appropriate tests as needed to help clarify sources of pain. The staff will evaluate the report on how much and on how often the individual asks for prn pain medications. Resident # 5: Resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident has long and short term memory loss and is moderately impaired in decision making according to the Minimum Data Set ((MDS) dated [DATE]. Comprehensive Care Plan (CCP) entitled Dental Care with an effective date of 2/9/14 documented poor repair edentulous, left jaw pain. Goals included: oral discomfort will be addressed by dentist in next 7 days; oral discomfort shall be managed as per physician (MD) and patient shall experience no unrelieved pain over the next 90 days. Dental note dated 8/28/13 documented, follow-up appointment, patient had a full mouth extraction and healing well. All tissues appear healthy/within normal limits. CCP entitled Pain and dated as effective 9/19/13 documented, Alteration in comfort, Pain related to leg spasms. Interventions included administer pain management regime as ordered, inform MD if ineffective/inadequate, consider changing regime if indicated. Nursing progress notes documented that Resident began complaining of pain on 2/23/14 to her left lower jaw area. Description of Resident's pain ranged from yelling out in pain to stating severe pain. Complaints of pain continued and Resident was administered prn Tylenol 650 mg through 2/24/14. Nursing progress note dated 2/24/14 at 12:06 am documented the resident is yelling out with discomfort in spite of having received two Tylenol. She stated she had severe pain in the left side of her lower gum line in a tooth socket where a tooth is missing. Telephone call placed to Registered Physician Assistant (RPA) and new orders received, [MEDICATION NAME] as needed (prn) taken from E-kit and administered. Placed on ill visit for MD to evaluate. Nursing progress notes documented the resident continued to complain of pain from 2/25/14 through 2/27/14. Description of pain ranged from screaming in pain, stating gums are killing me, to stating extreme pain. Resident was administered prn [MEDICATION NAME] 5 mg on 3 occasions or prn Tylenol 650 mg on 4 occasions. physician progress notes [REDACTED]. She is edentulous, there is some swelling of the posterior left gum, but exam is limited. There is no obvious redness, ulcers, mandible nontender. She will not allow a good exam. Plan: try [MEDICATION NAME] 2% as needed (prn) three times per day (tid). Try Pen VK 500 mg tid times 5 days. She may need a dental consult if she does not improve. There was no change made to the prn pain medication to a standing pain medication. Nursing progress notes documented the resident continued to complain of pain from 2/28/14 through 3/6/14. Description of pain ranged from screaming in pain, to yelling out in pain. Resident was administered prn [MEDICATION NAME] 5 mg on 9 occasions or prn Tylenol 650 mg on 1 occasion. physician progress notes [REDACTED]. Because of this I advised dentistry to see her a couple of days ago, I gave the order through the nurses. Resident sometimes yells out with pain, she has [MEDICATION NAME] used as needed. The night before last she apparently was awake most of the night complaining of left lower jaw pain. Documented under ears/nose/throat (ENT) problems: left posterior mandible/gum pain, ongoing since at least 2/14/14 and onward. Dental consult pending. Rule out (r/o) [DIAGNOSES REDACTED]/tic douloureux, r/o from occult canker sores, r/o from thrush. Documented under plan: [MEDICATION NAME] is continued for the breakthrough pain, but I think because she has the pain almost chronically I think she should get routine Tylenol three times a day. We will treat the thrush with Fluconazole 150 mg times one. Review of physician orders [REDACTED]. There was no order documented for Tylenol three times a day. Nursing progress notes revealed resident continued to complain of pain from 3/7/14 through 3/10/14. Description of pain ranged from yelling out her mouth hurts, yelling out her mouth really hurts. Resident was administered prn [MEDICATION NAME] 5 mg on 2 occasions. Resident continued to complain of pain. On 3/10/14 review of the resident records revealed there was no record of a Dental consult having been performed. The Director of Nursing provided the consult after contacting the dentist on 3/10/14 for a faxed copy. Dental consult dated 3/7/14 documented, evaluated complaints of mouth pain, Staff states patient was complaining of mouth pain. Patient pointed to lower left quadrant. Upon exam no apparent pathology. All remaining teeth had been extracted, no root fragments were observed. Patient did not want to cooperate or be touched. Recommended to see outside oral surgeon. Nursing progress note dated 3/10/14 at 4:13 pm documented clarified orders with MD # 2 for mouth pain. Tylenol 650 mg three times per day routine and prn. Continue with [MEDICATION NAME] for breakthrough pain. Restarted the [MEDICATION NAME] gel to mouth prn. During an interview on 3/10/14 at 12:30 pm RN # 1 stated that the Resident had been complaining frequently of pain to her jaw and was seen by dental recently. RN was not sure if any diagnostic testing had been done. During an interview on 3/10/14 at 12:40 pm LPN # 2 stated that Resident # 5 was crying out in pain that morning and received [MEDICATION NAME]. Stated that Resident was treated for [REDACTED]. During an interview on 3/10/14 at 2:00 pm Assistant Director of Nursing (ADON) stated on 2/26/14 she had assessed the Resident for pain and had called the niece to make her aware of it. ADON told the former Nurse Manager to let the MD know about the pain the next day. Stated on 2/27/14 MD saw the Resident and ordered [MEDICATION NAME] and antibiotic. ADON was not aware that the Resident was crying out in pain so frequently. During an interview on 3/11/14 at 12:15 pm MD # 2 stated the Resident's pain is under control as of today. Stated he did not know the resident's pain was out of control, and he would not have wanted any resident to have pain. He stated he did write in his note on 3/6/14 to start the Tylenol as routine but it did not make it to the orders. 10 NYCRR 415.12

Based on record review and interview, the Governing Body failed to ensure the establishment and implementation of policies and procedures related to the management and operation of the facility; specifically including timely and thorough investigations following alleged violations involving abuse, neglect, and mistreatment, including injuries of unknown origin. This resulted in Immediate Jeopardy and Substandard Quality of Care. F225 is a repeat deficiency from the survey of April 2013. The facility has not been in compliance with state and federal regulations since an Immediate Jeopardy in July 2013. This was evidenced by: Refer to Quality of Care F 225 scope and severity-L Refer to Quality of Care F 323 scope and severity - G Refer to Resident Assessment F 490 scope and severity-L During an interview on 10/18/13 at 3:00 pm, the Vice President (VP) of Clinical Services stated that he is responsible to insure that facility is provided support regarding policies and procedures, staffing and audits. The VP of Clinical Services stated that he oversees facility operations through on-site visits and monthly reports from the facility, in addition to providing on-site corporate level assistance. The VP of Clinical Services stated that he recognized that investigations could be better and that he and his team have been working with the facility on concerns over Incidents and Accidents. The VP of Clinical Services stated that he feels that the staffing and personnel changes in the last year contribute to the on-going issues in the facility, stating, "we have a new team and we are providing consultants who are identifying issues and we are making steps forward, but we understand that the process has not been tight." The VP of Clinical Services stated that from a corporate level, on-site support to the facility will continue to work through all of the issues. 415.26 (b)(3)(1) . .

Based on record review and staff interview during a partial extended abbreviated survey (Complaint # NY 796), the facility failed to thoroughly investigate all alleged violations involving abuse, neglect, and mistreatment, including injuries of unknown origin for 4 (Resident #s 1, 2, 4, 5) of 5 residents reviewed. Specifically, Resident #1 fell from a mechanical lift. There was no assessment or care planning for the correct Hoyer pad size and loop placement to use for a safe transfer. As a result, the resident was transferred to the hospital and was found to have a subarachnoid hemorrhage. Resident #2, with multiple incidents and accidents, sustained a laceration to his head after a fall and in a separate incident, experienced a choking episode after being provided a food item inconsistent with his physician ordered therapeutic diet. The facility did not complete a thorough and comprehensive investigation to identify root cause. Resident #4 the facility did not complete an thorough and accurate investigation after the resident fell and sustained a [MEDICAL CONDITION]. Resident #5 with a documented history of falls prior to admission, fell while in the facility on 9/5/13, however the facility failed to initiate an investigation. Subsequently, the resident had three additional falls which were not thoroughly investigated. This resulted in actual harm for Resident #s- 1 and 2 and no actual harm with the potential for more than serious harm that is Immediate Jeopardy and Substandard Quality of Care. This has the potential to effect all of the residents in the facility. This is a repeat deficiency from the abbreviated survey in April 2013. The facility has not been in compliance with State and Federal regulations since an Immediate Jeopardy in July 2013. This was evidenced by: The Policy and procedure (P&P) entitled Abuse Investigations and dated 2/25/13 documented all reports of resident abuse, neglect, mistreatment, misappropriation of resident property, resident grievance, and injuries of unknown source shall be promptly and thoroughly investigated by the facility management. Should an incident or suspected incident of abuse, mistreatment, neglect, misappropriation or injury of unknown source be reported, the nurse it is reported to will immediately start an investigation. The individual conducting the investigation will, as a minimum; review the forms and medical record, interview persons involved; witness; resident; physician; staff members in contact with resident last 24 hours; roommate, family visitors and review events leading up to incident. Accused employees are suspended, investigator will consult daily with Administrator, results of investigation will be documented, and completed within five working days, inquiries concerning abuse reporting and investigation should be referred to the Administrator or Director of Nursing (DON). Resident #1: The resident was admitted to the facility on [DATE] diagnosed with [REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident with severe cognitive impairment. The P&P titled Musculoskeletal Disorder Prevention dated 7/26/12 documented the policy is provide resident care in a safe, appropriate manner in accordance with the individual resident's care plan. The policy documents that residents will be assessed upon admission, readmission and for significant changes related to assistance with transfer activities and documents that the requirements of the policy will be reflected in the residents, care plan, aide sheet and MDS. The policy further documented that the success of the safe lift policy is the correct assessment of the residents for lift and transfer equipment, clear and consistent communications regarding the need for assistive aides and devices for individuals, and the skillful use and familiarity of the lift, transfer and repositioning equipment by the care givers. The policy documented that the sling selection is based on initial and on-going assessment and the number and types of slings should be considered. The policy documented the standard sling as a divided or full body sling which should be used for handling normal resident transfers. The Comprehensive Care Plan (CCP) title Transfers initiated on 12/29/11 documented that the resident required total assistance with 2 people and/or mechanical lift. The care plan was last reviewed on 4/17/13 and documented as appropriate. The care plan did not include specific Hoyer pad size or loop placement. The CORP (Resident Care Guide/care tracker) printed on 10/15/13 documented that the for the period of 7/1/13 through 10/1/13, Resident #1's transfer status was Hoyer lift, no ambulation. The care guide did not include specific Hoyer pad size or loop placement. Review of an Incident and Accident (I&A) Report dated 10/1/13 at 8:00 am documented that Resident #1 fell on to the floor witnessed by two Certified Nurses Assistants (CNAs) out of the Hoyer lift during transfer from bed to wheel chair. Nurse's Note dated 10/1/13 at 8:29 am documented that the family of Resident #1 was updated about being transferred to the hospital after a fall. A facility statement signed by CNA #1 dated 10/1/13, documented that she and CNA #2 were transferring Resident #1 using a Hoyer lift from his bed and "everything was in place where it was suppose to be" and "I don't know why it happened because we did everything right except I think the pad was too big for him. I would rather use a full body pad." A facility statement signed by CNA #2 undated, documented that CNA #1 had request her assistance to transfer Resident #1. CNA #2 documented that when she entered the resident's room, the resident had a Hoyer pad under him and was hooked up on CNA #1's side. CNA #2 documented that she asked CNA #1 what color (loops on the Hoyer pad to be attached to the Hoyer lift) she had on, and CNA #1 responded "purple" and therefore CNA #2 placed her side on purple. CNA #2 documented that the resident leaned forward while in the lift and fell down instantly, hitting his head on the legs of the Hoyer. Computerized Tomography (CT) Scan report dated 10/1/13 documented a new small subarachnoid hemorrhage (when blood leaks into the space between two membranes that surround the brain.) An Investigative Report dated 10/2/13 signed by the Administrator documented Resident Neglect on 10/1/13 while resident #1 was being transferred via a Hoyer lift out of bed, the resident slipped forward out of the Hoyer sling and fell to the floor hitting his head on the leg of the lift. The conclusion documented that the resident sustained [REDACTED].#1 did not ensure the resident was safe while performing a transfer from bed to wheelchair. The conclusion further documented that CNA #1 was neglectful when she admitted that the Hoyer sling was too big and did not ensure that she had the right size sling pad prior to the transfer. Additionally, the conclusion documented that CNA #1 demonstrated the wrong procedure when hooking up the resident, as she did not use the appropriate loops to hook the resident up to the Hoyer lift. During an interview on 9/15/13 at 11:30 am, CNA #5 stated that in the last couple of years, Hoyer pads have not been specified on the resident's care profiles. CNA #5 stated that she was using the same size pad for everyone. During an interview on 9/15/13 at 11:45 am, CNA #6 stated that she prefers using a full body Hoyer sling, however, if there wasn't a full body sling available, "we use what we can find". CNA #6 stated that the sling size nor the loops were identified on the residents care profile in care tracker. During an interview on 9/15/13 at 12:45 pm, the Director of Physical Therapy (PT) stated that the PT department is responsible for assessing the mechanical devices needed to transfer a resident safely, for example a Hoyer lift versus a stand lift. The Director of PT stated that nursing staff are responsible for determining which Hoyer sling; full body or divided leg sling, and, placement of the loops of the sling onto the lift. During an interview on 9/15/13 at 1:00 pm, Registered Nurse Manager (RNM) #1 stated that the facility utilizes a lift mobility assessment to determine the most appropriate mechanical transfer for residents. RNM #1 stated that the PT department is responsible for identifying the size of the sling used to Hoyer a resident and then the nurse managers or nurse supervisors would update the resident's care plan and the care tracker used by the CNAs. Upon review of Resident #1's care plan and care guide/tracker prior to the resident's fall, the RNM stated that at the time of the fall the sling and loops were not on the care plan or the care tracker and that the lift/mobility assessment was intimated after Resident #1's fall. During an interview on 9/15/13 at 1:50 pm, the Administrator stated that an investigation was initiated after Resident #1's fall from the Hoyer lift and it was determined that CNA #1 used poor judgement in transferring the resident in a Hoyer sling that she admitted may have been too big for the resident. The Administrator stated that with the assistance of corporate staff, the facility identified that the Hoyer slings (size and type) best suited for the resident's safety during transfers was not identified in the care plans or on the care tracker. The Administrator stated that after the fall, all residents requiring Hoyer transfers were assessed, the sling was identified, documented in the resident's care plan and on the care tracker. The Administrator stated that there had been some discussion about determining placement of the Hoyer pad loops onto the Hoyer lift, however, that had not been done yet. During an interview on 9/16/13 at 8:45 am, the Assistant Administrator stated that in preparation to demonstrate the Hoyer lift transfer, she was unable to locate the exact Hoyer pad used in Resident #1's fall from the Hoyer lift. The Assistant Administrator stated that after a visit from the corporate risk manager, it was determined that the Hoyer sling used on the day of the event should not have been used for anyone in the facility. That type of Hoyer sling were taken off of the nursing units. During an interview on 9/16/13 at 12:00 pm, CNA #1 stated that she was assigned to Resident #1 on 10/1/13 and stated that she asked CNA #2 to assist her from moving the resident from his bed to his wheelchair. CNA #1 stated that she used the sling that was on a chair in the resident's room but she preferred the full body sling. CNA #1 stated that prior to calling for CNA #2 to assist, she dressed the resident and placed the Hoyer sling under the resident in preparation for the transfer and attached the purple loops to the top and bottom hooks of the lift. CNA #1 stated that she placed the purple loops on the Hoyer lift because she was told that everyone is lifted using the purple loops. CNA #1 stated that she was operating the lift and CNA #2 was guiding the resident's legs when suddenly the resident fell out of the side of Hoyer sling. CNA #1 stated that the four corners of sling were attached to the Hoyer lift, but she does not recall if the loops on the sides were connected. CNA #1 stated that she didn't believe that the facility had provided her proper training on the Hoyer lift and the slings. During an interview on 9/18/13 at 9:30 am, CNA #7 who works for an agency, stated that there is no information on the care tracker that identifies which loops should be used to attach to the Hoyer lift for a particular resident. CNA #7 stated that the decision is made by looking at the resident and trying to use good judgement on the placement of the loops. During an interview on 9/18/13 at 9:45 am, CNA #8 stated that she was unaware of what loops on the Hoyer pad to use, that the information is not in the care tracker and she will usually just ask another CNA that she is working with. During an interview on 9/18/13 at 10:00 am, CNA #9 stated that she uses the top loop for the upper body and the green loops for the feet for everyone. Resident #2: The resident was admitted to the facility on [DATE] diagnosed with [REDACTED]. Finding 1: The CCP titled Accidents and Incidents initiated on 8/9/13 documented multiple interventions for the prevention of accidents and incidents, including; bed in the lowest position except during care initiated 9/15/13, flat beveled safety mats in the floor on both sides of the bed initiated on 9/16/13, Lap Buddy on when up, and offer toileting, snack, blanket when resident appears restless on 10/7/13. CORP - Profile History Report for General Information for the period of 10/2/13 - 10/9/13 documented flat beveled mats on both sides of the bed and a lap buddy. Nurse's note dated 10/8/13 at 1:41 pm signed by Licensed Practical Nurse (LPN) #1 documented that Resident #2 was out of bed in the morning and placed in his wheelchair for breakfast, immediately after 20 minutes, resident was attempting to transfer to a high bed. In the afternoon, resident continually taking lap buddy off and trying to stand. I&A Report dated 10/8/13 at 2:30 pm signed by LPN #1 and the Director of Nursing (DON) documented an unwitnessed transfer from the wheelchair to bed mat on floor, alarm sounding found sitting on mat. Conclusion of incident investigation signed by the DON documented no evidence of abuse, neglect or mistreatment found, poor impulse control with a history of non-compliance, floor mat. Employee Statement signed by LPN #1 documented that she was called to resident's room, wheelchair alarm was sounding and found resident sitting on floor bed mat. DON called, transferred to wheelchair. Nurse's note dated 10/8/13 at 3:02 pm signed by LPN #1 documented that she was called to Resident #2's room at 2:30 pm. Resident was sitting on the bed mat that was placed next to his bed on the floor. Staff stated that his wheelchair alarm was sounding and he was sitting on the mat. Registered Nurse (RN) was called to assess, no injuries noted. Lap buddy was unattached from the wheelchair, resident was placed back in his wheelchair and the lap buddy was reattached. I&A dated 10/9/13 at 2:00 am signed by RNS #1, DON (undated) and by the Administrator dated 10/9/13, documented that the resident was observed on the floor, blood noted on towel over right eye, CNA responded to bed alarm and found resident lying on the right side bleeding. Post Fall investigation documented environmental factors contributing to the incident, "Mats?" and obstacles as "floor mat on one side, mattress." Immediate action taken to prevent further incidents was documented as "full size mattress next to bed that resident tripped over removed immediately from scene." Conclusion, signed by the DON dated 10/9/13 documented "not enough evidence for abuse, neglect, mistreatment secondary as it is reasonable to believe that the resident, who has been known to move furniture. Resident may have been moving mattress himself and fell . Mattress removed from room." Employee Statement signed by CNA #10 documented that she responded to an alarm, found resident lying on the floor on his right side, reported to nurse. Employee Statement signed by CNA #11 documented, responded to an alarm and found resident on his right side, reported to nurse. Nurse's note dated 10/9/13 at 2:19 am signed by Registered Nurse Supervisor (RNS) #1 documented "called to floor urgently. CNA with resident holding towel to his right forehead. laying on his side on the floor next to a regular sized mattress...per staff, resident appeared to have tripped on mattress attempting to get out of bed and fell to floor hitting head. Nurse's note dated 10/9/13 at 2:54 am signed by LPN #2 documented that CNA responded to a bed alarm at approximately 2:00 am found resident hunched on the floor next to a mattress on the floor at the bedside, bleeding from laceration to right brow. Sent out for evaluation. Nurse's note dated 10/9/13 at 8:02 am signed by the DON documented a late entry from 10/8/13 at 2:30, documented that Resident #2 was found sitting on bed mat beside bed, with no apparent injury. Nurse's note dated 10/9/13 at 8:17 am signed by RNS #1 documented a call received by the hospital, per emergency room , stitches to the right eye, resident returned to the facility and settled in bed. During an interview on 10/16/13 at 1:30 pm, CNA #10 stated that she was working on 10/9/13 when she responded to Resident #2's bed alarm and found the resident on the floor bleeding from his head. CNA #10 stated there was a full size mattress on the floor on the right side next to the resident's bed and the residents floor mats were doubled up on the left side of the bed.. CNA #10 stated that she did not know why the mattress was there, and thought that it may have been there for a week prior to the incident. During an interview on 10/16/13 at 4:00 pm, the DON stated that regarding the resident's fall on 10/9/13, the DON reviewed the I&A and identified that there was a full size mattress at the side of the resident's bed which he apparently tripped over and the DON demonstrated disbelief and stated, "I rely on the fact that the information I get is thorough and accurate, who would have thought that there was a full size mattress next to the resident's bed." During an interview on 10/17/13 at 10:00 am, CNA #12 stated that she has worked with Resident #2 for some time and stated that she was aware that there was a full size mattress placed on the window side of the residents bed prior to the resident's fall on 10/9/13. CNA #12 stated that when she first saw it there, she thought "is this something new?" and thought that maybe because the resident had fallen so much maybe it was placed there so the resident wouldn't get hurt, so that he had more padding than the regular floor mat. CNA #12 stated that she thinks she noticed the mattress placed beside his bed about a week before his 10/9/13 fall. During an interview on 10/17/13 at 10:15 am, LPN #1 stated that on 10/8/13 she was called out of a meeting to respond to Resident #2's fall. LPN #1 stated that the resident was found on a bed mattress on the side of his bed. LPN #1 was unable to recall the first time she observed the full size mattress next to the residents bed but thought it had been there during the weekend prior to this fall. LPN #1 stated that she did not think the full size mattress was in the resident's care plan, nor did she question the mattress to supervisory staff. LPN #1 stated that the DON was called to assess the resident at the time of the fall. LPN #1 was asked identify the mattress that was on the floor and pointed to a mattress on a bed in a room on the unit and stated, "it was like that one, blue and gray." During a follow-up interview on 10/17/13 at 10:25 am, the DON stated that he did respond to Resident #2's room to assess the resident after an unwitnessed fall. The DON stated that he did not document the assessment of the resident in the nurse's notes at that time. The DON was asked if during the assessment of the resident, did he notice the resident sitting on a full size mattress in his room and the DON responded, "no, my family is in the furniture business, I would have known if it was a full size mattress." During a follow up interview on 10/17/13 at 10:30 am, LPN #1, in the presence of the DON, was asked to identify the mattress that she found the resident on when she called the DON to assess the resident on 10/8/13, and LPN #1, pointed to the same mattress as in her 10:15 am interview, and stated "that one". During an interview on 10/17/13 at 11:30 am, RNM #2 stated that she was aware that there was a full size mattress next to Resident #2's bed, but did not know where it had come from. During an interview on 10/17/13 at 1:30 pm, LPN #2 stated that she was called to the resident's room on 10/9/13 when the resident was found bleeding after apparently tripping over a full size mattress in his room. LPN #2 stated that the mattress on the floor was blue and gray and his two floor mats were on the other side of the bed one on top of the other. During an interview on 10/17/13 at 2:15 pm, CNA #11 stated that she was working on the unit with Resident #2 on 10/9 and 10/10/13. CNA #11 stated that on 10/9/13, she and CNA #10 responded to the resident's alarm and found the resident on the floor in his bedroom, apparently after tripping on the mattress on the side of his bed. CNA #11 stated that she recalled seeing the mattress by his bed and thinks that it had been there for at least a few days prior to his fall. CNA #11 stated that she had asked one of the nurses why the mattress was there, but she thought it was an agency nurse who didn't know. CNA #11 stated that the resident's two floor mats had been placed on top of each other and place on the doorway side of the bed. During an interview on 10/17/13 Physician #1 stated that Resident #2 has had numerous falls and that the DON asked if it would be okay to put a mattress on the floor for the resident to sleep on so that if he were to roll out of bed, he would not be injured. Physician #1 stated that it is was her understanding that "we were going to trial putting his mattress on the floor without a frame" but was not sure if it made it to the care plan. Physician #1 stated that it was not her believe that a mattress would be placed beside his bed. During an interview on 10/17/13 at 4:15 pm, RNS #1, stated that she responded to Resident #2's room on 10/9/13 and found him on the floor, bleeding from his right eye after apparently tripping over the full size mattress that was next to his bed. RNS #1 stated she was unaware of why the mattress was there and had asked the other staff if the mattress was care planned. RNS #1 stated that she immediately removed the full size mattress from the resident's room. Finding2: The CCP titled Nutrition initiated on 8/9/13 documented that the resident's diet was pureed diet with honey thick liquids. physician's orders [REDACTED]. CORP - Profile History Report for Meals and Snacks for the period of 9/30/13 - 10/11/13 documented food consistency of Ground with honey thick liquids with a set up. Nurse's note dated 10/10/13 at 6:52 am signed by RNS #2 documented Resident started choking on a cupcake at 3:30 am, resident recovered quickly, close observation of resident while awake. I&A dated 10/10/13 at 3:30 am signed by RNM #2 documented that the resident started coughing after eating a cupcake and documented CNA #10 as a witness. Post fall investigation documented that the witness gave the resident a cupcake, that the action taken to prevent further incidents was "educated importance of following consistencies and that the resident was on a pureed with nectar thick liquid diet." Nurse's note dated 10/10/13 at 12:14 pm signed by RNM #2 documented an nurse's note addendum "resident given a cupcake and started coughing, he was able to clear. Has a good strong cough and is aware that he needs to cough." During an interview on 10/16/13 at 4:00 pm, the DON reviewed the I&A dated 10/10/13 at 3:30 am for Resident #2 and was asked about the choking incident. The DON stated that the resident had a coughing incident, not a choking incident. The DON reviewed the nurse's note dated 10/10/13 at 6:52 am signed by RNS #2 and stated he had not seen the nurse's note. The DON reviewed the I&A dated 10/10/13 signed by RNM #2 and stated that RNM was not on duty on 10/10/13 at 3:30 am and therefore must have completed the I&A for the RNS #2 but at no time had anyone portrayed the incident as a choking incident. When asked to identify the witness statements, the DON stated, I don't know, there are no statements attached to the I&A. The DON identified his signature at the bottom of the I&A but stated that the investigation into the incident didn't appear complete and stated that "it looks like it missed a step" as he would expect follow up on the incident. The DON stated that he did identify that there were discrepancies between the physician ordered diet and the information in the care tracker. During an interview on 10/17/13 at 11:30am RNM #2 stated that the resident's physician had brought in cupcakes for the resident to trial with speech, which were placed in her office with the resident's name on them, and someone gave the resident a cupcake at 3:30 am. RNM#2 stated that she wrote the incident as a coughing incident after talking to staff, but could not identify the staff she spoke with, and identified that there were no statements attached to the I&A. RNM #2 stated that if the resident had choked, he should have been assessed at the time for lung sounds etc, and should have been referred to speech for an evaluation, however, that had not been done. During an interview on 10/17/13 at 2:15 pm CNA #11 stated that she was working on 10/10/13 after the resident had come back from the hospital and during the night he got up and was hungry. CNA #11 stated that there were cupcakes in the RNM's office with the resident's name on them, so she and CNA #10, gave him the cupcake. CNA #11 stated that the resident began to choke for a few minutes and she thought the cupcake was stuck. CNA #11 was asked to specifically identify what the resident was doing that made he believe that the resident was choking and CNA #11 stated, "I wish they had us fill out an incident report because I don't remember exactly right now, I got nervous, I paged the nurse STAT and he was a little better when she got there, but I told her that he was choking." During an interview on 10/17/13 , physician #1 stated that she had brought Resident #2 cupcakes and placed them in the RNM's office for the resident as speech was trying to upgrade the resident's diet. Physician #1 stated that she heard the resident was given the cupcake in the middle of the night, that staff were probably trying to settle him, and that he coughed after eating the cupcake. Physician #1 stated that she was never informed that the resident choked, but that if the resident stopped talking, was unable to get air and started to turn color, he was probably choking. Physician #1 stated that the resident should have been assessed at the time and she should have been made aware of the incident. During an interview on 10/16/13 at 1:30pm CNA #10 stated that she was working on 10/10/13 and the resident was up and down several times during the night. CNA #10 stated that a container of cupcakes brought in by the resident's physician were in the RNM's office with the resident's name on it and that she gave the resident one of the cupcakes. CNA #10 stated the resident was very excited about the cupcake and ate the cupcake very quickly and on his last bite, he began to choke. CNA #10 stated that she tapped his back a little bit and he appeared okay but as she sat at the nurse's station, she noticed that the resident had stopped talking, and was alerted by CNA #11 of a concern. CNA #10 stated that CNA #11 called for the RN STAT and a short time later the resident "finally got a breath" When asked how long the incident took, CNA #10 stated "2-3 minutes, long enough that his face started turning color." CNA #10 stated at first the resident was talking, and then he was coughing for a minute or so and then he stopped and he was light grayish, you could tell he wasn't getting any air, you could tell he was choking." CNA #10 stated that she returned for the 3:00 pm - 11:00 pm shift and was approached by RNS #2 who asked her, "what were you guys thinking, the resident is on a pureed diet", and CNA#10 told her that the care tracker documented that the resident's diet was ground and since the cupcakes had the resident's name on them, she thought he could have them. CNA #10 stated that after being questioned she went to the care tracker, confirmed that the care tracker said that the resident was on a ground diet and printed it out and gave it to RNS #2. During an interview on 10/16/13 at 3:30 pm, RNS #2 stated that she responded to an overhead page for the RN STAT on 10/10/13 for Resident #2. RNS #2 stated that when she responded, CNA #10 and CNA #11 had reported that the resident had choked on a cupcake. RNS #2 stated that she observed the resident and he appeared okay when she arrived but that she sat with the resident for about 15 minutes assisting him in eating a magic cup. RNS #2 stated that the resident continued to cough intermittently throughout the fifteen minutes and it sounded as though the cough was due to the dry consistency of the cupcake. RNS #2 stated that she did not complete an I&A regarding the incident because she didn't think that it was an incident because by the time she got there the resident was coughing. RNS#2 stated that the CNAs did report that the resident was choking, she wrote a nurses note, but did not assess the resident at the time. RNS #2 stated that when the DON came in, she brought the cupcakes to him, told him about the incident and at that the he DON looked in the computer and told her the resident was on a pureed diet. RNS #2 stated that she returned for the 3:00 pm - 11:00 pm shift and approached CNA #10 about the resident's diet. RNS #2 stated that CNA #10 told her that the resident's diet was listed in care tracker as ground and that the CNA printed it for her and she gave the printed diet to the DON. During an interview on 10/16/13 at 4:00 pm, the DON reviewed the I&A dated 10/10/13 at 3:30 am for Resident #2 and was asked about the choking incident. The DON stated that the resident had a coughing incident, not a choking incident. The DON reviewed the nurse's note dated 10/10/13 at 6:52 am signed by RNS #2 and stated he had not seen the nurse's note. The DON reviewed the I&A dated 10/10/13 signed by RNM #2 and stated that RNM was not on duty on 10/10/13 at 3:30 am and therefore must have completed the I&A for the RNS #2 but at no time had anyone portrayed the incident as a choking incident. When asked to identify the witness statements, the DON stated, I don't know, there are no statements attached to the I&A. The DON identified his signature at the bottom of the I&A but stated that the investigation into the incident didn't appear complete and stated that "it looks like it missed a step" as he would expect follow up on the incident. The DON stated that he did identify that there were discrepancies between the physician ordered diet and the information in the care tracker. During an interview on 10/16/13 at 4:00 pm, the DON reviewed the I&A dated 10/10/13 at 3:30 am for Resident #2 and was asked about the choking incident. The DON stated that the resident had a coughing incident, not a choking incident. The DON reviewed the nurse's note dated 10/10/13 at 6:52 am signed by RNS #2 and stated he had not seen the nurse's note. The DON reviewed the I&A dated 10/10/13 signed by RNM #2 and stated that RNM was not on duty on 10/10/13 at 3:30 am and therefore must have completed the I&A for the RNS #2 but at no time had anyone portrayed the incident as a choking incident. When asked to identify the witness statements, the DON stated, I don't know, there are no statements attached to the I&A. The DON identified his signature at the bottom of the I&A but stated that the investigation into the incident didn't appear complete and stated that "it looks like it missed a step" as he would expect follow up on the incident. The DON stated that he did identify that there were discrepancies between the physician ordered diet and the information in the care tracker. During an interview on 10/17/13 at 11:30 am, RNM#2 reviewed the I&A that she signed on 10/10/13 at 3:30 am in which resident started coughing after eating a cupcake. The RNM stated that she was not in the facility on 10/10/13 at 3:30 am, but when she review the nurses' notes on the morning of 10/10/13 she completed the I&A based on RNS#2's nurses note at 6:52 am because it had not been done. RNM #2 stated that the resident's physician had brought in cupcakes for the resident to trial with speech, which were placed in her office w

Based on medical record review and interviews during an partial extended abbreviated survey (Complaint # NY 796), the facility failed to ensure it was administrated in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the Administration failed to thoroughly investigate incidents to rule out abuse, neglect and mistreatment and to identify and address root causes of the incidents to prevent further incidents for four residents (#1, 2, 4, & 5) of five residents reviewed. Additionally, the facility failed to ensure that residents were appropriately protected from accidents involving assistive devices, that individualized care plans were reviewed and modified or revised as indicated, and that interventions included in the investigation were added to the care plan and CORP report (care guide/tracker used by the direct care givers) to communicate the identified needs for three residents (#1, 2, and 5) of five residents reviewed. This resulted in actual harm for residents #1, 2, and 5 that is Immediate Jeopardy and Substandard Quality of care. F 225 is a repeat deficiency from the survey of April 2013. The facility has not been in compliance with State and Federal regulations since an Immediate Jeopardy in July 2013. Investigation revealed that residents sustained significant injuries that required hospitalization as a result of accident hazards and failure to ensure safety devices were careplanned, properly and thoroughly communicated to direct care staff and implemented to prevent accidents. Incidents and accidents ( I&A) were not thoroughly investigated and the Administrator, Director of Nursing and Physician of the facility, had signed off on these investigations as completed. This was evidenced by: Refer to Quality of Care F 225 scope and severity-L Refer to Quality of Care F 323 scope and severity - G Refer to Quality of Care F 492 scope and severity - L During a follow-up interview on 10/18/13 at 12:00 pm, the Administrator stated that the facility had recently implemented a new process to review I&As to determine root cause of incidents timely. The Administrator stated that in morning meetings, incidents were discussed and if more information was needed or incidents were not thorough, the incidents would be returned to the appropriate staff member for follow-up. The Administrator stated that an investigation was conducted after Resident #1's fall from the Hoyer lift, and many changes were made including identifying the appropriate sling for each of the residents. The Administrator stated that she is not sure why the loop placement is not in the care tracker for the Certified Nursing Assistants to use. The Administrator stated that it appears that the investigations for Resident #2 were not complete and it appears that they got logged into the system before all pertinent information was gathered. The Administrator stated that "our process is not tight, we are still working very hard on getting everything where it needs to be." The Administrator reviewed nursing notes and the investigation from Resident #2's I&A from 10/8/13 and stated that it did not appear that there were statements from any one other than Licensed Practical Nurse #1, and it appeared as though the resident had been removing the lap buddy earlier. The Administrator stated that the team should have known that the resident was removing the lap buddy so that the intervention could be reevaluated. The Administrator reviewed the I&A which referenced the bed mat and stated "I presume that it was a floor mat, I would not think that it was anything other than the mat for fall precautions. The Administrator reviewed the I&A dated 10/9/13 at 2:00 am, identified her signature at the bottom of the report which indicated that there was no abuse, neglect or mistreatment. The Administrator was asked to review Resident #2's care plan for I&As and stated that a full size mattress next to the resident's bed was not documented as an intervention. The Administrator stated that she does not know when or how the full size mattress got next to the resident's bed and that there does not appear to be any investigation into how, when or why it was there. The Administrator reviewed Resident #2's I&A dated 10/10/13 at 3:30 am and stated as far as she knew the resident had coughed after eating a cupcake and apparently Registered Nurse Manager #2 realized that an I&A had not been completed by RN Supervisor (RNS) #2 and began the I&A. The Administrator was asked to review RNS #2's nurses note from 10/10/13 at 6:52 am, and the Administrator stated "I have never seen that before, if I had, I would have investigated this case much differently." The Administrator stated that she had not signed off on the I&A yet, but it should have been completed and forwarded for her signature prior to today. The Administrator stated that the current tracking system used by the facility is for logging in I&As and not necessarily tracking to make sure I&As and investigations are completed timely. The Administrator stated "we are working on all of our processes for quality assurance and trying to determine the appropriate systems to address serious concerns." 10NYCRR 415.26

Based on medical record review and staff interviews the Quality Assurance (QA) program failed to have a program that readily identified issues that had the potential to cause serious harm to residents during a partial extended abbreviated survey. Specifically, for four (#s- 1, 2, 4, and 5) of five residents reviewed the QA program failed to have a procedure in place to ensure timely and thorough investigations were completed following alleged violations involving abuse, neglect, and mistreatment, including injuries of unknown origin. Additionally, the facility failed to ensure that residents were appropriately protected from accidents involving assistive devices, that individualized care plans were reviewed, modified or revised as indicated, and that interventions included in the investigation were added to the care plan and CORP report (care guide/tracker used by the direct care givers) to communicate the identified needs. This resulted in actual harm that is Immediate Jeopardy and Substandard Quality of Care. F225 is a repeat deficiency from the survey of April 2013. The facility has not been in compliance with state and federal regulations since an Immediate Jeopardy in July 2013. This is evidenced by: Refer to Quality of Care F 225 scope and severity-L Refer to Quality of Care F 323 scope and severity - G Refer to Resident Assessment F 490 scope and severity-L Refer to Quality of Care F 492 scope and severity - L During an interview on 10/18/13 at 12:00 pm, the Administrator stated that the Quality Assurance team has been actively reviewing the areas previously identified. The Administrator stated after Resident #1's fall from the Hoyer lift, the facility investigated the incident, identified that the comprehensive care plans and the resident's care profile cards did not specifically identify the proper Hoyer slings to use for each resident. The Administrator stated that there has been a policy in place long before she was the administrator of the facility, she assumed that police and procedure was being followed and had no reason to question, prior to this incident, if care staff had the training and communication they needed to properly care for residents. The Administrator stated that she was unaware that the comprehensive care plans and the care profile's for residents because in late September, the issue was added as to the Process Improvement Program (PIP) and audits had not revealed discrepancies. The Administrator stated that the Interdisciplinary Team has been reviewing Incidents and Accidents (I&As) and had been returning I&As back to nursing staff for follow-up, however, since there are I&As that do not have her signature, it appears as though the tracking of I&As is the problem, which had not been identified. 10NYCRR 415.27(a-c)

Based on observation, record review and staff interview during complaint investigation #NY 796, the facility failed to ensure that residents were appropriately protected from accidents involving assistive devices, that individualized care plans were reviewed and modified or revised as indicated, and that interventions included in the investigation were added to the care plan and CORP report (care guide/tracker used by the direct care givers) to communicate the identified needs for 3 residents (#1, 2, and 5) of 5 residents reviewed for falls and accidents. Specifically, Resident #1 fell and sustained a subarachnoid hematoma during an unsafe transfer with a mechanical Hoyer lift, Resident #2 sustained a head laceration requiring sutures, after tripping a second time on a full size mattress that was placed on the floor in his room, and Resident # 5 did not have an individualized Comprehensive Care Plan developed, modified, or changed that included the known high risk for falls, and subsequently sustained a head laceration that required sutures during the fourth documented fall. This resulted in actual harm for Residents # 1, 2 and 5 that is not immediate jeopardy This is evidenced by: The Policy & Procedure (P&P) entitled Falls and Fall Risk Managing and dated 5/16/13 documented: based on previous evaluations and current data, the staff will identify interventions related to the residents specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Approaches included; the staff with the input of the attending physician will identify appropriate interventions to reduce the risk of falls; if falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant, if underlying causes cannot be readily identified or corrected, staff will try various interventions based on assessment of the nature or category or falling until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable; in conjunction with the attending physician staff will identify and implement relevant interventions to try to minimize serious consequences of falling; staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling; if resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions; the resident's reaction to interventions and ability to comprehend the risks of falling and should be considered when implementing interventions. a balance between maintaining the resident's independence and their safety should be justified in the care plan when appropriate interventions require a choice between the two. The P&P entitled Falls-Clinical Protocol and dated 5/16/13 documented as part of the initial assessment, the physician will help identify individuals with a history of falls and risk factors for subsequent falling; the form "falls risk evaluation" will be completed by staff within 48 hours of admission and updated quarterly and with significant changes in status. In addition, the nurse shall assess and document/report the following: vital signs, recent injury, musculoskeletal function, change in cognition/consciousness, neurological status, pain, frequency of falls, precipitating factors, medications associated with dizziness or lethargy, and active diagnosis. Staff will document risk factors for falling in the resident's record and discuss the resident's fall risk. The physician will identify medical conditions affecting fall risk. Staff will evaluate and document falls that occur while the individual is in the facility. The P&P entitled Assessing Falls and Their Causes and dated 5/16/13 documented purpose of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. Preparation included, review the resident's careplan to assess for any special needs of the resident, and identify current medications and medical conditions. General guidelines included, residents must be assessed in a timely manner for potential for falls, relevant environmental issues should be addressed promptly. Steps in procedure included, if a resident has just fallen or is found on the floor without a witness to the event, nursing staff will record vital signs and evaluate for possible injuries to the head, neck, spine and extremities. A RN must be contacted to assess the extent of any significant injury identified. If there is no RN in the building, one will be contacted via phone prior to lifting the resident off the floor. For serious injuries the resident will not be lifted or moved until the Emergency Medical Technicians (EMT) have arrived. Nursing staff will notify the resident's physician and family in an appropriate time frame. Nursing staff will observe for delayed complications of a fall for approximately forty eight hours. Documentation will include any observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility and any changes of responsiveness/consciousness. An incident report must be completed for all resident falls. The charge nurse will start the report, the unit manager will complete the report and submit to the Assistant Administrator or Director of Nursing (DON) no later than 24 hours after fall. Resident #1: The resident was admitted to the facility on [DATE] diagnosed with [REDACTED]. Minimum Data Set ((MDS) dated [DATE] assessed the resident with severe cognitive impairment. The P&P titled Musculoskeletal Disorder Prevention dated 7/26/12 documented the policy is provide resident care in a safe, appropriate manner in accordance with the individual resident's care plan. The policy documents that residents will be assessed upon admission, readmission and for significant changes related to assistance with transfer activities and documents that the requirements of the policy will be reflected in the residents, care plan, aide sheet and MDS. The policy further documented that the success of the safe lift policy is the correct assessment of the residents for lift and transfer equipment, clear and consistent communications regarding the need for assistive aides and devices for individuals, and the skillful use and familiarity of the lift, transfer and repositioning equipment by the care givers. The policy documented that the sling selection is based on initial and on-going assessment and the number and types of slings should be considered. The policy documented the standard sling as a divided or full body sling which should be used for handling normal resident transfers. The Comprehensive Care Plan (CCP) title Transfers initiated on 12/29/11 documented that the resident required total assistance with 2 people and/or mechanical lift. The care plan was last reviewed on 4/17/13 and documented as appropriate. The care plan did not include specific Hoyer pad size or loop placement. The CORP (Resident Care Guide/care tracker) printed on 10/15/13 documented that the for the period of 7/1/13 through 10/1/13, Resident #1's transfer status was Hoyer lift, no ambulation. The care guide did not include specific Hoyer pad size or loop placement. Review of an Incident and Accident (I&A) Report dated 10/1/13 at 8:00 am documented that Resident #1 fell on to the floor witnessed by two Certified Nurses Assistants (CNAs) out of the Hoyer lift during transfer from bed to wheel chair. Nurse's Note dated 10/1/13 at 8:29 am documented that the family of Resident #1 was updated about being transferred to the hospital after a fall. A facility statement signed by CNA #1 dated 10/1/13, documented that she and CNA #2 were transferring Resident #1 using a Hoyer lift from his bed and "everything was in place where it was suppose to be" and "I don't know why it happened because we did everything right except I think the pad was too big for him. I would rather use a full body pad." A facility statement signed by CNA #2 undated, documented that CNA #1 had request her assistance to transfer Resident #1. CNA #2 documented that when she entered the resident's room, the resident had a Hoyer pad under him and was hooked up on CNA #1's side. CNA #2 documented that she asked CNA #1 what color (loops on the Hoyer pad to be attached to the Hoyer lift) she had on, and CNA #1 responded "purple" and therefore CNA #2 placed her side on purple. CNA #2 documented that the resident leaned forward while in the lift and fell down instantly, hitting his head on the legs of the Hoyer. Computerized Tomography (CT) Scan report dated 10/1/13 documented a new small subarachnoid hemorrhage (when blood leaks into the space between two membranes that surround the brain.) An Investigative Report dated 10/2/13 signed by the Administrator documented Resident Neglect on 10/1/13 while resident #1 was being transferred via a Hoyer lift out of bed, the resident slipped forward out of the Hoyer sling and fell to the floor hitting his head on the leg of the lift. The conclusion documented that the resident sustained [REDACTED].#1 did not ensure the resident was safe while performing a transfer from bed to wheelchair. The conclusion further documented that CNA #1 was neglectful when she admitted that the Hoyer sling was too big and did not ensure that she had the right size sling pad prior to the transfer. Additionally, the conclusion documented that CNA #1 demonstrated the wrong procedure when hooking up the resident, as she did not use the appropriate loops to hook the resident up to the Hoyer lift. During an interview on 9/15/13 at 11:30 am, CNA #5 stated that in the last couple of years, Hoyer pads have not been specified on the resident's care profiles. CNA #5 stated that she was using the same size pad for everyone. During an interview on 9/15/13 at 11:45 am, CNA #6 stated that she prefers using a full body Hoyer sling, however, if there wasn't a full body sling available, "we use what we can find". CNA #6 stated that the sling size nor the loops were identified on the residents care profile in care tracker. During an interview on 9/15/13 at 12:45 pm, the Director of Physical Therapy (PT) stated that the PT department is responsible for assessing the mechanical devices needed to transfer a resident safely, for example a Hoyer lift versus a stand lift. The Director of PT stated that nursing staff are responsible for determining which Hoyer sling; full body or divided leg sling, and, placement of the loops of the sling onto the lift. During an interview on 9/15/13 at 1:00 pm, Registered Nurse Manager (RNM) #1 stated that the facility utilizes a lift mobility assessment to determine the most appropriate mechanical transfer for residents. RNM #1 stated that the PT department is responsible for identifying the size of the sling used to Hoyer a resident and then the nurse managers or nurse supervisors would update the resident's care plan and the care tracker used by the CNAs. Upon review of Resident #1's care plan and care guide/tracker prior to the resident's fall, the RNM stated that at the time of the fall the sling and loops were not on the care plan or the care tracker and that the lift/mobility assessment was intimated after Resident #1's fall. During an interview on 9/15/13 at 1:50 pm, the Administrator stated that an investigation was initiated after Resident #1's fall from the Hoyer lift and it was determined that CNA #1 used poor judgement in transferring the resident in a Hoyer sling that she admitted may have been too big for the resident. The Administrator stated that with the assistance of corporate staff, the facility identified that the Hoyer slings (size and type) best suited for the resident's safety during transfers was not identified in the care plans or on the care tracker. The Administrator stated that after the fall, all residents requiring Hoyer transfers were assessed, the sling was identified, documented in the resident's care plan and on the care tracker. The Administrator stated that there had been some discussion about determining placement of the Hoyer pad loops onto the Hoyer lift, however, that had not been done yet. During an interview on 9/16/13 at 8:45 am, the Assistant Administrator stated that in preparation to demonstrate the Hoyer lift transfer, she was unable to locate the exact Hoyer pad used in Resident #1's fall from the Hoyer lift. The Assistant Administrator stated that after a visit from the corporate risk manager, it was determined that the Hoyer sling used on the day of the event should not have been used for anyone in the facility. That type of Hoyer sling were taken off of the nursing units. During an interview on 9/16/13 at 12:00 pm, CNA #1 stated that she was assigned to Resident #1 on 10/1/13 and stated that she asked CNA #2 to assist her from moving the resident from his bed to his wheelchair. CNA #1 stated that she used the sling that was on a chair in the resident's room but she preferred the full body sling. CNA #1 stated that prior to calling for CNA #2 to assist, she dressed the resident and placed the Hoyer sling under the resident in preparation for the transfer and attached the purple loops to the top and bottom hooks of the lift. CNA #1 stated that she placed the purple loops on the Hoyer lift because she was told that everyone is lifted using the purple loops. CNA #1 stated that she was operating the lift and CNA #2 was guiding the resident's legs when suddenly the resident fell out of the side of Hoyer sling. CNA #1 stated that the four corners of sling were attached to the Hoyer lift, but she does not recall if the loops on the sides were connected. CNA #1 stated that she didn't believe that the facility had provided her proper training on the Hoyer lift and the slings. During an interview on 9/18/13 at 9:30 am, CNA #7 who works for an agency, stated that there is no information on the care tracker that identifies which loops should be used to attach to the Hoyer lift for a particular resident. CNA #7 stated that the decision is made by looking at the resident and trying to use good judgement on the placement of the loops. During an interview on 9/18/13 at 9:45 am, CNA #8 stated that she was unaware of what loops on the Hoyer pad to use, that the information is not in the care tracker and she will usually just ask another CNA that she is working with. During an interview on 9/18/13 at 10:00 am, CNA #9 stated that she uses the top loop for the upper body and the green loops for the feet for everyone. Resident #2 The resident was admitted to the facility on [DATE] diagnosed with [REDACTED]. Finding1: Observation on 10/18/13 at 11:00 am, Resident was being wheeled about the unit by CNA #4 without a lap buddy on his wheelchair and then CNA #13 started to wheel the resident off the unit without a lap buddy. The CCP titled Accidents and Incidents initiated on 8/9/13 documented multiple interventions for the prevention of accidents and incidents, including; Lap Buddy on when up. CORP - Profile History Report for General Information for the period of 10/2/13 - 10/9/13 documented flat beveled mats on both sides of the bed and a lap buddy. Nurse's note dated 10/8/13 at 1:41 pm signed by LPN #1 documented that Resident #2 was out of bed in the morning and placed in his wheelchair for breakfast, immediately after 20 minutes, resident was attempting to transfer to a high bed. In the afternoon, resident continually taking lap buddy off and trying to stand. Nurse's note dated 10/8/13 at 3:02 pm signed by LPN #1 documented that she was called to Resident #2's room at 2:30pm. Resident was sitting on the bed mat that was placed next to his bed on the floor. Staff stated that his wheelchair alarm was sounding and he was sitting on the mat. Registered Nurse (RN) was called to assess, no injuries noted. Lap buddy was unattached from the wheelchair, resident was placed back in his wheelchair and the lap buddy was reattached. The I&A dated 10/8/13 at 2:30 pm signed by LPN #1 and the Director of Nursing (DON) documented and unwitnessed transfer from the wheelchair to bed mat on floor, alarm sounding found sitting on mat. Conclusion of incident investigation signed by the DON documented no evidence of abuse, neglect or mistreatment found, poor impulse control with a history of non-compliance, floor mat. Employee Statement signed by LPN #1 documented that she was called from a meeting to resident's room, wheelchair alarm was sounding and found resident sitting on floor bed mat. DON called, transferred to wheelchair. During an interview on 10/18/13 at 11:05 am, CNA #4 was asked by the surveyor if Resident #2 needed a lap buddy while up in his wheelchair, and CNA #4 stated "no". When asked by the surveyor to check the care tracker, CNA #4 checked the care tracker and stated, "yes, he needs a lap buddy." CNA #4 stated she had been wheeling the resident about the unit all morning as she was assigned to him as a 1:1, but was not aware that he needed a lap buddy not did she use a lap buddy. During an interview on 10/18/13 at 11:15 am, CNA #13 stated that she was assigned to Resident #2 as a 1:1 so that CNA #4 could take a break. CNA #13 stated that she was not aware that the resident needed a lap buddy in his wheelchair when she took over the 1:1 assignment with Resident #2. During a interview on 10/18/13 at 12:00 pm, the Administrator stated that it appears that the investigations for Resident #2 were not complete and it appears that they got logged into the system before all pertinent information was gathered. The Administrator stated that "our process is not tight, we are still working very hard on getting everything where it needs to be." The Administrator reviewed nursing notes and the investigation from Resident #2's I&A from 10/8/13 at stated that it did not appear that there were statements from any one other than LPN #1, and it appeared as though the resident had been removing the lap buddy earlier. The Administrator stated that the team should have known that the resident was removing the lap buddy so that the intervention could be reevaluated. Finding 2: The CCP titled Accidents and Incidents initiated on 8/9/13 documented multiple interventions for the prevention of accidents and incidents, including; bed in the lowest position except during care initiated 9/15/13, flat beveled safety mats in the floor on both sides of the bed initiated on 9/16/13. CORP - Profile History Report for General Information for the period of 10/2/13 - 10/9/13 documented flat beveled mats on both sides of the bed and a lap buddy. Nurse's note dated 10/8/13 at 1:41 pm signed by Licensed Practical Nurse (LPN) #1 documented that Resident #2 was out of bed in the morning and placed in his wheelchair for breakfast, immediately after 20 minutes, resident was attempting to transfer to a high bed. In the afternoon, resident continually taking lap buddy off and trying to stand. I&A Report dated 10/8/13 at 2:30 pm signed by LPN #1 and the Director of Nursing (DON) documented an unwitnessed transfer from the wheelchair to bed mat on floor, alarm sounding found sitting on mat. Conclusion of incident investigation signed by the DON documented no evidence of abuse, neglect or mistreatment found, poor impulse control with a history of non-compliance, floor mat. Employee Statement signed by LPN #1 documented that she was called to resident's room, wheelchair alarm was sounding and found resident sitting on floor bed mat. DON called, transferred to wheelchair. Nurse's note dated 10/8/13 at 3:02 pm signed by LPN #1 documented that she was called to Resident #2's room at 2:30 pm. Resident was sitting on the bed mat that was placed next to his bed on the floor. Staff stated that his wheelchair alarm was sounding and he was sitting on the mat. Registered Nurse (RN) was called to assess, no injuries noted. Lap buddy was unattached from the wheelchair, resident was placed back in his wheelchair and the lap buddy was reattached. I&A dated 10/9/13 at 2:00 am signed by RNS #1, DON (undated) and by the Administrator dated 10/9/13, documented that the resident was observed on the floor, blood noted on towel over right eye, CNA responded to bed alarm and found resident lying on the right side bleeding. Post Fall investigation documented environmental factors contributing to the incident, "Mats?" and obstacles as "floor mat on one side, mattress." Immediate action taken to prevent further incidents was documented as "full size mattress next to bed that resident tripped over removed immediately from scene." Conclusion, signed by the DON dated 10/9/13 documented "not enough evidence for abuse, neglect, mistreatment secondary as it is reasonable to believe that the resident, who has been known to move furniture. Resident may have been moving mattress himself and fell . Mattress removed from room." Employee Statement signed by CNA #10 documented that she responded to an alarm, found resident lying on the floor on his right side, reported to nurse. Employee Statement signed by CNA #11 documented, responded to an alarm and found resident on his right side, reported to nurse. Nurse's note dated 10/9/13 at 2:19 am signed by Registered Nurse Supervisor (RNS) #1 documented "called to floor urgently. CNA with resident holding towel to his right forehead. laying on his side on the floor next to a regular sized mattress, per staff, resident appeared to have tripped on mattress attempting to get out of bed and fell to floor hitting head. Nurse's note dated 10/9/13 at 2:54 am signed by LPN #2 documented that CNA responded to a bed alarm at approximately 2:00 am found resident hunched on the floor next to a mattress on the floor at the bedside, bleeding from laceration to right brow. Sent out for evaluation. Nurse's note dated 10/9/13 at 8:02 am signed by the DON documented a late entry from 10/8/13 at 2:30, documented that Resident #2 was found sitting on bed mat beside bed, with no apparent injury. Nurse's note dated 10/9/13 at 8:17 am signed by RNS #1 documented a call received by the hospital, per emergency room , stitches to the right eye, resident returned to the facility and settled in bed. During an interview on 10/16/13 at 1:30 pm, CNA #10 stated that she was working on 10/9/13 when she responded to Resident #2's bed alarm and found the resident on the floor bleeding from his head. CNA #10 stated there was a full size mattress on the floor on the right side next to the resident's bed and the residents floor mats were doubled up on the left side of the bed.. CNA #10 stated that she did not know why the mattress was there, and thought that it may have been there for a week prior to the incident. During an interview on 10/16/13 at 4:00 pm, the DON stated that regarding the resident's fall on 10/9/13, the DON reviewed the I&A and identified that there was a full size mattress at the side of the resident's bed which he apparently tripped over and the DON demonstrated disbelief and stated, "I rely on the fact that the information I get is thorough and accurate, who would have thought that there was a full size mattress next to the resident's bed." During an interview on 10/17/13 at 10:00 am, CNA #12 stated that she has worked with Resident #2 for some time and stated that she was aware that there was a full size mattress placed on the window side of the residents bed prior to the resident's fall on 10/9/13. CNA #12 stated that when she first saw it there, she thought "is this something new?" and thought that maybe because the resident had fallen so much maybe it was placed there so the resident wouldn't get hurt, so that he had more padding than the regular floor mat. CNA #12 stated that she thinks she noticed the mattress placed beside his bed about a week before his 10/9/13 fall. During an interview on 10/17/13 at 10:15 am, LPN #1 stated that on 10/8/13 she was called out of a meeting to respond to Resident #2's fall. LPN #1 stated that the resident was found on a bed mattress on the side of his bed. LPN #1 was unable to recall the first time she observed the full size mattress next to the residents bed but thought it had been there during the weekend prior to this fall. LPN #1 stated that she did not think the full size mattress was in the resident's care plan, nor did she question the mattress to supervisory staff. LPN #1 stated that the DON was called to assess the resident at the time of the fall. LPN #1 was asked identify the mattress that was on the floor and pointed to a mattress on a bed in a room on the unit and stated, "it was like that one, blue and gray." During a follow-up interview on 10/17/13 at 10:25 am, the DON stated that he did respond to Resident #2's room to assess the resident after an unwitnessed fall. The DON stated that he did not document the assessment of the resident in the nurse's notes at that time. The DON was asked if during the assessment of the resident, did he notice the resident sitting on a full size mattress in his room and the DON responded, "no, my family is in the furniture business, I would have known if it was a full size mattress." During a follow up interview on 10/17/13 at 10:30 am, LPN #1, in the presence of the DON, was asked to identify the mattress that she found the resident on when she called the DON to assess the resident on 10/8/13, and LPN #1, pointed to the same mattress as in her 10:15 am interview, and stated "that one". During an interview on 10/17/13 at 11:30 am, RNM #2 stated that she was aware that there was a full size mattress next to Resident #2's bed, but did not know where it had come from. During an interview on 10/17/13 at 1:30 pm, LPN #2 stated that she was called to the resident's room on 10/9/13 when the resident was found bleeding after apparently tripping over a full size mattress in his room. LPN #2 stated that the mattress on the floor was blue and gray and his two floor mats were on the other side of the bed one on top of the other. During an interview on 10/17/13 at 2:15 pm, CNA #11 stated that she was working on the unit with Resident #2 on 10/9 and 10/10/13. CNA #11 stated that on 10/9/13, she and CNA #10 responded to the resident's alarm and found the resident on the floor in his bedroom, apparently after tripping on the mattress on the side of his bed. CNA #11 stated that she recalled seeing the mattress by his bed and thinks that it had been there for at least a few days prior to his fall. CNA #11 stated that she had asked one of the nurses why the mattress was there, but she thought it was an agency nurse who didn't know. CNA #11 stated that the resident's two floor mats had been placed on top of each other and place on the doorway side of the bed. During an interview on 10/17/13 Physician #1 stated that Resident #2 has had numerous falls and that the DON asked if it would be okay to put a mattress on the floor for the resident to sleep on so that if he were to roll out of bed, he would not be injured. Physician #1 stated that it is was her understanding that "we were going to trial putting his mattress on the floor without a frame" but was not sure if it made it to the care plan. Physician #1 stated that it was not her believe that a mattress would be placed beside his bed. During an interview on 10/17/13 at 4:15 pm, RNS #1, stated that she responded to Resident #2's room on 10/9/13 and found him on the floor, bleeding from his right eye after apparently tripping over the full size mattress that was next to his bed. RNS #1 stated she was unaware of why the mattress was there and had asked the other staff if the mattress was care planned. RNS #1 stated that she immediately removed the full size mattress from the resident's room. During an interview on 10/18/13 at 12:00pm the administrator reviewed the I&A which referenced the bed mat and stated "I presume that it was a floor mat, I would not think that it was anything other than the mat for fall precautions. The Administrator reviewed the I&A dated 10/9/13 at 2:00 am, identified her signature at the bottom of the report which indicated that there was no abuse, neglect or mistreatment. The Administrator was asked to review Resident #2's care plan for I&As and stated that a full size mattress next to the resident's bed was not documented as an intervention. The Administrator stated that she does not know when or how the full size mattress got next to the resident's bed and that there does not appear to be any investigation into how, when or why it was there. The Administrator stated that the current tracking system used by the facility is for logging in I&As and not necessarily tracking to make sure I&As and investigations are completed timely. The Administrator stated "we are working on all of our processes for quality assurance and trying to determine the appropriate systems to address serious concerns." Finding 3: The CCP titled Nutrition initiated on 8/9/13 documented that the resident's diet was pureed diet with honey thick liquids. physician's orders [REDACTED]. CORP - Profile History Report for Meals and Snacks for the period of 9/30/13 - 10/11/13 documented food consistency of Ground with honey thick liquids with a set up. Nurse's note dated 10/10/13 at 6:52 am signed by RNS #2 documented Resident started choking on a cupcake at 3:30 am, resident recovered quickly, close observation of resident while awake. I&A dated 10/10/13 at 3:30 am signed by RNM #2 documented that the resident started coughing after eating a cupcake and documented CNA #10 as a witness. Post fall investigation documented that the witness gave the resident a cupcake, that the action taken to prevent further incidents was "educated importance of following consistencies and that the resident was on a pureed with nectar thick liquid diet." Nurse's note dated 10/10/13 at 12:14 pm signed by RNM #2 documented an nurse's note addendum "resident given a cupcake and started coughing, he was able to clear. Has a good strong cough and is aware that he needs to cough." During an interview on 10/16/13 at 4:00 pm, the DON reviewed the I&A dated 10/10/13 at 3:30 am for Resident #2 and was asked about the choking incident. The DON stated that the resident had a coughing incident, not a choking incident. The DON reviewed the nurse's note dated 10/10/13 at 6:52 am signed by RNS #2 and stated he had not seen the nurse's note. The DON reviewed the I&A dated 10/10/13 signed by RNM #2 and stated that RNM was not on duty on 10/10/13 at 3:30 am and therefore must have completed the I&A for the RNS #2 but at no time had anyone portrayed the incident as a choking incident. When asked to identify the witness statements, the DON stated, I don't know, there are no statements attached to the I&A. The DON identified his signature at the bottom of the I&A but stated that the investigation into the incident didn't appear complete and stated that "it looks like it missed a step" as he would expect follow up on the incident. The DON stated that he did identify that there were discrepancies between the physician ordered diet and the information in the care tracker. During an interview on 10/17/13 at 11:30am RNM #2 stated that the resident's physician had brought in cupcakes for the resident to trial with speech, which were placed in her office with the resident's name on them, and someone gave the resident a cupcake at 3:30 am. RNM#2 stated that she wrote the incident as a coughing incident after talking to staff, but could not identify the staff she spoke with, and identified that there were no statements attached to the I&A. RNM #2 stated that if the resident had choked, he should have been assessed at the time for lung sounds etc, and should have been referred to speech for an evaluation, however, that had not been done. During an interview on 10/17/13 at 2:15 pm CNA #11 stated that she was working on 10/10/13 after the resident had come back from the hospital and during the night he got up and was hungry.

Based on interview during an abbreviated partially extended survey (#NY 718) the facility did not ensure the quality assessment and assurance committee (QA) identified issues that had the potential to cause serious harm to residents. Specifically, for 7 ( #s- 1,2,3,4,5,6 and 7) of 15 residents reviewed, the QA failed to ensure residents received physician ordered laboratory testing and did not ensure that resident's received physician ordered anticoagulant therapy. This is a repeat deficiency from the abbreviated survey dated 7/15/13., which resulted in Immediate jeopardy . The facility is currently in their correction phase from the 7/15/13 Immediate jeopardy. This resulted in no actual harm with the potential for more than serious harm that is Immediate Jeopardy to resident health and safety. This was evidenced by: Refer to F 329 -scope and severity- K- Unnecessary Medications Refer to F 309- scope and severity- K - Quality of Care During an interview on 9/16/13 at 9:50 am, the Director of Nurses (DON) stated that she was actively involved in auditing to ensure that resident's were receiving all of their physician ordered medications in a timely manner. The DON stated that the PT( [MEDICATION NAME])/INR's ( international normalized ratio ) , both blood teats to measure blood coagulation , were recorded on a flow sheet in which nursing staff would document the INR value, call the physician and obtain another order which was placed on the flow sheet. The DON stated that the flow sheets are what the nursing staff and physician's used to communicate values and orders for anticoagulant therapy. The DON stated by utilizing the flow sheet as the orders, the physician orders [REDACTED]. The facility did not identify that residents had missed INRs, and had missed or received inaccurate doses of medications. During an interview on 9/16/13 at 10:15 am the Medical Director (MD) stated the nursing staff and the physicians have been using the flow sheet to record INR values and subsequent MEDICATION ORDERS FOR [REDACTED]. MD stated that the nursing staff responsible for testing and medication administration are focused on the computerized system and so while the long term nurses carried out physician's orders [REDACTED]. The MD stated she was working with the facility to review timeliness of medications, but this issue did not come up during those reviews, because everything was on the flow sheet and not in the computer. During an interview on 9/16/13 at 11:00 am the Administrator stated that she was reviewing audit and compliance reports for the timeliness of medication administration and this issue did not come up. The Administrator stated that the issues did not appear because all of the orders on the flow sheet, did not make it to the computerized system. 10NYCRR 415.27(a-c)

Based on record review and staff interviews, the Administration failed to ensure that the facility operated in a manner that enabled it to effectively use its resources to maintain the highest practicable well-being and safety of each resident. (#NY 718) Specifically, for 7 (1, 2, 3, 4, 5, 6 and 7) of 15 residents reviewed, the Administration failed to have systems in place to ensure that staff consistently and accurately completed the process for acquiring orders for [MEDICATION NAME] (an anticoagulant , thins blood) dosing and INR ( international normalized ratio ) testing; failed to ensure that residents received the correct dose of [MEDICATION NAME] and had INR ' s drawn on days indicated by physicians. This resulted in residents not receiving [MEDICATION NAME] or not receiving the correct dose of [MEDICATION NAME] as indicated by the physician on physicians orders or on the INR flow sheet; not having INR ' s drawn on the date indicated by physician's order [REDACTED]. Interviews revealed that all staff were not instructed on the use of INR machines and the process for acquiring and implementing [MEDICATION NAME] and INR orders and that [MEDICATION NAME] doses and dates for future INR testing were not consistently entered into the electronic medical record (EMR) as physician orders; that registered nurses and physicians were unaware that [MEDICATION NAME] doses and dates for future INRs were not entered into EMR as orders and were not aware of the number of medication errors made involving [MEDICATION NAME] administration. Investigation further revealed that residents missed INR tests and doses of [MEDICATION NAME], or did not receive the correct dose of [MEDICATION NAME] as indicated by physicians (MDs) / nurse practitioner (NPs) on the INR flow sheets. Investigation further revealed that the testing for and administration of [MEDICATION NAME] was not being monitored by the facility administration and the administration was not aware of this being an issue. This had the potential to affect all residents receiving anticoagulants. This resulted in no actual harm but had the potential for more than serious harm that is Immediate Jeopardy to resident health and safety. This was evidenced by: Refer to F-309 scope and severity K- Quality of Care Refer to F-329 scope and severity K - Unnecessary Medications During an interview on 9/13/13 at approximately 2:00pm the facility Medical Director (MD#1) stated that she was aware that there had been problems with some of the INR ' s being done when they should have been but was not aware there had been so many errors in [MEDICATION NAME] administration. MD #1 stated there are so many agency staff nurses her and I would imagine it is overwhelming for them to figure things out. It ' s a problem to have so many staff who are unfamiliar with the residents and the way we do things here. MD# 1 was assuming that the orders she gave on the phone or wrote on the flowsheet were being documented as orders in the EMR and was surprised to hear the information was not being entered in the EMR as orders. MD# 1 generally desired a therapeutic range for the residents INR ' s between 2.0 and 3.0 MD# 1 stated she felt that the problems with [MEDICATION NAME] administration and INR ' s had to be addressed immediately and to prevent resident s being harmed. During an interview on 9/13/13 at approximately 12:30pm, the facility Director of Nursing (DON) stated that she was aware that some of the residents had not had INRs done on 9/3 or 9/4/13 but was unaware of the number of errors made involving the administration of [MEDICATION NAME] and was not aware that what the MD ' s were documenting on the INR flow sheets, was not being transcribed into the electronic medication administration record (EMAR). The DON stated that if the order that the MD indicated on the flowsheet had been entered into the EMAR and entered accurately that it was a great tool to ensure that the accurate [MEDICATION NAME] dose was administered and that the next INR was done on the correct day. The DON assumed the staff was following the process. When shown the number of errors with [MEDICATION NAME] dosing, errors of omission and missed INRs, the DON stated that she had no idea the problem (with [MEDICATION NAME] administration and INRs) was so big. Although the staff was doing audits for medication administration the DON stated that this particular issue would not have shown up on those audits. The DON stated that it was troubling. During an interview on 9/13/13 at approximately 1:30pm the facility Administrator (FA) stated that she had been at the facility for just a couple of months and was aware that there were issues with medications but not aware of the problems that had been identified with [MEDICATION NAME] and INRs. Because there had been issues identified in the past, the staff had been auditing medications. The FA stated that the audits currently being done would not have identified the problems with [MEDICATION NAME] and INRs. The FA was made aware on 9/5/13 when she returned from a holiday weekend, that several residents had not had INRs done when the MD wanted them. Upon hearing this information the FA instructed nursing administration to start an investigation to find out what went wrong. The FA stated that she was aware that there was agency staff in the building and she was not comfortable with the number of agency staff that they were using. She had contacted the agency and instructed them to use consistent agency staff whenever possible. The FA added that she was attempting to hire new staff and reduce the number of agency staff that was being utilized. 10NYCRR 415.26

Based on medical record review and staff interviews during a partial extended abbreviated survey for a complaint (#NY 718), the facility failed to ensure that 5 ( #s-1 , 2, 3, 4, 6 and 7) of 15 residents reviewed did not receive unnecessary drugs; did not receive excessive dosing of drugs and did not receive adequate monitoring for drugs. Specifically, the facility failed to perform Residents INR ' s (international normalized ratio, a test to monitor blood clotting time) on the dates indicated by the physicians; failed to consistently ensure that physicians were aware of INR results so dosing could be adjusted appropriately amd failed to withhold drugs when indicated by the physician. This had the potential to affect all of the residents in the facility receiving anticoagulants. This resulted in no actual harm, with the potential for more than serious harm that is Immediate Jeopardy to residents' health and safety and Substandard Quality of Care for the residents. The facility is currently in the correction phase of an Immediate Jeopardy and Substandard Quality of Care in the area of significant medication errors. The facility was able to remove the immediacy prior to exit by implementing the following: -Revision of the Policy and Procedure for Anticoagulation. -Reviewing and auditing daily of all residents receiving anticoagulation therapy to ensure PT/INRs have been completed by policy and procedure. This includes a report generated from the EMR to identify new/renewed anticoagulation medications for current residents and/or new admissions. The daily audits will be reviewed by the ADON to ensure the process has been completed. -90% of all scheduled staff have been re-educated on completing PT/INR testing and transcription of Physicians orders, including licensed agency staff. Additional licensed agency staff will receive education prior to accepting assignment. No licensed staff will render direct care prior to receiving education. -All orders for anticoagulation medication will be entered into the EMR directly by the physician or via verbal order and signed by the physician within 48 hours. This is evidenced by the following: Resident #1 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15, or cognitively intact. On a facility provided document, titled INR flow sheet and identified to be for Resident # 1, the Resident ' s INR on 9/3/13 was documented to be 3.4 (above the identified therapeutic range of 2.0 to 3.0). After reviewing this, the physician (MD#1) wrote on 9/3/13 to hold the resident ' s dose of [MEDICATION NAME] and draw an INR on the morning of 9/4/13. On 9/4/13 the resident s INR was identified to be 3.8, and the MD documented that the residents [MEDICATION NAME] should once again be held. On 9/5/13 the residents INR is documented to be 4.2 and the MD wrote to hold the resident ' s [MEDICATION NAME]. Resident # 1 ' s medication administration record (MAR) for September 2013, revealed the resident received [MEDICATION NAME] 1.5mgs (milligrams) on September 3rd and 4th. During an interview on 9/11/13 at approximately 3:45pm a licensed practical nurse (LPN#1) stated that she worked the 3:00pm to 11:00pm shift on 9/3/13 and 9/4/13 and was responsible for passing medications including [MEDICATION NAME]. LPN#1 stated that she gave Resident # 1 [MEDICATION NAME] because it was on the MAR to give it. There was no order to discontinue or hold the resident ' s [MEDICATION NAME] in the computer or on the MAR. LPN #1 stated she probably should have waited and looked at the INR flowsheet in the unit binder, but at the time she was passing medications, she could not find the binder on the unit and decided to give the medication anyway, thinking the resident needed her [MEDICATION NAME]. LPN#1 did not know if the physician had seen the INR results that day. The physician orders [REDACTED]. Resident # 3 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS assessed the resident to have a BIMS score of 14 or cognitively intact. On a facility provided document, titled INR flow sheet and identified to be for Resident #3, MD #1 wrote on 9/3/13 to give [MEDICATION NAME] 4.5mg and draw the next INR on 9/4/13. There is no INR drawn on 9/4/13. On 9/5/13 the resident ' s INR was noted to be 1.3, below the therapeutic range of 2.0 to 3.0. A review of Resident # 3 ' s MAR for September revealed the resident did not receive any [MEDICATION NAME] on 9/3/13 and 9/4/13. physician's order [REDACTED]. In addition, there was no order written for [MEDICATION NAME] for 9/3/13 and 9/4/13. Resident # 7 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS assessed the resident had long and short term memory impairment. On a facility provided document, titled INR flow sheet and identified to be for Resident #7, MD #1 wrote on 8/30/13 to give [MEDICATION NAME] 3.5mg and draw the next INR on 9/3/13. There was no INR documented on 9/3/13 or on 9/4/13. The next INR was drawn on 9/5/13 when the resident ' s INR was noted to be 1.3 and below the therapeutic range of 2.0 to 3.0. A review of Resident # 7 ' s MAR for August 2013 revealed the resident did not receive any [MEDICATION NAME] on 8/30/13. During an interview on 9/12/13 at approximately 10:00am, an agency LPN (LPN#2) stated that she worked on 9/3/13 from 7:00am to 3:30pm and there were a number of residents who were scheduled to have INRs drawn. LPN#2 stated the LPN on the other medication cart was also an agency LPN which was unusual as typically there was one agency LPN and one LPN that worked for the facility. LPN#2 was asked by the second agency LPN to do all of the INR ' s as she was not really comfortable doing them and most were on LPN#2 ' s side. LPN#2 agreed and although she had never used an INR machine before, she stated that she " muddled through it and eventually figured out " how to do the INR ' s. After documenting the results on the flow sheets in the unit binder, she was told by the Nurse Manager to give the binder to the MD. LPN#2 thought she did INR ' s on all of the residents that should have had them done that day but was not sure if the MD wrote [MEDICATION NAME] orders. She did not put any [MEDICATION NAME] orders into the computer because she did not know she was expected to do that. LPN#2 stated she felt that things fell through the cracks at the facility and because she was an agency nurse and did not know the facility process in a lot of areas, she worried about things getting done the right way. During an interview on 9/12/13 at approximately 11:00am, an agency LPN (LPN#3) stated that he had worked the day shift on 9/4/13 and was informed by someone that he was expected to draw the INR ' s for the residents on the unit. LPN#3 stated he told the Unit manager (RNUM#1) that he was unfamiliar with the machine and that he would not be doing the INR ' s. LPN#3 stated that at some time toward the end of his shift that day, he was taught how to use the INR machine by a nurse educator. He did not do the residents INR ' s that day because he thought the unit manager (RNUM#1) had done them. During an interview on 9/12/13 at approximately 1:00pm, registered nurse unit manager (RNUM #1) stated that on 9/4/13 she was told by LPN#3 that he was unfamiliar with the INR machine and how to operate it. RNUM#1 stated that she took the time then to instruct LPN#3 on how to operate the machine and assumed that he would then go and perform the INRs and document results on the flow sheets. Later in the day RNUM #1 asked LPN#3 if everything was going okay and when he replied that it was, she assumed he had completed the INR ' s without any trouble. She was not made aware that many INRs had not been done that day. During an interview on 9/11/13 at approximately 3:00pm, a facility RNUM#2 stated that day shift nurses drawn the INRs and enter the results on the INR flow sheets and when the MDs make rounds, they review the INR results and document on the flow sheet when the next INR should be drawn and how much [MEDICATION NAME] the resident should receive until the next INR. If the MD is not in the building, they are contacted by phone and the same information is obtained. The nurse then should enter the [MEDICATION NAME] dose and the date for the next INR into the electronic medical record (EMR) and that information drops into the electronic MAR. The RNUM stated that the MDs could enter their own [MEDICATION NAME] orders into the EMR but are reluctant to do so and would rather have the nurse do that for them. During an interview on 9/13/13 at approximately 12:30pm, the facility Director of Nursing stated that she was aware that some of the residents had not had INRs done on 9/3 or 9/4/13 but was unaware of the number of errors made involving the administration of [MEDICATION NAME] and was not aware that what the MD ' s were documenting on the INR flow sheets, was not being transcribed into the EMAR. The DON stated that if the order that the MD indicated on the flowsheet had been entered into the EMAR and entered accurately that it was a great tool to ensure that the accurate [MEDICATION NAME] dose was administered and that the next INR was done on the correct day. The DON assumed the staff was following the process. When shown the number of errors with [MEDICATION NAME] dosing, errors of omission and missed INRs, the DON stated that she had no idea the problem (with [MEDICATION NAME] administration and INRs) was so big. Although the staff were doing audits for medication administration the DON stated that this particular issue would not have shown up on those audits. The DON stated that it was troubling. 10 NYCRR 415.12(i)(1)

Based on medical record review and staff interviews during a partial extended abbreviated survey for complaint (#NY 718), the facility failed to ensure that necessary care and services were provided to maintain 7 ( #s- 1,2,3,4,5,6 and 7) of 15 residents reviewed, at their highest practicable physical, mental and psychosocial well-being, in accordance with their comprehensive assessment and plan of care. Specifically, the facility failed to ensure that residents received the dose of [MEDICATION NAME] indicated by the physician (MD)on the flow sheets, failed to consistently enter [MEDICATION NAME] and INR orders into the electronic medical record; failed to ensure that physician orders [REDACTED]. This had the potential to affect all of the residents in the facility receiving anticoagulants. This resulted in no actual harm, with the potential for more than serious harm that is Immediate Jeopardy to residents' health and safety and Substandard Quality of Care for the residents. The facility is currently in the correction phase of an immediate jeopardy and substandard quality of care in the area of significant medication errors. The facility was able to remove the immediacy prior to exit by implementing the following: -Revision of the Policy and Procedure for Anticoagulation. -Reviewing and auditing daily of all residents receiving anticoagulation therapy to ensure PT/INRs have been completed by policy and procedure. This will include a report generated from the EMR to identify new/renewed anticoagulation medications for current residents and/or new admissions. The daily audits will be reviewed by the ADON to ensure the process has been completed. -90% of all scheduled staff have been re-educated on completing PT/INR testing and transcription of Physicians orders, including licensed agency staff. Additional licensed agency staff will receive education prior to accepting assignment. No licensed staff will render direct care prior to receiving education. -All orders for anticoagulation medication will be entered into the EMR directly by the physician or via verbal order and signed by the physician within 48 hours. This is evidenced by the following: Resident # 2 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessed the resident had long and short term memory loss. On a facility provided document, titled INR flow sheet and identified to be for Resident #2, the Nurse Practitioner wrote on 8/30/13, to change the resident ' s dose of [MEDICATION NAME] to 5mg each day and to perform the next INR on 9/3/13. There was no entry on the flowsheet from 8/30/13 until 9/5/13, when a nurse documented that the resident ' s INR on 9/5/13, is 1.6 (a sub therapeutic result) and the MD documented that the resident should receive [MEDICATION NAME] 7.5mg and to draw an INR on 9/6/13. A review of Resident # 2 ' s Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The physician's order [REDACTED]. Resident #4 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS assessed the resident to have a BIMS score of 10, or moderate impairment with cognitive abilities. On a facility provided document, titled INR flow sheet and identified to be for Resident #4, MD#1 wrote on 8/26/13, to change the resident ' s dose of [MEDICATION NAME] to 7.5mg each day and to perform the next INR on 8/30/13. On 8/30/13, the Nurse Practitioner wrote to change the resident ' s dose of [MEDICATION NAME] to 2mg and to draw the next INR on 9/3/13. There was no entry on the flowsheet from 8/30/13 until 9/5/13, when a nurse documented that the resident ' s INR on 9/5/13 was 3.7 (a level above the therapeutic range of 2.0 to 3.0) and to hold the residents [MEDICATION NAME] and draw an INR on 9/6/13. A review of Resident # 4 ' s MAR from 8/30/13 to 9/5/13 revealed that the resident received [MEDICATION NAME] 7.5mg on 8/31/13 as well as on 9/1/13 through 9/4/13. The resident did not receive any [MEDICATION NAME] on 8/30/13. A review of the physician's order [REDACTED]. Resident# 5 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS assessed the resident to have long and short memory problems. On a facility provided document, titled INR flow sheet and identified to be for Resident #5, MD#1 wrote on 8/29/13 to administer the " same " dose of [MEDICATION NAME] that had been previously ordered (2.5mg on Monday and Fridays and 5mg every other day). On 9/3/13 MD#1 wrote to change the dose of [MEDICATION NAME] to 5mg each day and to draw the next INR on 9/4/13. The resident ' s INR ' s are documented on the flowsheet as: 8/29/13= 2.1, 8/30/13=1.8 and 9/3/13=1.4 . A review of Resident # 5 ' s MAR from 8/29/13 to 9/5/13 revealed that the resident did not receive [MEDICATION NAME] 5mg on 8/29/13. A review of the physician's order [REDACTED]. During an interview on 9/12/13 at approximately 10:00am, an agency LPN (LPN#2) stated that she worked on 9/3/13 from 7:00am to 3:30pm and there were a number of residents who were scheduled to have INRs drawn. LPN#2 stated the LPN on the other medication cart was also an agency LPN. LPN#2 was asked by the second agency LPN to do all of the INR ' s as she was not really comfortable doing them and most were on LPN#2 ' s side of the unit. LPN#2 agreed and late in the day, started to do the INR ' s Although she had never used an INR machine before, she stated that she " muddled through and eventually figured out " how to do the INR ' s. LPN#2 stated the RNUM was at meetings most of the morning and not available for instruction. After documenting the results on the flow sheets in the unit binder and not knowing what to do next she waited for the Nurse Manager, who instructed her to give the binder to the MD. LPN#2 thought she did INR ' s on all of the residents that should have had them done that day but was not sure if the MD wrote [MEDICATION NAME] orders. LPN#2 did not put any [MEDICATION NAME] or INR orders into the computer and did not know she was expected to do that. LPN#2 stated she felt that things fell through the cracks at the facility and because she was an agency nurse and did not know the facility process in a lot of areas, she worried about things getting done the right way. During an interview on 9/12/13 at approximately 11:00am, an agency LPN (LPN#3) stated that he had worked the day shift on 9/4/13 and was informed by someone that he was expected to draw the INR ' s for the residents on the unit. LPN#3 stated he told the Unit manager (RNUM#1) that he was unfamiliar with the machine and that he would not be doing the INR ' s. LPN#3 stated that at some time toward the end of his shift that day, he was taught how to use the INR machine by a nurse educator. He did not do the residents INR ' s that day because he thought the unit manager (RNUM#1) had done them. He stated he did not know about entering [MEDICATION NAME] or INR orders into the computer. During an interview on 9/12/13 at approximately 1:00pm, RNUM #1 stated that on 9/4/13 she was told by LPN#3 that he was unfamiliar with the INR machine and how to operate it. RNUM#1 stated that she took the time then to instruct LPN#3 on how to operate the machine and assumed that he would then go and perform the INRs and document results on the flow sheets. Later in the day RNUM #1 asked LPN#3 if everything was going okay and when he replied that it was, she assumed he had completed the INR ' s without any trouble. She was not made aware that many INRs had not been done that day. During an interview on 9/11/13 at approximately 3:00pm, a facility RNUM#2 stated that day shift nurses drawn the INRs and enter the results on the INR flow sheets and when the MDs make rounds, they review the INR results and document on the flow sheet when the next INR should be drawn and how much [MEDICATION NAME] the resident should receive until the next INR. If the MD was not in the building, they are contacted by phone and the same information is obtained. The nurse then should enter the [MEDICATION NAME] dose and the date for the next INR into the electronic medical record (EMR) and that information drops into the electronic MAR. The RNUM stated that the MDs could enter their own [MEDICATION NAME] orders into the EMR but are reluctant to do so and would rather have the nurse do that for them. During an interview on 9/13/13 at approximately 2:00pm the facility Medical Director (MD#1) stated that she was aware that there had been problems with some of the INR ' s being done when they should have been but was not aware there had been so many errors in [MEDICATION NAME] administration. MD #1 stated there are so many agency staff nurses her and I would imagine it is overwhelming for them to figure things out. It ' s a problem to have so many staff here who are unfamiliar with the residents and unfamiliar with the way we do things here. MD# 1 was assuming that the orders she gave on the phone or wrote on the flowsheet were being documented as orders in the EMR and was surprised to hear the information was not being entered in the EMR as orders. MD# 1 generally desired a therapeutic range for the residents INR ' s was between 2.0 and 3.0 MD# 1 stated she felt that the problems with [MEDICATION NAME] administration and INR ' s had to be addressed immediately and to prevent resident s being harmed. 10 NYCRR 415.12

Based on interview, during an abbreviated survey (#NY 511) the facility did not ensure the quality assessment and assurance committee (QA) identified issues that had the potential to cause serious harm to residents. Specifically, the QA failed to ensure residents received significant necessary medications on the day of admission/readmission. This resulted in no actual harm with the potential for serious harm that is IMMEDIATE JEOPARDY to resident health and safety. This was evidenced by: Refer to F 333 scope and severity- K- Medication Errors During an interview on 5/15/13 at 12:10 pm, the Director of Nurses (DON) stated she was not aware of a problem with newly admitted residents receiving their medications. She stated that there was one instance this past week when she was notified by an LPN that a new Resident ' s medications did not arrive for the first administration. The DON stated the pharmacy and MD were notified of this occurrence. The DON stated she did not think to look into other newly admitted residents. DON stated that when the new pharmacy began a couple of months ago that the pharmacy was in the facility for a week in-servicing nurses. DON stated that there was no medication issues discussed in QA. Stated that new admissions were discussed in morning meeting and she would ask if medications arrived and was never told that the medications did not come in until the following day. Nurses should have been using the back-up box for medications and notifying the physician and pharmacy, the facility had a local back-up pharmacy as well. During an interview on 7/11/13 at 3:00 pm the Administrator stated that she had only been working in the facility for a few weeks and during that time she was not made aware of any problems with the admissions or readmissions not receiving their medications. Stated that in the morning meetings there is a review of the timeliness of medications and there has been no recent issues. During an interview on 7/15/13 at 10:45 am the Administrator stated that on 7/12/13 the Quality Improvement committee (QA) convened for a special meeting to review Resident # 1's readmission and found that the medications had not been given on the evening of her readmission. The facility had no prior knowledge of a problem with her readmission or other admissions/readmissions before the abbreviated survey. QA meets on a monthly basis and the attendees include all department heads, the Nurse Managers were not included in the meetings. The Quarterly QA meetings include the Medical Director, Pharmacy consultant, Corporate consultant as well as the department heads. The DON is in charge of the QA program. Administrator stated there will be changes to the QA process in the future to include the Nurse Managers attending, and a more extensive agenda. During an interview on 7/11/13 at 3:45 pm the Medical Director stated the pharmacy does have three delivery runs per day and an emergency pharmacy backup, and she would expect to be notified if a medication was unavailable. Medical Director was aware that the facility was having trouble getting discharge summaries from the hospital prior to an admission/readmission, but was not aware that there was a problem with medications being available and administered. 10NYCRR 415.27(a-c)

Based on record review, and staff interviews, the Administration failed to ensure that the facility operated in a manner that enabled it to effectively use its resources to maintain the highest practicable well-being and safety of each resident. (#NY 511) Specifically, for 6 (1, 2, 3, 4, 5, 10) of 7 residents reviewed, the Administration failed to have systems in place to ensure that staff completed the admission /readmission process timely. This resulted in a delay for those residents receiving physician ordered significant medications. Interviews revealed staff failed to complete the admission or readmission process for newly admitted and readmitted residents in a timely manner, resulting in residents not receiving medications as ordered by the physician. Investigation further revealed that the staff were not following the facility policy by notifying the physician, pharmacy and supervisor when medications were not available for administration. Investigation further revealed that the administration of medications for readmitted or newly admitted residents was not being monitored by the facility administration and the administration was not aware of this being an issue. This resulted in no actual harm but had the potential for serious harm that is IMMEDIATE JEOPARDY to resident health and safety. The facility was able to remove the immediacy prior to exit. This was evidenced by: Refer to F 333 scope and severity- K- Medication Errors During an interview on 7/11/13 at 2:00 pm Director of Nursing (DON) stated that after the start of the complaint survey a review was done of Resident # 1's readmission. DON could not explain what had happened on her readmission and why the Resident did not receive her medications. DON began an investigation into the Resident's readmission and would be talking with the staff. The Resident did have her medications here in the facility so it was not a matter of getting the medications, but the orders had not been received. DON was not aware that readmitted and newly admitted residents were not receiving their medications on the evening of admission. DON stated that there was daily monitoring of the computer system to assure timeliness of medication administration and there were no issues that she was aware of. During an interview on 7/11/13 at 3:00 pm the Administrator stated that she had only been working in the facility for a few weeks and during that time she was not made aware of any problems with the admissions or readmissions not receiving their medications. Stated that in the morning meetings there is a review of the timeliness of medications and there has been no recent issues. During an interview on 7/15/13 at 10:45 am the Administrator stated that on 7/12/13 the Quality Improvement committee reviewed Resident # 1's readmission and found that the medications had not been given on the evening of her readmission. The facility had no prior knowledge of a problem with her readmission or other admissions/readmissions before the abbreviated survey. During an interview on 7/11/13 at 3:45 pm the Medical Director stated it would be an extreme exception for a resident not to receive their medications on the day of admission/readmission. The pharmacy does have three delivery runs per day and an emergency pharmacy backup, and she would expect to be notified if a medication was unavailable. Medical Director was aware that the facility was having trouble getting discharge summaries from the hospital prior to an admission/readmission, but was not aware that there was a problem with medications being available and administered. 10NYCRR 415.26

Based on medical record review and staff interview during a partially extended abbreviated survey (#NY 511) the facility failed to ensure that residents were free of significant medication errors. Specifically, for 6 (1, 2, 3, 4, 5 and 10) of 7 residents reviewed the facility failed to ensure residents received significant necessary medications. A record review noted delays in medications for newly admitted and/or readmitted residents. Significant medication omissions included a 24 hour delay with the administration of several medications critical to resident care including [MEDICATION NAME] insulin, [MEDICATION NAME]with fingerstick, [MEDICATION NAME], and [MEDICATION NAME]. In addition, the orders for residents who are being admitted or readmitted are not being transcribed for up to ten hours after being admitted /readmitted . Interviews revealed staff were not completing the admissions in a timely manner to ensure medications were available and there was a lack of communication between the unit nurses and nursing supervisors. This had the potential to affect all residents admitted and/or readmitted who will be receiving medication. This resulted is no actual harm with potential for serious harm that is Immediate Jeopardy and Substandard Quality of Care. The facility was able to remove the immediacy prior to exit by implementing the following: 1. Revision of the Policy and Procedures. 2. Reviewing and auditing all new admissions and readmissions for completion and accuracy of physician's orders [REDACTED]. 3. All licensed staff were educated on the areas of concern noted in the deficiencies, including electronic physician order [REDACTED]. Additionally, all licensed staff were educated regarding the purpose and use of the electronic board indicating late medications and the Electronic Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. This is evidenced by the following: The Policy & Procedure (P&P) for Medication Orders, Receiving and Errors dated 4/2010 documented it is the responsibility of the unit nurse dispensing medications to monitor the response to the specific medications administered. No medication will be dispensed without a physician's orders [REDACTED]. A medication error is any preventable event that may lead or cause, or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient or consumer. The physician will be notified when a medication error is noted to determine the significance of the error. Examples of medication errors included, omitted doses, missed doses and/or medications not available. The P&P for Physician/prescriber authorization and communication of orders to pharmacy, dated 1/2012 documented this policy sets forth procedures relating to Physician/prescriber authorization and communication of orders. Procedures included, authorized staff and prescribers enter prescriber orders into a medical record system that securely transmits prescriber orders electronically to the pharmacy. An electronic Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Facility should reconcile transfer/transition and admission orders [REDACTED]. Facility should verify transfer/transition and admission orders [REDACTED]. The P&P for Administering Medications dated 4/2010 documented medications shall be administered in a safe and timely manner, and as prescribed. The Director of Nursing (DON) will supervise and direct all nursing personnel who administer medications and/or have related functions. Medications must be administered in accordance with the orders, including any required time frame. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Resident # 1: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident has severe cognitive impairment according to the Minimum Data Set ((MDS) dated [DATE]. Physician orders [REDACTED]. [MEDICATION NAME] 20 mg bid. [MEDICATION NAME]22 units sq in pm. [MEDICATION NAME]35 units sq in am. [MEDICATION NAME]per sliding scale before meals. The hospital discharge documentation dated 6/28/13 and signed by the hospital physician documented the discharge instructions. The discharge medications included: [MEDICATION NAME] (treats [MEDICAL CONDITION] and [MEDICAL CONDITION]) 0.5 milligrams (mg), twice per day (bid). [MEDICATION NAME] (used to treat [MEDICAL CONDITION] reflux disease)20 mg, bid. [MEDICATION NAME](a long-acting human insulin), 22 units subcutaneously (sq) at bedtime (hs). Humalog insulin (a fast acting insulin) before meals, per sliding scale (amount of insulin is based on blood glucose ranges). Progress note dated 6/28/13 revealed the Nursing Admission Evaluation was completed at 2:32 pm and was signed by the LPN, Nurse Manager (LPNM). Progress notes dated 6/28/13 at 2:38 pm and signed by a Licensed Practical Nurse (LPN) documented the resident was readmitted at 2:05 pm. Physician orders [REDACTED]. [MEDICATION NAME] 0.5 mg bid [MEDICATION NAME]22 units sq in pm [MEDICATION NAME]35 units sq in am Orders did not include insulin sliding scale coverage. MAR dated June 2013 documented all of the following medications with a start date of 6/29/13 at 2:53 am: [MEDICATION NAME] 20 mg bid at 6:00 am and 6:00 pm, had an X (placed by the computer) in the signature box indicating medication not given on 6/28/13 at 6:00 pm. First dose was administered 6/29/13 at 6:00 am. [MEDICATION NAME] 0.5 mg bid at 9:00 am and 8:00 pm, had an X in the signature box indicating medication not given. First dose was administered 6/29/13 at 9:00 am. [MEDICATION NAME]22 units sq at 9:00 pm, had an X in the signature box indicating medication not given on 6/28/13 at 9:00 pm. [MEDICATION NAME]35 units sq at 9:00 am, first dose was administered 6/29/13 at 9:00 am. [MEDICATION NAME]per sliding scale before meals at 7:00 am, 12:00 pm, and 5:00 pm, had an X in the signature box indicating fingerstick not done and medication not given at 5:00 pm. (There was no physicians order for the sliding scale.) Progress notes revealed there was no documentation between the readmission note on 6/28/13 at 2:38 pm and the 6/29/13 note at 5:59 pm. Progress note dated 6/29/13 at 5:59 pm documented 7:00 am blood sugar was 174, coverage given plus routine [MEDICATION NAME]. There was no mention of medications not given the evening of the readmission or whether notification was made to the physician. During an interview on 7/11/13 at 2:00 pm Director of Nursing (DON) stated that after the start of the complaint survey a review was done of Resident # 1's readmission. DON could not explain what had happened on her readmission and why the Resident did not receive her medications. DON began an investigation into the Resident's readmission and would be talking with the staff. The Resident did have her medications here in the facility so it was not a matter of getting the medications, but the orders had not been received. DON was not aware that this was an issue in the facility. During an interview on 7/11/13 at 3:30 pm, Registered Nurse Supervisor (RNS) # 13 stated she started working at the facility at the end of April. RNS was not sure what happened with the readmission of Resident # 1, stated she was working that evening. She stated the Resident did not return with the discharge instructions and she had to call the hospital and request them. RNS stated she did not know why the Resident's orders were not put into the computer until 2:53 am when she was admitted before the end of the 7:00 am to 3:00 pm shift. RNS would usually try to get orders in by 5:00 pm, but if the physician had not yet approved them they could not be entered into the computer. New residents are not always communicated to the oncoming shift. There were times when the RNS would not know if a new resident was admitted until after the shift started. Communication in the facility is not good. If medications did not come in for the time of administration, they would need to get physician orders [REDACTED]. Resident # 2: The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident has long and short term memory problems with moderately impaired decision making skills, according to the MDS dated 7/2/13. The hospital discharge documentation dated 6/18/13 and signed by the hospital physician documented the discharge instructions. The discharge medications included: [MEDICATION NAME] (acts on the central nervous system to relieve spasms, cramping, and tightness of muscles) 10 mg, take 1.5 tablets bid. [MEDICATION NAME] (an [MEDICAL CONDITION] drug) 25 mg, take 1 in the am and 1 in the pm. Calcium [MEDICATION NAME] (a dietary supplement) 500 mg, three times per day (tid). [MEDICATION NAME] (cholesterol-lowering medication) 20 mg in the evening. Physician orders [REDACTED]. [MEDICATION NAME] 50 mg in evening [MEDICATION NAME] 25 mg in morning [MEDICATION NAME] 15 mg bid every day at 8:00 am and 8:00 pm Calcium [MEDICATION NAME] 500 mg, three times per day (tid) [MEDICATION NAME] 20 mg in the evening. MAR dated June 2013 documented the following medications with a start date of 6/18/13 at 7:00 pm: [MEDICATION NAME] 50 mg in evening, had an initial and star ( following the legend) in the signature box indicating medication not given on 6/18/13 at 8:00 pm. [MEDICATION NAME] 25 mg in the morning, first dose was administered on 6/19/13 at 8:00 am. [MEDICATION NAME] 15 mg bid every day at 8:00 am and 8:00 pm, had an initial and star in the signature box indicating medication not given on 6/18/13 at 8:00 pm. First dose was administered 6/19/13 at 8:00 am. Calcium [MEDICATION NAME] 500 mg, three times per day (tid), had an initial and star in the signature box indicating medication not given on 6/18/13 at 8:00 pm. First dose was administered 6/19/13 at 8:00 am. [MEDICATION NAME] 20 mg in the evening, had an initial and star in the signature box indicating medication not given on 6/18/13 at 8:00 pm. First dose was administered 6/19/13 at 8:00 pm. Progress note dated 6/18/13 revealed the Nursing Admission Evaluation was completed at 10:36 pm and was signed by the RNS. The evaluation documented that the Resident was admitted at 5:00 pm. Progress notes revealed there was no documentation before the Nursing Admission Evaluation at 10:36 pm. Progress note dated 6/19/13 at 5:59 am revealed there was no mention of medications not given the evening of the Admission or notification to the physician. During an interview on 7/11/13 at 1:15 pm LPN # 5 stated that when an admission or readmission comes in that if the Nurse Manager is able she will begin the paperwork, if not it can be done by any LPN. The discharge packet from the hospital should be reviewed when it arrives and a call should be placed to the physician. After the orders are approved by the physician they are put into the computer, if the resident comes in on the day shift some of the nurses will try to get the orders done before the shift ends. For drugs that are more pressing or important, a call should be made to the pharmacy. LPN stated that late orders and medications not arriving, would have been reported in the past but not so much recently. Agency nurses are also responsible for completing admission and readmission paperwork and they really don't know what they are doing. There is a checklist for readmission and admissions, not sure if they have them any longer. LPN stated there are too many loopholes in the system at the facility, which leaves them open for errors. During an interview on 7/15/13 at 9:50 am RNM # 11 stated that for an admission or readmission the facility would review the hospital discharge summary, the physician would be called for confirmation of the medications and then the pharmacy would be notified. RNM stated that for new medications that were needed for that day, the orders would be sent from the computer and the pharmacy should be notified via telephone. RNM was not aware of residents not receiving their medications on the day of admission and/or readmission. Resident # 3: The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident has no cognitive impairment according to the MDS dated [DATE]. The hospital discharge documentation dated 6/13/13 and signed by the hospital physician documented the discharge instructions. The discharge medications included: [MEDICATION NAME] (a blood thinner) 5 mg daily. [MEDICATION NAME] (used to prevent [MEDICATION NAME] in people with asthma or [MEDICAL CONDITION]) bid. [MEDICATION NAME] (used to treat hypertension) 12.5 mg bid. Physician orders [REDACTED]. [MEDICATION NAME] HFA Aerosol Inhaler, inhale 2 puffs by inhalation route bid in the morning and evening. Documented with a start date of 6/13/13 at 4:34 pm. [MEDICATION NAME] 12.5 mg bid. Documented with a start date of 6/13/13 at 4:44 pm. [MEDICATION NAME] 5 mg once daily. Documented with a start date of 6/14/13 at 10:52 am. MAR dated June 2013 documented the following medications with a start date of 6/14/13 at 12:00 am: [MEDICATION NAME] HFA Aerosol Inhaler, inhale 2 puffs by inhalation route bid in the morning and evening documented with a start date of 6/13/13 at 4:34 pm. First dose was administered on 6/13/13 at 8:00 pm. The medication was brought into the facility by the resident. [MEDICATION NAME] 12.5 mg bid documented with a start date of 6/13/13 at 4:44 pm. First dose was administered on 6/13/13 at 8:00 pm. The medication was brought into the facility by the resident. [MEDICATION NAME] 5 mg daily at 8:00 pm, documented with a start date of 6/14/13 at 12:00 am. The signature box for 6/13/13 at 8:00 pm had been left blank indicating medication not given. Progress note dated 6/13/13 revealed the Nursing Admission Evaluation was completed at 7:10 pm and was signed by the RN, Nurse Manager (RNM). The evaluation documented that the Resident was admitted at 1:00 pm. Progress note signed by RNM and dated 6/13/13 at 6:57 pm documented physician reviewed patient discharge paper work, his discharge summary and his orders. All orders clarified with physician and all new orders placed into computer. Progress note dated 6/13/13 at 10:24 pm, entitled nursing and signed with a name and no title, documented Resident brought in own inhalers and pills, one being [MEDICATION NAME]. Count will be added to narcotic book and counted per protocol and recommendation of the supervisor. Progress note signed by the facility physician dated 6/24/13 at 4:51 pm, was the first physician documentation for this Resident. Medications documented include: [MEDICATION NAME] 2.5 mg once daily, [MEDICATION NAME] 12.5 mg two times per day, and [MEDICATION NAME] 160 mcg-4.5 mcg/actuation 2 puffs bid. During an interview on 7/15/13 at at 9:30 am LPN # 6 stated that if the resident's discharge summary was in by 1:00 pm, they should be able to get the orders in and medications should arrive by 5:00 pm. If after 1:00 pm the medications would be delivered late on the 3:00 pm to 11:00 pm shift. LPN stated that the medication nurses would not know a person had medications due to be administered unless the orders were entered into the computer prior to the medication administration time. LPN stated this was not normal practice for the facility, that there have been so many changes and everything is so different now. LPN stated that the lack of communication is so frustrating and it causes these kinds of problems. During an interview on 7/11/13 at 11:30 am RNM # 12 stated that the Nurse Managers pull up the dashboard on the computer throughout every day to look for timeliness in medication passes. RNM was not aware of a problem with admission or readmissions receiving their medications. During an interview on 7/11/13 at 3:00 pm the Administrator stated that she had only been working in the facility for a few weeks and during that time she was not made aware of any problems with the admissions or readmissions not receiving their medications. Stated that in the morning meetings there is a review of the timeliness of medications and there has been no recent issues. During an interview on 7/15/13 at 10:45 am the Administrator stated that on 7/12/13 the Quality Improvement committee reviewed Resident # 1's readmission and found that the medications had not been given on the evening of her readmission. The facility had no prior knowledge of a problem with her readmission or other admissions/readmissions before the abbreviated survey. During an interview on 7/11/13 at 3:45 pm the Medical Director stated it would be an extreme exception for a resident not to receive their medications on the day of admission/readmission. The pharmacy does have three delivery runs per day and an emergency pharmacy backup, and she would expect to be notified if a medication was unavailable. Medical Director was aware that the facility was having trouble getting discharge summaries from the hospital prior to an admission/readmission, but was not aware that there was a problem with medications being available and administered. 10NYCRR 415.12(m)(2)

F-309 Based on record review and interview the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 5 ( #'s 13, 69, and 70, 104, and 115) of 9 residents reviewed during a complaint investigation (Case #'s NY 331, NY 010, and NY 069). Specifically, the facility did not ensure that a resident's (Resident #104) Una boots were changed every three days as ordered and the wound deteriorated. Additionally, the facility did not ensure that neurological checks were completed according to the facility's policy and procedure when residents (Resident #'s 13, 69, 70 and 115) had unwitnessed falls and/or hit their head. This resulted in actual harm for Resident #104 and no actual harm with the potential for more than minimal harm which is not Immediate Jeopardy for Resident #'s 13, 69, 70, and 115. This was evidenced by: Resident #104: The facility did not ensure that this resident's Una boots were changed every three days as ordered. The boots were changed on 2/15/13 and not again on 2/22/13. Subsequently, both legs were significantly worse, were raw, denuded (the top layer of skin had been eroded off) circumferentially (all the way around the legs) and were draining very large amounts of fluid. The facility had no policy for the application of Una boots. The resident was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Nursing Admission Evaluation Dated 2/15/13 at 3:26 pm, documented that the resident was alert and oriented to person, place and time. The resident's memory was intact and her vision, speech and hearing were adequate. The Hospital Discharge Summary dated 2/15/13, documented that the resident had venous stasis ulcers and [MEDICAL CONDITION] (an infection in the skin) on both legs. The resident was being discharged to the nursing home with Una boots. A physician's orders [REDACTED]. A Nurses Note, by an RN, dated 2/15/13 at 9:39 pm, documented that the resident had stasis ulcers and [MEDICAL CONDITION] to both lower legs and that there was a moderate amount of fluid drainage. There was a 3 centimeter (cm) by 3 cm and a 1 cm by 0.8 cm ulceration on the top of the left foot. The Una boots were changed. A Nurses Note, by LPN # 2, dated 2/18/13 at 11:01 pm, documented that the resident was asking about when her Una boots were changed. The resident was informed that they were to be changed every three days and that it was scheduled for the next day (2/19/13). A Physician's Progress Note dated 2/20/13 at 9:24 pm, documented that the NP was writing a late note and that the note was being written for 2/15/13. The NP documented that she was asked to evaluate the resident's legs for appropriateness of continuing the Una boots. The resident had a long history of [MEDICAL CONDITION] and nonhealing venous stasis ulcers and been recently treated for [REDACTED]. In a written statement dated 2/22/13, the Nurse Practitioner (NP) documented that she had been asked to look at this resident's lower legs after her Una boots had been removed. Both legs were significantly worse, were raw, denuded (the top layer of skin had been eroded off) circumferentially (all the way around the legs) and were draining very large amounts of fluid. The resident had told the NP that she thought she needed to go to the hospital because her legs were so bad and because she was in so much pain. The treatment and pain management plans were adjusted to make the resident more comfortable. The Treatment Administration Record (TAR) for 2/2013, documented that the residents Una boots were changed on 2/15/13. On 2/18/13 and 2/21/13 there was an "X" in the boxes where the nurses were to put their initials that the treatment had been completed. The legend on the TAR documented that the "X" meant that the treatment was not scheduled. In the initials box for 2/19/13, there was a dash ( - ). The legend on the TAR documented that a dash meant that the treatment was not documented. The Una boots were changed during the day shift on 2/22/13. A Nurses Note dated 2/22/13 at 4:04 pm, documented that the resident had chronic non-healed venous stasis ulcers on both lower legs. There was a cluster of areas with irregular borders 13 cm long and 12.5 cm wide on the right calf. The left calf had a 4 cm long by 5 cm wide wound, and the top of the left foot had a 1.6 cm by 1.5 cm wound. The depth of the wounds varied from 0.2 cm to 0.3 cm. There was a moderate amount of serous drainage. The surrounding skin was red, raw, moist and denuded. The resident's pain ranged from mild to severe. The Registered Nurse (RN) was unable to determine the progress from the last assessment. During an observation on 2/27/13 at 1:50 pm with the physician, Nurse Practitioner, RN#5 and the DON present, the Una boots were removed. There was a moderate amount of serous drainage noted and both lower legs were bright pink from below the knee to the top of the ankle. There were open areas noted on both calves. The Nurse Practitioner point to various parts of both legs and described that when she saw the legs on 2/22/13, large portions of the lower legs were raw and denuded and the skin was macerated. There was a large amount of serous drainage at that time. She also stated that the legs were in much worse condition than when she was admitted . The Nurse Practitioner also stated that, at this observation, the legs were improved from 2/22/13 but still worse than they were on admission. During an interview on 2/26/13 at 2:16 pm, the Nurse Practitioner (NP) stated that on 2/22/13 she was asked to look at this resident's legs after the Una boots were removed. She stated that the stasis ulcers on both legs were much worse than when she saw them on 2/15/13. There was a copious amount of serous drainage that had accumulated in the Una boots and that moisture against the skin for a protracted period of time caused worsened maceration (a condition of softened skin due to being soaked for long periods of time), and the lower legs were denuded. She stated that not changing the Una boots every three days caused significant worsening of the condition of her lower legs and that caused the course of treatment of [REDACTED]. She stated that this resident was harmed due to the Una boots not being changed. The NP stated that she wrote a statement and notified the Director of Nursing (DON) on 2/22/13 that the Una boots had not been changed as ordered and that as a result this residents lower legs were in much worse condition. She stated that she made it clear to the DON that she was very upset that the order was not followed and that the resident had been negatively affected in this way. During an interview on 2/26/13 at 2:30 pm, Resident #104 stated that during the week of 2/18/13 through 2/22/13, she reminded the LPN every day when the Una boots were due to be changed. The LPN told her that she had previously and would again let the RN know that they had to be changed. She stated that during that time, her legs hurt her a lot and she kept telling the nurses but her Una Boots were not changed until 2/22/13. During an interview on 2/26/13 at 3:05 pm, Licensed Practical Nurse (LPN) #10 stated that during the week of 2/15/13 and 2/22/13, the resident's Una boots were supposed to be changed on 2/18/13 and again 2/21/13. She stated that on 2/18/13, she told Registered Nurse Manager (RNM) #3 that the Una boots were due to be changed, and she left a written reminder to the RNM and taped it to her computer screen. On 2/19/13, the resident complained that the Una boots had not been changed. LPN#10 again reported this to the RNM and again left a written reminded taped to her computer screen reminding her that the Una boots needed to be changed. The LPN also stated that on 2/21/13 she reported to the Assistant Director of Nursing (ADON) that the resident's Una boots were due to be changed on 2/18/13 but still had not been. She also told the ADON that she had repeatedly told the RNM that the Una boots needed to be changed and that she had left a written reminder on the RNM's computer screen. During an interview on 2/26/13 at 11:00 am, the DON stated that on 2/22/13 she became aware that this resident's Una boots had not been changed on 2/18/13 and 2/21/13 as ordered by the physician. She stated that the ADON reported to her that there were problems with the RNM with managing wounds on the unit and that she had not changed this resident's Una boots as ordered. The DON also stated that on 2/22/13, the NP had reported to her that she felt the resident had been harmed by the nurses not changing the Una boots as ordered. The physician orders [REDACTED]. During an interview on 2/27/13 at 1:22 pm, Registered Nurse Manager (RNM) #3 stated that she did not know until 2/21/13 that this resident's Una boots needed to be changed. At that time she told RN#5 to change the boots. She stated that it was possible that staff had told her earlier in the week that the boots needed to be changed but she could not recall. She stated that she did not know who was responsible for changing the Una boots because only an RN could change them. During an interview on 2/27/13 at 1:12 pm, the Assistant Director of Nursing stated that on 2/26/13 a staff member came to her and reported that she witnessed LPN#10 repeatedly tell the RNM that the resident's boots needed to be changed during the week of 2/15/13 through 2/22/13. During an interview on 2/27/13 at 2:02 pm, the Medical Director stated that because the nurses did not change the Una boots every three days as ordered, the resident now had worsening stasis ulcers. She stated that the NP described to her that there was a copious (very large) amount of serous drainage in the Una boots which caused the wounds to worsen and the good skin around the wounds to become macerated and denuded. She stated that she would have expected the nursing staff to provide care and treatments as ordered by the NP or physician. During an interview on 2/27/13 at 3:00 pm, RN#5 stated that on 2/21/13 RNM#3 made her aware that the resident's Una boots needed to be changed. When she checked the Una boots they were dry and intact and decided not to change the boots until the next day when the NP would be in the facility. Resident # 13: The facility did not ensure that neuro checks were done following unwitnessed falls and falls in which the resident hit their head. Resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident has long and short memory problems and is moderately impaired in decision making according to the Minimum Data Set ((MDS) dated [DATE]. The undated and unsigned Policy and Procedure (P&P) for Incident/Accident (I&A) Report and Follow-up, documented that Neurological (neuro) checks were to be monitored for residents with identified head trauma, those suspected of having head trauma, or unwitnessed falls. The form entitled "Neuro Checks Post a Fall or Injury to the Head", is dated 6/9/2005. The form documented that the Neuro Checks are to be completed at the time of the event-one hour later-then every shift for nine shifts. Comprehensive Care Plan (CCP) dated 7/1/10 and entitled Accidents/Incidents and listed ecchymosis (bruises) and falls. Potential for fall due to unsteady gait, medications, confusion, dementia, and forgetfulness. Interventions included toilet every two hours routinely, encourage to take frequent rest periods when ambulating chair alarm and bed alarm. Incident & Accident (I&A) dated 2/2/13 documented that Resident was found on the floor in front of bed at 1:40 pm. Resident stated she was looking for her black shoes. There was no witness to the fall. Nurse notes dated 2/2/13 at 2:10 pm by a Registered Nurse (RN) documented that Resident was found on the floor. There was no documentation that Neuro Checks had been done. There was no Neuro Checks form completed in the Resident's chart for this incident. I&A dated 2/8/13 documented unwitnessed fall at 10:20 pm, Resident stated she was coming back from the bathroom and fell , she slid down the wall hitting her right elbow and left knee. Stated she did not hit her head this time. There was no witness to the fall. Nurse notes dated 2/8/13 at 10:50 pm by an RN documented that unwitnessed fall. Head was checked, no bumps or tenderness noted, she said she did not hit her head. There was no documentation that Neuro Checks had been done. There was no Neuro Checks form completed in the Resident's chart for this incident. I&A dated 1/25/13 at 5:15 pm documented that Resident was found on the floor she stated that stepped on the edge of the mat and fell backward. She stated she hit the back of her head, right elbow and landed hard on her buttocks. There was no witness to the fall. Nurse notes dated 1/25/13 at 5:44 pm by the Director of Nursing (DON) documented that Resident was found on the floor. She stated she hit her head. Documented she was somewhat resistive to neuro checks, will continue to monitor neuro checks. There was no documentation that neuro checks had been continued. There was no Neuro Checks form completed in the Resident's chart for this incident. I&A dated 1/14/13 at 5:40 pm documented that Resident was found lying on the floor on her back between kitchen and main dining room. Another resident reported seeing her trip on the wheel of her walker and hit her head. There was no staff witness to the fall. Nurse notes dated 1/14/13 at 7:08 pm by RN documented that Resident was found on the floor lying on her back. Resident stated she hit her head. Another resident stated she hit her head. Documented neuro checks initiated. There was no documentation that neuro checks had been continued. There was no Neuro Checks form completed in the Resident's chart for this incident. During an interview on 3/4/13 with RNM # 1 at 4:00 pm stated that neuro checks are not always done the way they should be. There is a clipboard that the active ones are placed on and when the neuro checks are completed they forms are placed in the residents charts. If neuro checks were done on Resident # 13 they should be in her chart. If the neuro checks are not in the chart they probably weren't done. During an interview on 3/2/13 with LPN # 6 at 11:15 am stated that neuro checks are to be done following unwitnessed falls and if a resident hits their head. If the neuro checks were done they should be in the chart. During an interview on 3/4/13 with the DON at 1:15 pm who stated that prior to now was not sure what the system was with neuro checks. Stated that she just wrote a policy on neuro checks and all unwitnessed falls and a resident hitting their head will result in neuro checks. Resident # 70: The facility did not ensure that neuro checks were done following unwitnessed falls and falls in which the resident hit their head. Facility did not ensure that Resident was visually in sight when independent in merry walker, according to her care plan. Resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident has long and short term memory problems with severely impaired decision making according to the MDS dated [DATE]. The undated and unsigned Policy and Procedure (P&P) for Incident/Accident (I&A) Report and Follow-up, documented that Neurological (neuro) checks were to be monitored for residents with identified head trauma, those suspected of having head trauma, or unwitnessed falls. The form entitled "Neuro Checks Post a Fall or Injury to the Head", is dated 6/9/2005. The form documented that the Neuro Checks are to be completed at the time of the event-one hour later-then every shift for nine shifts. CCP dated 9/13/11 and entitled Cognitive loss/Dementia documented the problems as short and long term memory problem, confusion, and impaired decision making. Interventions include provide 24 hour reality orientation, assist with safe decision making and monitor for changes in cognition. CCP dated 9/13/11 and entitled Locomotion documented modes of transportation as wheelchair or merry walker. Supervision is documented as independent in wheelchair, supervision, extensive assist of one with walking with gait belt. Documented she requires supervision while in the merry walker to ensure safety. CORP-Individual Plan Report (CNA care guide) which is not dated, documented that resident may be in merry walker independently in visual sight. She requires supervision while in merry walker to ensure safety (monitor her whereabouts). Unit B assignment form that is used for all CNAs and nurses, not dated for a particular day. This for documented under the title "reminders" Resident # 70 cannot be in Merry Walker unless staff keep a visual eye on her. She is not to be in this after supper. I&A dated 2/16/13 documented that Resident was found at 10:00 am laying on her right on the floor in another resident room, merry walker and resident were on their right side. I&A documented resident wandered into another resident room, got tangled into over bed table, all the staff busy giving care to other residents. I&A conclusion documented care plan violation resulting in fall without intent. Resident is to receive supervision for safety while in merry walker. Nurse notes dated 2/16/13 at 1:28 pm by Licensed Practical Nurse (LPN) # 8, documented resident found on floor, removed from merry walker and body audit done with no apparent injuries, supervisor made aware. There was no documentation that Neuro Checks had been done. Nurse notes dated 2/16/13 at 3:22 pm by Registered Nurse Manager (RNM) # 3, documented called to floor to assess resident who was observed on the floor still in merry walker. Vital signs stable, range of motion within normal limits, no injury noted at this time. There was no documentation that neuro checks had been done. There are no subsequent Nurse notes documenting neuro checks. There was no Neuro Checks form completed in the Resident's chart for this incident. I&A dated 1/5/13 documented resident was found by CNA on the floor on her butt near her wheelchair at 6:00 pm. Documented resident was found on the floor-no one saw her go from the wheelchair to the floor. Employee statement form completed by assigned CNA documented for time when you last saw the resident as 1 hour to 30 minutes before incident. Nurse notes dated 2/8/13 at 10:50 pm by an RN documented that unwitnessed fall. Head was checked, no bumps or tenderness noted, Resident said she did not hit her head. There was no documentation that Neuro Checks had been done. There was no Neuro Checks form completed in the Resident's chart for this incident. I&A dated 12/8/13 documented witnessed fall at 5:45 pm. Injury sustained is scant light bruising to left temple. Employee statement by RN # 4 documented, found resident on her lift side, CNA said she had landed on her head (left side) but other than minimal rubbing of left temple. She did not appear to be hurt, just tired. Ice was applied to left temple. Body checked for injury. legs equal in length, no guarding or pain noted in body. Bruise to left buttock, slight discoloration of left temple. There was no documentation of neuro checks. Nurse notes dated 12/8/12 at 12:17 am by RN # 4 documented the fall that she landed on her left side of head and left buttocks. Neuro checks showed her pupils were equal with sluggish reaction. Her hand grips were weak bilaterally but she was plenty strong when she needed to be in all her extremities. Nurse notes dated 12/9/12 at 4:05 am by RN # 6 documented no complaints of discomfort and her neuro checks are within normal limits for her. Nurse notes dated 12/9/12 at 7:23 pm by RN # 7 documented no ill effects from yesterdays fall. There was no documentation of neuro checks. Nurse notes dated 12/10/12 at 4:50 am by RN # 6 documented neuro checks have been within normal limits. Nurse notes dated 12/11/12 at 4:45 am by RN # 6 documented neuro checks are within normal limits. There are no subsequent Nurse notes documenting neuro checks. There was no Neuro Checks form completed in the Resident's chart for this incident. During an interview on 3/1/13 at 9:44 am, CNA # 3 stated that on 2/16/13 there were only two CNAs working on the day shift. Resident fell because no one was able to watch her. When she is in her merry walker she is to be watched at all times, but there was only two of us there and could not watch her so she fell . During an interview on 2/28/13 at 9:30 am, the ADON stated that on 2/16/13 there were only two CNAs on the day shift on B wing. Resident was in her merry walker without the supervision that is care planned for, and she ended up falling. This was a care plan violation, because the care plan was such, that she should have been supervised, but with two CNAs and one LPN there is not enough staff to supervise her. During an interview on 3/1/13 at 11:35 am LPN # 8, who stated that on 2/16/13 on the day shift, there was only two CNAs and she was the only LPN on the unit. There was a second LPN but she got floated to another unit. Resident was very restless in bed so they did not think it was safe to leave her in bed, so she made a decision to put her in her merry walker even though there was not enough staff to keep an eye on her. The care plan is that, she is supposed to be in view at all times when in her merry walker but there was not enough staff to keep an eye on her and she ended up falling. What are we supposed to do, we do not have enough staff and she wasn't safe in one place and thought the other was safer. 10NYCRR 415.12(i)(1)