Every finding on record at Henry J. Carter Skilled Nursing Facility

Based on observation, interviews, and record review conducted during an abbreviated survey (NY00380551), the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and in accordance with the residents' goals and preferences. This was evident for one (1) of three (3) residents (Resident #1) sampled for respiratory care and treatment. Specifically, on [DATE] at 4:01 PM, Resident #1 returned from the certified dialysis unit located within the facility. Resident #1 was on a portable ventilator accompanied by Escort #1 and Respiratory Therapist #1. Upon return to Resident #1's room Respiratory Therapist #1 disconnected the portable ventilator and connected Resident #1 to the bedside ventilator but did not take the bedside ventilator off standby mode or check that Resident #1 was being ventilated (receiving oxygen). Additionally, Registered Nurse #1 did not assess or check that Resident #1's ventilator was removed from standby mode, and that they were being ventilated. As a result, Resident #1 did not receive mechanical ventilation from the ventilator for 29 minutes and became unresponsive, requiring cardiopulmonary resuscitation to be initiated. Resident #1 was revived and then hospitalized where they ultimately expired. These circumstances resulted in actual harm to Resident #1 and the potential for serious harm to the health and safety of all thirty-nine (39) ventilator dependent residents in the facility, which was Immediate Jeopardy.The findings are:A review of the facility's policy on Respiratory Care Service-In House Transport of Residents on Oxygen/Ventilator dated [DATE] documented, it is the policy of the Respiratory Care Service to establish guidelines in order to ensure efficient and safe resident transports. Resident #1 was admitted to the facility with diagnosis including renal insufficiency (a condition where the kidneys are not functioning properly) , cerebrovascular accident (a medical emergency that occurs when blood flow to the brain is disrupted, causing brain cells to die) , and respiratory failure (occurs when the lungs cannot exchange oxygen and carbon dioxide effectively).A review of the Minimum Data Set (an assessment tool) dated [DATE], documented that Resident #1's cognition was severely impaired.A review of the Comprehensive Care Plan for Tracheostomy dated [DATE] documented interventions to ensure that tracheostomy ties are always secured and monitor/document Resident #1 for restlessness, agitation, confusion, increased and decreased heart rate.A nursing note dated [DATE] by Registered Nurse Supervisor #3 (for 8:00 AM-4:00 PM shift) at 7:44 PM documented Resident #1, connected to a portable ventilator, arrived from dialysis onto the unit at 4:01 PM via stretcher with Escort #1 and Respiratory Therapist # 1. At around 4:30 PM, Resident #1 was found unresponsive by Certified Nursing Assistants (#1 & #2). Registered Nurse #2 and Respiratory Therapist #1 were notified, and cardiopulmonary resuscitation was initiated. Code Blue was called at 4:34 PM and team arrived at 4:40 PM and compression and bagging (using a bag-valve-mask device to deliver breaths to a resident, often in conjunction with chest compressions) continued until the Emergency Medical Team arrived and took over. Resident #1 was revived and taken to the hospital at 5:10 PM.The facility's investigation dated [DATE] documented on [DATE] at 4:01 PM, Resident #1 returned from the certified dialysis unit located within the facility accompanied by Escort #1 and Respiratory Therapist #1. According to the camera review, Escort #1 reported to Registered Nurse #1 that Resident #1 had returned to the unit. At approximately 4:30 PM, Certified Nursing Assistants #1 and #2 were monitoring residents and observed Resident #1 was unresponsive. Registered Nurse #2 and Respiratory Therapist #1 were notified immediately, and cardiopulmonary resuscitation was initiated and continued until Resident #1 was revived and sent to the hospital for further evaluation at 5:10 PM. The facility concluded that Respiratory Therapist #1 and Registered Nurse's #1 and #3 did not follow the process of checking on Resident #1 upon receiving endorsement from Escort #1. The Registered Nurses were responsible for checking Resident #1's vitals, placing them back to bed and connecting them to the ventilator. A review of the unit hallway surveillance video recording dated [DATE] showed at 4:00 PM, Resident #1 was on a stretcher and being pushed by Respiratory Therapist #1 and Escort #1 into their room. Escort #1 exited the room seconds after entering the room and Respiratory Therapist #1 exited the room at 4:04 PM. Certified Nursing Assistants #1 and #2 appeared in the hallway at 4:22 PM and entered Resident #1's room at 4:25 PM. Between 4:25 PM and 4:30 PM, the Certified Nursing Assistants are seen exiting and reentering the room. At 4:30 PM, Registered Nurse #2 entered Resident #1's room. At 4:31 PM, Respiratory Therapist #1 entered the room. Additional responders observed entering the room at 4:32 PM.During an interview on [DATE] at 10:57 AM, Escort #1 stated that on [DATE] they and Respiratory Therapist #1 arrived on the unit with Resident #1 from dialysis at 4:00 PM. They stated they immediately went to Registered Nurse #1 and reported Resident #1 had returned from dialysis. Escort #1 stated that they were not in Resident #1's room when Respiratory Therapist #1 connected Resident #1 to the bedside ventilator.During a telephone interview on [DATE] at 1:09 PM, Respiratory Therapist #1 stated they were not comfortable answering questions about the incident.Respiratory Therapist #1 provided the facility with a statement dated [DATE]. They documented they disconnected Resident #1 from the portable ventilator and connected them to the bedside ventilator. Resident #1 was left on a stretcher bed in their room connected to the bedside ventilator that was on standby mode.During an interview on [DATE] at 2:10 PM, Registered Nurse Supervisor #3 stated that on [DATE] at the end of their shift, they observed Escort #1 inform Registered Nurse #1 that Resident #1 had returned from dialysis. Escort #1 also handed over Resident #1's dialysis communication book to Registered Nurse #1. Registered Nurse #3 stated that they were informed by Certified Nursing Assistant #1 (unsure of time) that Resident #1 was not looking right. Registered Nurse #3 stated that when they arrived in Resident #1's room they observed Registered Nurse #2 and Respiratory Therapist #1 performing cardiopulmonary resuscitation on Resident #1. Registered Nurse #3 stated they immediately called the Respiratory Team and 911. During an interview on [DATE] at 11:41 AM, Registered Nurse #1 stated that on [DATE] after 4:00 PM, Escort #1 announced to them that Resident #1 had returned from dialysis. Registered Nurse #1 stated that they were on a call with the staffing department when Escort #1 reported to them, so they did not immediately check on Resident #1. Registered Nurse #1 stated that they delegated to Certified Nursing Assistants #1 and #2 to monitor Resident #1's vitals and to transfer the resident from the stretcher bed to their bed. Registered Nurse #1 could not recall the time.During a telephone interview on [DATE] at 11:08 AM, Certified Nursing Assistant #1 stated they and Certified Nursing Assistant #2 were monitoring residents on the unit, and they entered Resident #1's room at 4:20 PM and observed Resident #1 lying on a stretcher. Certified Nursing Assistant #1 stated that Resident #1 was unresponsive, their eyes were glossy, and mouth was open with a white/yellow appearance. Certified Nursing Assistant #1 stated that the ventilator screen showed in big letters ‘ventilator off'. Certified Nursing Assistant #1 stated they informed Respiratory Therapist #1 and Registered Nurse #3.During a telephone interview on [DATE] at 11:19 AM, Certified Nursing Assistant #2 stated they and Certified Nursing Assistant #1 entered Resident #1's room at 4:20 PM and they observed Resident #1 lying on a stretcher. Certified Nursing Assistant #2 stated that Resident #1 was unresponsive, looked pale, eyes were closed, and head was tilted to the side (unsure of which side). Certified Nursing Assistant #2 stated they tapped and attempted to wake Resident #1, but the resident did not respond. Certified Nursing Assistant #2 stated they immediately reported to Respiratory Therapist #1. Certified Nursing Assistant #2 stated that the ventilator screen was black and turned off.During an interview on [DATE] at 9:52 AM, the Director of Nursing stated they received a call from the Assistant Director of Nursing on [DATE] late evening (unsure of time) that a code was called for Resident #1. The Assistant Director of Nursing told them that Resident #1 had returned from dialysis and was found unresponsive. The Director of Nursing stated that Resident #1 was disconnected from the portable ventilator and connected to the bedside ventilator by Respiratory Therapist #1, however, Respiratory Therapist #1 did not remove the ventilator off standby mode. The Director of Nursing stated that the facility's investigation concluded that Registered Nurse #1, Registered Nurse #3and Respiratory Therapist #1 failed to follow procedures after Resident #1 returned from dialysis. During an interview on [DATE] at 2:30 PM, the Administrator stated they were informed by the Risk Manager on [DATE] (unsure of time) that a resident had returned from dialysis and was switched from the portable ventilator to the bedside ventilator, but that the bedside ventilator was left in standby mode. During an interview on [DATE] at 2:40 PM, the Assistant Medical Director stated that they were informed by the Medical Director, who is currently on vacation, that there was an incident with Resident #1. The Assistant Medical Director stated that the Medical Director did not give them any details of the incident. During a telephone interview on [DATE] at 2:48 PM, Registered Nurse #2 stated that on [DATE] at around 4:31 PM, Certified Nursing Assistant #1 called them to Resident #1's room. Registered Nurse #2 stated that they assessed Resident #1 who was unresponsive and pulseless. Registered Nurse #2 stated they checked the ventilator and observed the screen was on standby mode, and they immediately informed Respiratory Therapist #1.Based on the corrective actions taken by the facility, which are listed below, there was sufficient evidence the facility corrected the identified non-compliance and was in substantial compliance for this specific regulatory requirement on [DATE], prior to surveyors' onsite visit on [DATE]. Considering that the surveyors' investigation has determined this matter to be Immediate Jeopardy (IJ) Past Non-Compliance the facility will not be required to submit a Plan of Correction (POC).Corrective Actions On [DATE], a Quality Review Report meeting was held to discusses the incident and corrective actions the facility would be implementing to prevent a reoccurrence of the incident. On [DATE], Policy and Procedure on Respiratory Care Services was reviewed and revised. On [DATE], facility in-serviced the Registered Nurses on the process of endorsement of residents on a ventilator from dialysis. On [DATE], the facility in-serviced the Respiratory Therapists on the updated [DATE] policy/procedure for inhouse transport of residents on oxygen/ventilator when they return from dialysis. Respiratory Care Service Policies and Procedures In House Transport of Residents on Oxygen/Ventilator was revised [DATE] to include that the Respiratory Therapist and Nurse will refer to the Ticket to Ride form and ensure that resident's ventilator is connected, and resident is stable. Ticket to Ride Report form (communication report) was developed on [DATE] to communicate when a resident is removed from standby mode, and when a resident is connected to the ventilator and is stabilized. Form must be signed by both nurse and therapist. One (1) resident on a ventilator and dialysis had dialysis hand-off done and communication report (ticket to ride) reviewed three (3) times a week each week beginning the week of [DATE]. Additionally, residents on a ventilator that were transported off the unit had communication report (ticket to ride) reviewed. Quality Assurance Meeting to be held monthly starting [DATE] to discuss the circumstances of this incident, ventilator issues and protocol, corrective actions, and preventive measures. Subsequent meetings were held on [DATE] and [DATE]. Attendance sheets observed. As of [DATE], 61/68 Registered Nurses (89%) received in-service and 47/50 Respiratory Therapists (94%) received in-service. 10 NYCRR 415.12(k)(5)(4)

Based on observation, record review, and interviews during an abbreviated survey (NY00374171), the facility did not ensure that each resident received adequate supervision to prevent an elopement. This was evident for one (1) out of three (3) residents (Resident #2) sampled for elopement. Specifically, a nursing note, by Registered Nurse #1, dated 03/02/2025 at 6:14 PM documented that Resident #2's adult child visited at around 3:00 PM and reported Resident #2 was not in their room. The Hospital Police and staff searched the building and Resident #2 was not found. The facility video surveillance footage dated 03/02/2025 showed Resident #2, who had a tracheostomy tube and was at high risk for elopement, exited the facility at 1:24 PM undetected by staff. The Certified Nursing Assistant Task sheet for March 2025 showed, under purposeful rounding conducted every two (2) hours, Resident #2 was last monitored at 6:00 AM on 03/02/2025 as indicated by staff's initial. An addendum on the Intake Information sheet dated 03/07/2025, documented that Resident #2's adult child reported that Resident #2 was found unresponsive by New York City Housing Authority in the hallway of a building at approximately 10:52 AM on 03/05/2025. Emergency Medical Service was called and pronounced the resident dead. The Findings are:The Elopement and Wandering policy dated 02/27/2024 documented the purpose of the policy is to prevent occurrences of residents leaving the facility undetected.The Wandering/Elopement Prevention/Rounding Every 2-Hours policy dated 03/03/2025 documented the purpose of the policy is to provide a safe environment for residents who are identified at risk of wandering or elopement, and to prevent injury and leaving the facility undetected.An undated Post Duties and Responsibilities documented of First Floor - Main Lobby. According to this undated document, personnel assigned: to verify that patients who are leaving the facility have a proper pass signed by the Head Nurse or Physician. Registered all patients and residents exiting and entering the facility. Register all visitors in the Visitor Management System, issuing visitor badges to authorized visitors. Register residents presenting a valid pass in the Resident Pass Log Computer System. Notification to resident ward (unit) when a resident attempt or leaves the facility without a valid pass, or appropriate color arm band. Detained any patient or resident attempting to depart the facility who has not been identified by nursing as not having decisional capacity to make judgments in his/her own best interests. Retrieve and scan visitor's badge. Resident #2 was admitted to the facility with diagnoses including history of elopement, history of Asthma, Alcohol and Poly Substance Abuse, and Respiratory Failure. The Minimum Data Set (a resident assessment tool) dated 03/02/2025 documented that Resident #2's has a Brief Interview for Mental Status and scored 15 denoting intact cognition. Resident #2 was independent with most activities of daily living. An Elopement Risk Assessment form dated 02/08/2025 showed that Resident #2 was assessed for elopement and scored two (2) denoting risk for elopement. According to this form, any score above one (1) indicates risk for elopement. A Risk for Wandering/Elopement Care Plan with revision date of 11/20/2024, Aero Scout applied to left wrist and weekly restraint rounds. The interventions documented to encourage Resident #2 in purposeful activity, identify if there was a certain time of day wandering/elopement attempted, schedule time for regular walks and appropriate activity. There was no documented evidence of monitoring on the elopement care plan.A Physician's readmission Order dated 03/01/2025 documented application of the Aero Scout Bracelet. The Certified Nursing Assistant Task sheet for March 2025 showed under purposeful rounding, Resident #2 was last monitored at 6:00 AM on 03/02/2025. A nursing note, by Registered Nurse #1, dated 03/02/2025 at 6:14 PM documented that Resident #2's adult child visited at around 3:00 PM and reported Resident #2 was not in their room. The Hospital Police and staff searched the building and Resident #2 was not found. Resident #2 removed the Aero Scout device from their left wrist, and it was found on their bed. Cameras' review showed Resident #2 left the building at 1:24 PM wearing a long winter coat, a furry bucket hat, and was carrying a black bag. Resident #2's adult child reported that the resident verbalized to them that they wanted to go home. New York Police Department was notified. The facility's Department of Nursing Quality Review Report dated 03/03/2025 documented Resident #2 has had several discharges and readmission and was recently transferred to the hospital on [DATE]. While Resident #2 was in the hospital the resident stole a patient wallet and credit cards. The stolen items were found in Resident #2's possession and the resident were arrested and charged with Felony/Grand Larceny. Resident #2 was readmitted to the facility on [DATE] and an elopement bracelet was applied to their left wrist on 03/02/2025 at 9:00 AM by Hospital Police Officer (#1). Resident #2 was observed by staff eating their lunch in their room at 12:30 PM on 03/02/2025. Resident #2's adult child visited at 3:00 PM and reported Resident #2 was not in their room. A search for Resident #2 was unsuccessful. The Hospital Police reviewed the camera and Resident #2 left the building at 1:24 PM while unit staff were completing feeding residents around that time. A Hospital Police Investigation/Timeline document dated 03/11/2024 (should be 2025) documented at the time the resident exited the building, Hospital Police Officer (#1) who was assigned to post 1A was speaking with a visitor in the waiting area and did not see the resident go by. Hospital Police Officer (#2) on post 1B was viewing the computer screen at the time and did not see the resident exiting the building. Neither of the officers identified the resident exiting the facility. The Facility's Surveillance Camera footage reviewed on 07/25/2025 with the Director of Nursing, showed Resident #2 left their room at 1:20 PM fully dressed in street clothes. Resident #2 took the service elevator located across from their room and exited the elevator on the first floor. Resident #2 then walked past Hospital Police Officers #1 and #2 at 1:24 PM and exited through the main entrance door in the lobby. Resident #2 walked off facility grounds, crossed the street and disappeared out of camera view. During a telephone interview on 07/25/2025 at 3:23 PM, Resident #2's adult child stated that they visited the facility on 03/02/2025 at 3:05 PM and Resident #2 was not in their room. Resident #2's adult child stated that facility staff was not aware Resident #2 was missing. During an interview on 07/24/2025 at 12:57 PM, Resident #2's assigned Certified Nursing Assistant #3 stated that they were aware that Resident #2 was at risk for elopement and had an Aero Scout Bracelet to the left wrist. Certified Nursing Assistant #3 stated they received report from the nurse notifying them that Resident #2 was independent. Certified Nursing Assistant #3 stated that they made rounds every two (2) hours during their shift (morning shift) and last saw the resident having lunch (unsure of time) in their room. Certified Nursing Assistant #3 stated that they documented the 2-hour their rounds on the Certified Nursing Assistant's task section in the electronic record. Certified Nursing Assistant #3 stated that they became aware that Resident #2 was not in their room when they were notified by Resident #2's adult child who came to the facility between 3:00 PM and 3:30 PM (unsure of time). Certified Nursing Assistant #3 stated that they and Registered Nurse #1 were at the nurse's station when Resident #2's adult child approached them and reported Resident #2 missing and they started searching for the resident. During a telephone interview on 08/04/2025 at 03:32 PM, Registered Nurse #1 stated that Resident #2 was readmitted to the facility from the hospital on [DATE] and was assessed to be at high risk for elopement. Registered Nurse #1 stated that an Aero Scout Bracelet was applied to Resident #2's left wrist by the Hospital Police (#1) in their presence on 03/02/2025 at 9:00 AM. Registered Nurse #1 stated that they became aware that Resident #2 was not in their room on 03/02/2025 (unsure of date) and they all searched for the resident. The Hospital Police and contacted 911. Registered Nurse #1 stated that Resident #2 had a tracheostomy but was not on oxygen treatment and was stable. Registered Nurse #1 stated that staff generally made rounds everyone (1) to two (2) hours, or more frequently for high-risk residents. Registered Nurse #1 stated that the staff document their rounds on the Certified Nursing Assistant 's task sheet in the Electronic Medical Record. During an interview on 08/04/2025 at 12:28 PM, Hospital Police Officer #2 stated that they were on duty on 03/02/2025 and was assigned to area 1B, closer to the designated exit side of the lobby. Hospital Police #2 stated that Hospital Police Officer #1 was assigned to the entrance side of the lobby. Hospital Police Officer #2 stated that they were informed (unsure of time) on 03/02/2025, by their supervisor (Chief of Police), that Resident #2 had left the facility. Hospital Police Officer #2 stated that they participated in the search at 3:00 PM on 03/02/2025.During a telephone interview on 08/06/2025 at 10:41 AM, Hospital Police Officer #1 stated that they were answering questions from a visitor (in the visitor's section located behind the Hospital Police desk) and that their back was turned to the hallway; they did not see Resident #2 exit the facility. They left the facility when their shift ended (work from 7:30 AM to 4:00 PM) for the day and did not participate in the search.During a telephone interview on 08/20/2025 at 10:02 AM the facility's Chief of Hospital Police stated that Hospital Police Supervisor #1 received a call at 3:53 PM on 03/02/2025, from Registered Nurse #1 stating that Resident #2 was missing. The Chief of Hospital Police stated that Hospital Police Officer #1 and #2 had already gone for the day (3:49 PM) and did not participate in the search for Resident #2. Chief of Hospital Police stated that Hospital Police Officer #1 and #2 were not paying attention when Resident #2 exited the facility. The Chief of Hospital Police stated that the Officers stationed on the entrance side of the lobby are required to log visitors as they enter, and Officers on the exit side of the lobby are to log them out as they exited the facility. The Chief of Hospital Police stated that the designated entrance and exit indicators (arrows and wordings) were at the lobby desk months prior to the incident. During a telephone interview with the Director of Nursing on 08/20/2025 at 11:50 AM, they stated that Resident #2 was not admitted with the outfit that they wore out of the facility on 03/02/2025 at 1:24 PM when they exited the facility. The Director of Nursing stated that they do not know where Resident #2 get the outfit that was seen on the camera. The Director of Nursing stated that there was no monitoring documentation on the Document Survey Report for 03/02/2025. 10 NYCRR 415.12(h) (2)

Based on observation, interview, and record review conducted during the Recertification survey from [DATE] to [DATE], the facility did not ensure drugs were labeled in accordance with currently accepted professional principles. This was evident for 2 (2nd Floor and 3rd Floor) of 5 units observed for medication storage. Specifically, 1) the 3rd Floor medication cart contained undated eye drops, and 2) the 2nd Floor medication cart contained an unlabeled inhaler. The findings are: The facility policy titled Safe Medication Use dated [DATE] documented licensed nurses verify medications have not expired. The undated facility policy titled Long Term Care Pharmacy documented store Brinzolamide/Timolol at room temperature and discard after 4 weeks of opening. Dorzolamide/Timolol must be used within 15 days of opening. 1) On [DATE] at 09:49 AM, the 3rd Floor medication cart was observed with opened bottles of Carboxymethylcell 0.5% eye drops without an open or discard date, Brimonidine 0.15 % without an open or discard date, and Brinzolamide 1% eye drop without a resident name, open date, or discard date. On [DATE] at 09:55 AM, Registered Nurse #1 was interviewed and stated they were not the regularly assigned nurse for the 3rd Floor and could not explain the reason the eye drop medications were not properly labeled with open or discard dates. On [DATE] at 10:15 AM, an interview was conducted with Registered Nurse #2 who stated eye drops should be labeled with a date when the medication was opened and a date the medication should be discarded. All medications were checked for proper labeling every Wednesday by the medication nurses. The Pharmacy Consultant checked medication labeling monthly. On [DATE] at 10:36 AM, the Assistant Director of Nursing #1 was interviewed and stated unlabeled medications should not be kept in the medication carts. The unlabeled medications should be discarded. 48931 2) On [DATE] at 12:02 PM, the 2nd Floor medication cart was observed with Symbicort aerosol inhaler ,d+[DATE].5 MCG/ACT that was not labeled with a resident's name. On [DATE] at 12:32 PM, an interview was conducted with Licensed Practical Nurse #1 who stated the Symbicort inhaler was labeled by the pharmacy, but the nurse cut the label off when they placed it in a plastic storage bag. The label was kept in the plastic storage bag but went missing. Licensed Practical Nurse #1 did not report the unlabeled inhaler to the nurse manager. On [DATE] at 12:43 PM, an interview was conducted with Registered Nurse #4 who stated the Symbicort inhaler label with the resident's name was supposed to be placed in the plastic storage bag or the inhaler should have been kept in the box that had the was labeled with the prescribed resident's name. Registered Nurse #4 stated they were not made aware the label with the resident's name was missing from the Symbicort inhaler. On [DATE] at 01:29 PM, an interview was conducted with the Chief Nurse Officer who stated inhalers were labeled by the pharmacy. The nurse was responsible for reporting to the nursing office if a medication label was missing. 10 NYCRR 415.18(e)(,d+[DATE])

Based on observations, record review, and interviews conducted during the recertification survey from 01/16/2024 to 01/23/2024, the facility did not ensure infection control practices and procedures were maintained. This was evident for 1 (Resident #29) of 31 total sampled residents. Specifically, Licensed Practical Nurse #1 and a Patient Care Technician #1 did not perform hand hygiene during wound care for Resident #29. The findings are: The facility policy titled Wound Care: Clean Dressing Technique dated 5/252023 documented hand hygiene must be performed and clean gloves must be worn as required during the procedure. On 01/17/2024 at 10:38 AM, Licensed Practical Nurse #1 was observed performing a wound care dressing change on Resident #29's right foot. Licensed Practical Nurse #1 donned gloves, removed Resident #29's soiled dressing from their right foot, cleansed the wound with normal saline, applied ointment to the wound, and used both hands to cover the wound with sterile gauze and a foam dressing. Licensed Practical Nurse #1 was not observed performing hand hygiene or changing their gloves in between removing the soiled, cleansing the wound, and applying a sterile dressing. During the wound care observation of Resident #29, Patient Care Technician #1 was present and assisted with holding the resident's right leg with gloved hands. Patient Care Technician #1 was twice observed taking their cell phone out of their left back pocket with their left gloved hand, placing the cell back in their left back pocket, and returning their left hand to Resident #29's right leg. Patient Care Technician #1 was not observed changing gloves or performing hand hygiene in between handling their cell phone and handling Resident #29's right leg. On 01/22/2024 at 10:00 AM, an interview was conducted with Licensed Practical Nurse #1 who stated they were nervous during the wound care observation for Resident #29 and missed some infection control procedures. On 01/22/2024 at 10:40 AM, an interview was conducted with Patient Care Technician #1 who stated they should have performed hand hygiene after handling their cell phone with gloved hands during Resident #29's wound care treatment. On 01/22/2024 at 11:48 AM, an interview was conducted with Registered Nurse #4 who stated they regularly conduct rounds on the unit to ensure staff were complying with infection control practices. They have not observed any breeches in infection control. On 01/23/2024 at 11:32 AM, an interview was conducted with the Infection Preventionist who stated the staff who provide wound care were competent in infection control procedures. They performed wound care rounds and provided infection control inservice on 1/8/2024. 10 NYCRR 415.19(a)(1-3)

Based on observation, record review, and interviews conducted during the Recertification survey from 01/16/2024 to 01/23/2024, the facility did not ensure records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation. This was evident for 1 (2nd Floor) of 5 units observed for medication storage. Specifically, the 2nd Floor Narcotics Sheet did not document an initial count of oxycodone for Resident #103. The findings are: The facility policy titled Safe Medication Use dated 8/25/2023 documented the unit nurse will store controlled medications in a doubled-locked cabinet inside the unit medication room and initiate a Narcotics Sheet that comes with that medication. On 01/18/2024 at 12:21 PM, the 2nd Floor medication room was observed with 3 blister packs of oxycodone 10mg prescribed to Resident #103. The Narcotics Sheet with the blister packs did not document an initial count of oxycodone 10 mg received by the unit nurse. On 01/18/2024 at 12:37 PM, an interview was conducted with Licensed Practical Nurse #1 who stated the initial count of oxycodone 10mg for Resident #103 was not documented by the unit nurse on the Narcotics Sheet when they received the medication. On 01/18/2024 at 12:47 PM, an interview was conducted with Registered Nurse #4 who stated the Narcotics Sheet was sent by the pharmacy with all narcotics medication delivered to the facility. Every Narcotics Sheet was labeled with resident specific information. Registered Nurse #4 was unaware the Narcotics Sheet for Resident #103 did not document the amount of oxycodone 10 mg received from the pharmacy. On 01/23/2024 at 01:23 PM, an interview was conducted with the Chief Nurse Officer who stated the receiving nurse on the unit was responsible for documenting the number of narcotics received by the pharmacy on the Narcotics Sheet. 10 NYCRR 415.18(b)(1)(2)(3)

Based on observations, interviews, and record review conducted during the recertification survey from 1/16/2024 to 1/23/2023, the facility did not ensure that a person-centered comprehensive care plan addressing a resident's needs was developed and implemented. This was evident for 1 (Resident #101) of 2 residents reviewed for Advance Directives out of 31 total sampled residents. Specifically, a comprehensive care plan related to Advance Directive status was not developed and implemented for Resident #101. The findings are: The facility policy titled Interdisciplinary Care Plan Meeting dated 12/01/2022 documented comprehensive person-centered care plans were developed utilizing an interdisciplinary approach. Resident #101 had diagnoses of chronic respiratory failure and hypertension. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #101 was cognitively intact and did not document Resident #101 had Advance Directives. Medical Doctor Orders dated 1/22/2024 documented Resident #101 was a full code and cardiopulmonary resuscitation be administered if necessary. There was no documented evidence a comprehensive care plan related to Advance Directive status was developed or implemented to reflect Resident #101's full code status. On 01/22/2024 at 09:49 AM, an interview was conducted with Social Worker #1 who stated they were recently assigned to Resident #101 and was unfamiliar with their plan of care. Social Worker #2 did not know the reason a comprehensive care plan related to Advance Directives was not developed for Resident #101. On 01/23/2024 at 10:58 AM, an interview was conducted with the Director of Social Work who stated Resident #101 had a full code Advance Directive status. This means a comprehensive care plan related to Advance Directive status was not necessary, and the Social Worker would not be responsible for the completion of the care plan. On 01/23/2024 at 01:41 PM, an interview was conducted with the Chief Nurse Officer who stated the Social Worker was responsible for developing the comprehensive care plan related to Advance Directive status and a resident's status should be documented on the care plan. 10 NYCRR 415.11(c)(1)

Based on observation, interviews, and record review conducted during the recertification survey from 1/16/2024 to 1/23/2024, the facility did not ensure a resident's right to voice care and treatment grievances with a prompt effort to resolve grievances. This was evident for 1 (Resident #56) of 31 total sampled residents. Specifically, Resident #56's missing property grievance was not investigated. The findings are: The facility policy titled Coordinated and Formal Resolution of Complaints and Grievances dated 10/7/2021 documented a resident's right to voice grievances regarding lost clothing was supported and the facility actively seeks a resolution, keeping the resident appropriately apprised of its progress. Resident #56 was admitted to the facility on [DATE] with diagnoses of alcohol dependence and traumatic subdural hemorrhage. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #56 was cognitively intact. On 1/16/2024 at 12:20 PM, Resident #56 was interviewed and stated they were admitted to the facility with a red gown, and it went missing. They informed various staff but received no follow up report regarding an investigation into their missing clothing. Resident #56 was observed wearing a hospital gown. A Social Work Note dated 4/13/2022 documented Resident #56 reported a missing computer, jewelry, and clothing to the Social Worker. The Patient Relations Advocate was contacted and informed Resident #56 also wished to speak with them. There was no documented evidence a grievance was filed nor promptly resolved for Resident #56's report of missing personal property. On 1/19/2024 at 9:29 AM, Social Worker #2 was interviewed and stated Resident #56 reported missing personal property to them on 4/13/2022. Social Worker #2 contacted the hospital to inquire about the missing items and was told Resident #56 needed to file a report. Social Worker #2 stated they informed the Patient Relations Advocate that Resident #56 wanted to speak with them and was missing personal property. Social Worker #2 did not know whether the Patient Relations Advocate followed up with Resident #56 and whether the missing property was further investigated. Resident #56 brought up the issue regarding their missing property multiple times in passing with Social Worker #2 and during care plan meetings with the interdisciplinary team. On 1/23/2024 at 9:26 AM, the Patient Relations Director was interviewed and stated the Patient Relations Advocate was responsible for obtaining information from residents and resident representatives to complete grievance reports and then entering the grievance report information into their electronic medical record. Grievance investigations were initiated immediately upon report and completed within a timeframe. The resident and/or resident representative was informed of the grievance investigation outcome. The Patient Relations Director stated they were not aware of a missing property grievance for Resident #56 and there was no record of a grievance being filed for this resident. The Patient Relations Advocate was on leave and unable to be interviewed or provide further information regarding Resident #56's missing property grievance. 10 NYCRR 415.3(d)(1)(ii)

Based on observation, interviews, and record review conducted during the recertification survey from 1/16/2024 to 1/23/2024, the facility did not ensure a resident received notice of their rights and services upon admission. This was evident for 1 (Resident #56) of 31 total sampled residents. Specifically, Resident #56 was not provided with an Admission Agreement explaining their rights as a resident and services provided by the facility upon admission. The findings are: The facility policy titled Coordinated and Formal Resolution of Resident Complaints and Grievances dated 10/7/2021 documented the admission packet was provided to all residents. Resident #56 was admitted to the facility on [DATE] with diagnoses of alcohol dependence and traumatic subdural hemorrhage. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #56 was cognitively intact. On 1/16/2024 at 12:20 PM, Resident #56 was interviewed and stated they were not told of the policies and procedures upon admission to the facility. There was no documented evidence Resident #56, who was cognitively intact, was provided with an Admission Agreement containing their rights as a resident and the facility's provided services upon their admission to the facility. On 1/23/2024 at 9:26 AM, the Patient Relations Director stated Resident #56's admission packet was mailed to a friend listed on the resident's facesheet upon admission on 4/29/2021 and readmission from the hospital 5/28/2022. The facility policy was for the Patient Relations Advocate to review the Admission Agreement with all residents upon their admission to the facility. The Admission Agreement was mailed to designated representatives of residents that were unable to understand when the Admission Agreement was explained to them. The Patient Relations Director stated they were unable to determine the reason Resident #56 was not provided with their Admission Agreement because the Patient Relations Advocate was on leave from the facility. 10 NYCRR 415.3(h)(2)(i)

Based on interviews and record review during an Abbreviated Survey (NY00324386), the facility failed to ensure that all alleged violations of abuse, neglect, exploitation, misappropriation of resident property, exploitation, and mistreatment, including injuries of unknown source are thoroughly investigated. This was evident in 1 (Resident #1) of 3 residents reviewed for abuse. Specifically, on 09/11/23, Resident #1 was noted with discoloration on the left eye. There was no documented evidence that the facility investigated the alleged injury of unknown source. The findings are: The facility policy titled Incident Reporting within the Nursing Facility with the Abuse Prohibition Protocol dated 11/09/22 stated that allegations of abuse, neglect, exploitation, mistreatment, misappropriation of property, quality of care concern and/or suspicion of a crime will be investigated promptly with appropriate follow up action taken. The policy stated that daily assessment of residents is conducted to observe for signs and symptoms of abuse which can include welts, bruises, black eyes, abrasions, and fractures. The policy documented for an injury of unknown origin to be reported to the New York State Department of Health (NYSDOH), two elements are needed: injury without known incident and facility was unable to rule out abuse or care plan violation. Resident #1 was admitted to the facility with diagnosis of Hemiplegia and Unspecified Dementia without Behavioral Disturbance. The quarterly Minimum Data Set, dated dated dated [DATE] documented Resident #1 was severely cognitively impaired. A nurses' note dated 09/11/2023 at 8:30 am documented at 6:40 am, Resident #1 was noted with black and blue discoloration on the left eye. No bleeding was noted. Primary medical doctor was notified. There was no documentation that the next of kin was notified. A physician's note dated 09/11/23 at 10:30 am documented Resident was noted with discoloration under left eye, no swelling, no discharge, no history of trauma, to monitor. There was no documentation that the next of kin was notified. There was no documented evidence that Resident #1's left eye discoloration was investigated and no documented evidence that the injury was reported to the NYSDOH. During an interview with the Chief Nursing Officer on 11/21/2023 at 12:19 pm, they were unable to provide a reason a reason why there was no facility investigation on Resident #1's left eye discoloration. During an interview with the Administrator on 12/29/23 at 12:32 pm, the Administrator stated it is the facility's policy to complete an investigation for injuries of unknown origin, report the injury to the NYSDOH, and to notify the next of kin. The Administrator stated they were not familiar with the specific case but will investigate why the above measures were not taken. 10 NYCRR 415.4 (b)(3)

Based on observations, interview, and record review conducted during the Recertification Survey and Complaint investigations (NY 646) the facility did not ensure that a resident who is unable to carry out Activities of Daily Living (ADLs) is provided with care and interventions in accordance with the resident's assessed needs, goals for care, preferences, and recognized standards of practice that address the identified limitations in ability to perform ADLs. Specifically, a resident was not taken out of bed, appropriately dressed, or assisted with eating and drinking as needed. This was evident in 1 of 2 residents reviewed for ADLs (Resident #32) out of 37 sampled residents. The finding is: Resident #32 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS), Assessment Reference Date (ARD) 07/22/2021 documented the resident had severely impaired cognition with long and short-term memory problems. The MDS documented the resident is sometimes understood, has clear speech, and rarely/never understands. The MDS documented the resident required Extensive Assistance of 2 for Bed Mobility. The resident was totally dependent on staff for transfer, locomotion on/off unit, and toileting. The resident required extensive assistance of 1 for Dressing, Eating, and Personal Hygiene. On 10/14/21 at 10:36 AM, a telephone interview was conducted with the resident's family (Complainant). The Complainant stated that whenever the family visited, Resident #32 smelled awful and was not groomed. The resident had long nails with feces under them, and their teeth were not brushed. There was no pitcher of water, and the resident reported that staff were not providing water. Complainant stated, sometimes a large gallon of water is seen on the resident's table which may contain no water, and resident is paralyzed on one side which makes it difficult for resident to reach the water. The Complainant also stated that the call bell is sometimes out of reach. The staff never get the resident out of bed to the wheelchair, and the resident is always in bed when they visit. The following observations were made of the resident during the onsite recertification/complaint survey between 10/14/2021 and 10/19/2021: On 10/14/21 at 11:39 AM, resident was observed in bed wearing a hospital gown, holding the call bell. One-liter cup observed on overbed table, no water observed in the cup. Resident was unable to use the call bell appropriately. On 10/14/21 at 12:51 PM, resident was observed in bed wearing a hospital gown feeding self with no supervision by staff. No water observed in the cup. On 10/14/21 at 02:23 PM, resident was observed in bed awake, wearing a hospital gown. There was an empty pitcher on resident's table. On 10/15/21 at 08:47 AM, resident was observed in room sleeping wearing a hospital gown. Breakfast tray was observed with about 25% of food remaining on the tray on the overbed table. On 10/15/21 at 12:10 PM, resident observed in bed sleeping wearing a hospital gown. An empty cup was observed on the overbed table. Lunch tray not yet served. On 10/18/21 at 09:59 AM, resident was observed sleeping, wearing a hospital gown. A left-over food tray was observed on the side table. No staff noted in the room. On 10/18/21 at 12:43 PM, resident was observed in bed in bed awake wearing a hospital gown. On 10/19/21 at 08:15 AM, resident was observed in bed awake wearing a hospital gown. The resident just finished breakfast. On 10/19/21 at 01:15 PM, resident observed in bed awake wearing a hospital gown. No water was observed on resident's overbed table. The Comprehensive Care Plan (CCP) for ADL dated 12/5/2019, last revised 8/20/2021, documented that resident has an ADL self-care performance deficit r/t [CONDITION(S)], [CONDITION(S)], and Respiratory Failure. The Goals were for the resident to maintain current level of function and be clean, free from body odor, and well-groomed daily for 3 months; Resident will be Out of bed (OOB) to wheelchair 6 days a week, Sunday, Monday, Tuesday, Wednesday, Thursday, Friday and as needed. Interventions included: transfers out of bed with total assist of 2 staff via mechanical lifter, total assist of 2 staff to provide bath daily, shower weekly and as necessary, extensive assist of 2 staff to turn and reposition in bed, total assist of 1 staff to dress, extensive assist of 1 staff for eating and personal hygiene, and total assist of 1 staff for toileting and incontinent care. The Comprehensive Care Plan (CCP) for Chewing dated 2/4/2020, last update 8/20/2021 documented that resident has Chewing Problem - Level 2 supervision - modified consistency diet - On soft, thin liquids, prefers to eat outside of his room, near nurses' station. Interventions included: Check Level of consciousness before feeding the resident. Ensure resident is fully awake during feeding. Encourage patient to chew thoroughly and eat slowly during meals. Position patient at 90-degree angle, whether in bed or in a chair or wheelchair. Maintain upright position for 30 to 45 minutes after feeding. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documented evidence in the Certified Nursing Assistant (CNA) Accountability Record that Resident #32 refused to get out of bed or that the resident threw water on the floor There was no documented evidence in the Nurses Notes or Progress Notes that Resident #32 refused to be taken out of bed or that the resident threw water on the floor. There was no documented evidence of a CCP documenting non-compliance by the resident with ADL care or a CCP documenting the residents behavior of throwing water on the floor. On 10/19/21 02:17 PM, an interview was conducted with the assigned Certified Nursing Assistant (CNA #1). CNA #1 stated Resident #32 was noted scratching the back of the left shoulder this morning when CNA #1 served the breakfast tray, but CNA #1 was not able to change Resident #32's gown at that time because there were other residents that required urgent attention. CNA #1 stated Resident #32's gown was changed later, but there was no time to change Resident #32 from a gown to regular clothes because it would take too long. CNA #1 stated they are assigned 10 residents that require a lot of time to give care. CNA #1 stated that they are unable to take Resident #32 out of bed today because it is just too much. CNA #1 stated that they did not think Resident#32 could be dressed in regular clothes if they were not taken out of bed. CNA #1 stated Resident #32 is able to feed self with tray set up. Water is not left in the pitcher for the resident because the resident might throw the water on the floor if there is no close supervision. On 10/19/21 at 01:17 PM, an interview was conducted with the Registered Nurse, (RN #1). RN #1 stated that resident is able to feed self with set up tray, is assisted during meals and provided hydration as needed. RN #1 stated that the CNAs or the nurses can assist the resident in getting water when needed. RN #1 also stated that resident is taken out of bed 3 days a week, but sometimes the resident refused to be taken out of bed. RN #1 was unable to explain why Resident #32 was always observed in a hospital gown and with an empty pitcher. On 10/19/21 at 02:39 PM, an interview was conducted with the Activity Therapist, (AT). AT stated that resident is Spanish speaking. If resident is in the bed, activity staff goes to the resident's room to check if the sunlight comes through the resident's window and checks the TV to ensure that it has Spanish programs. If the resident is out of bed and in the wheelchair, resident is asked of their preferred location on the unit and we take the resident there. AT further stated that resident was expected to have been taken out of bed on Thursday, Friday and Saturday before the unit went on quarantine. AT could not explain why the resident was not out of bed for those days and could not explain why resident was in a hospital gown during the period observed by the surveyor. AT stated that it is the responsibility of nursing to dress the resident appropriately and get the resident out of bed as needed. AT stated that resident could sometimes verbalize needs and attempts would be made to clarify why resident has not been out of bed, and not dressed up with regular clothes. On 10/20/21 at 10:34 AM, an interview was conducted with the Unit Charge Nurse, RN #2. RN #2 stated that the charge nurse is supposed to go around to check that the staff are giving care to the residents as per interventions documented in the plan of care. RN #2 also stated that the CNAs are given the assignment list and are notified of any unusual things going on with the residents while giving assignment reports every tour. RN #2 stated that the CNAs expected responsibilities are written on the assignment sheets with the special notations to do for each resident. RN #2 stated that rounds were made this morning to ensure Resident #32 has water in the pitcher. RN #2 is unable to explain why the resident was in in bed with a hospital gown, and the pitcher not filled with water during the period of observation. On 10/20/21 at 12:56 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that for every new resident that comes into the facility, a comprehensive assessment is done, and interventions are in place to address the resident's issues. Staff are educated on what needs to be done for the resident. The charge nurse is expected to monitor and see that care is done correctly as per the resident's plan of care. The DON also stated that if a resident or family member reports that care is not being performed as expected, each ADN (Assistant Director of Nursing) , Supervisor, or Charge Nurse spot checks on the unit and ask if there are any issues or concerns and tries to educate the staff on the best way to take care of the residents. DON was not aware that expected interventions were not being done for Resident #32 as per resident's plan of care. Progress note Therapeutic Recreation Note dated 10/19/2021 15:35:00 documented: Recreation note . Resident met at bedside with the Spanish language interpreter 5. Resident asked if the clothes are clean (limpia), stated, Yes, everything is clean (limpia). Resident asked if .(they) would like to get out of bed: Resident stated that . (they) would like to get out of bed .has a shirt .would like to wear . 415.12(a)(3)

Based on observations and staff interviews during the recertification survey, the facility did not ensure that a clean, comfortable environment was maintained. Specifically, stains on a resident's wall located behind the bed and debris on the floor in a resident's room were observed. (rooms [ROOM NUMBERS] A) The finding is: From 04/09/19 through 4/11/19, during tours of the unit, the following was observed: dried beige, cream colored drip marks on the wall behind the head of the bed in resident room [ROOM NUMBER] and Christmas tree needles from a plant on top of the resident's wardrobe were noted on the floor next to the bed and in front of the wardrobe in resident room [ROOM NUMBER] A. On 04/11/19 at 11:11 AM, an interview with conducted with CNA #1 who was assigned to provide care for resident in room [ROOM NUMBER]. CNA #1 stated that she comes into the resident's room at the start of her shift to check on the resident. CNA #1 also stated that she returns to the room to reposition the resident every 2 hours. CNA #1 further stated that she makes sure the resident room is clean and if there is a spill or something we will notify the charge nurse and call housekeeping and they will come and clean up. On 04/11/19 at 11:00 AM, an interview was conducted with CNA #2 who was assigned to provide care for resident in room [ROOM NUMBER] A. CNA #2 stated when she comes in the morning she will make rounds for the residents she is assigned to and return to reposition the resident every 2 hours. CNA#2 also stated the CNA's make sure the residents' rooms are clean and if the room is not clean housekeeping staff is called. CNA#2 further stated the housekeeper is on the floor all day and she did not report the debris that was observed on the floor of the resident's room to the housekeeper. On 04/11/19 at 11:16 AM, an interview was conducted with the housekeeper (HSK) who was assigned to the 5th floor. HSK stated that she was floated to the unit and her daily duties include collecting trash, making sure the floor is clean, sweeping wherever there is dirt or stains, and mopping in rooms every day. HSK also stated staff will communicate with her if they spill something in the room, however staff rarely ask her to clean up spills or report any spills to her. If there is a stain on the wall we use something to wipe it off. When State Agent (SA) showed HSK the debris on the floor in room [ROOM NUMBER] A, staff reported that she would clean it up right away. When SA asked about the stains on the wall in room [ROOM NUMBER] staff reported she was not aware of these stains as unit 5 was not her regular floor. HSK further stated that the stains probably were not coming off the wall and that is why they were still there. On 04/11/19 at 11:50 AM, an interview was conducted with the Assistant Director of Environmental Services (ADES). The ADES stated his role is training staff, setting up shifts, providing coverage, and making sure the facility is clean and sanitized according to Department of Health standards. The ADES also stated he does rounds every day and several times per day throughout the day and goes room by room to make sure trash is pulled, the bathroom is clean, and floors are swept and sanitized. The ADES further stated there is a weekly schedule for specialized cleaning which includes high dusting, low dusting, wall washing, cleaning corners and edges, and glass cleaning. If something comes up before the designated day the housekeepers take care of it. The stains on the wall should have been addressed. 415.5(h)(2)

Based on interviews and record review conducted during an abbreviated survey (NY 662), the facility did not ensure that a resident was free of accident. This was evident for 1 out of 4 residents sampled (Resident #1). Specifically, Resident #1's Caregivers' Accountability Record documented that the assistance of two persons was needed for bed mobility with the two-upper side-rails in the up position for turning/positioning (no Bumper Guard on the side-rails). On [DATE], Certified Nursing Assistant #1 (CNA #1) provided care to Resident #1 by herself without assistance. While CNA #1 was turning Resident #1, who was in a persistent vegetative state, the resident's head struck the side-rail; Resident #1 sustained laceration, bleeding, swollenness and bruising to her forehead. Subsequently, CNA #1 was not disciplined and was not reeducated with respect to accident prevention and resident safety. CNA #1 continued to work on Resident #1's unit through [DATE]. The findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS, an assessment tool) dated [DATE], documented that Resident #1 was total dependence for bed mobility and required extensive assistance of two plus persons' physical assist as well as total dependence for Personal Hygiene requiring one-person physical assist. A Comprehensive care plan (CCP) dated [DATE], documented that Resident #1 required two staff assist for bed mobility and toilet use. The interventions included staff to provide two persons' assist for some areas of Activity of Daily Living (ADLs) every shift, as needed, and to provide gentle handling during care as well as keep two upper side-rails up during some ADLs every shift, as needed. Bumper Guards to the upper side-rails added after the incident. A Caregiver Accountability Record for the period of [DATE] to [DATE], documented that Resident #1 needed two-staff person assist for bed mobility and two side-rails up for turning/positioning. The Bumper Guards to upper side-rails that was documented in the care plan dated [DATE], was not reflected on the Caregiver's Accountability Record dated ,[DATE]. A nursing note dated [DATE] documented that Resident #1 was observed with slight swollenness to her right forehead; scratch mark on right side and middle of forehead. The resident was transferred to radiology department where Computed [NAME]ography (CT) scan of the head was done. Resident #1 returned to the facility via stretcher and was placed in bed with Bumper Guard applied to upper side rails (Bumper Guard added post incident). An Attending Physician's Progress Note dated [DATE] which was time stamped 2:26PM, documented that the physician was called to evaluate Resident #1 for swollenness and abrasion on the right side of her forehead. Assessment revealed a linear skin abrasion measuring-3cm at the middle of the swollen area along with another scratch mark at the middle of forehead measuring 1.5cm. The progress note documented that the physician's action plan included neurological check to be done every 4hours over 24hours and ice pack applied for swelling. Review of the facility's undated investigation report which facility indicated was complete, documented that on [DATE] at approximately 11: 45AM, CNA #1 assisted Resident #1 with Personal Hygiene care and did it by herself. Resident #1 was on order for two-persons assist. Resident #1 sustained injury to her right forehead area with slight bleeding. Post incident, Resident #1 was assessed, seen and examined by the covering physician and given needed care. Neurological check was done without issues and CT scan of Resident #1 ' s head was done. The result was negative for both intracranial bleeding and fracture. The Facility made the determination that CNA #1 did not follow Resident #1's plan of care as she was supposed to have buddied up with the assigned CNA for care giving to Resident #1. CNA #1 would be given progressive counselling for failing to follow Resident #1's plan of care. Review of CNA #1's personnel file revealed that prior to [DATE] CNA #1 did not receive any form of disciplinary action and was not re-educated with respect to the need to follow Resident #1's plan of care and accident prevention. After the onsite visit of [DATE] by the New York State Department of Health Surveyor, facility initiated a request on [DATE] for CNA to be disciplined. The Licensed Practical Nurse (LPN) who covered the 4th floor on [DATE] during the 7:30AM to 4:0PM shift was interviewed on [DATE] at 1:50PM and stated that on [DATE], she went into Resident #1's room to administer an ordered treatment. She observed some fresh blood stain on Resident #1's bed linen. CNA #1 was standing in Resident #1's room on the window side of the bed and Resident #1 was lying on the bed facing the door. She stated that she asked CNA #1 where the blood was from and the CNA reacted in a way to indicate that she was not aware of the existence of the blood stain. She stated that she looked closely and observed that Resident #1 had suffered injury to her right forehead area which was the source of the blood that stained the linen. CNA #1 was interviewed on [DATE] at 2:33PM and stated that she was scheduled to buddy with Resident #1's assigned CNA on [DATE], to assist her in providing care to Resident #1. However, she smelled fecal odor coming from the direction of Resident #1 and noted that the resident needed incontinent care which she thought she could safely provide by herself without assistance. Resident #1 struck her head against the side-rail of the bed (no Bumper Guards were on the side-rails of the bed) and suffered injury to the right forehead area. She stated that she was never removed from the unit, was never suspended and did not receive any re-in-servicing. She stated that she was on duty, working in Resident #1's unit on [DATE] (while surveyor was onsite). The Registered Nurse (RN) covering the 4th floor for the 7:30AM to 4:0PM shift was interviewed on [DATE] at 3:54PM. She stated that when she got to Resident #1's room, she observed Resident #1 with a raised area to her right forehead, a cut and a little scratch to the middle of her forehead. She called the doctor who gave orders that were followed. She stated that Resident #1 was treated for [REDACTED]. The Assistant Director of Nursing (ADN) was interviewed on [DATE] at 4:34PM and stated that the facility did not discipline CNA #1 and did not remove her from the 4th floor following the incident of [DATE]. She stated that a referral had to be made to Human Resources so that they could determine what disciplinary action was appropriate to initiate. The Director of Nursing #2 (DON #2) was interviewed on [DATE] at 10:35 AM and stated that she was not the DON at the time of the incident involving Resident #1. She stated that the records revealed that a request for hearing was made to Human Recourses on [DATE], in respect of the disciplinary action to be taken against CNA #1. The hearing was held on [DATE] and CNA #1 was disciplined. A follow up interview was conducted with the DON and she stated that the CNAs use the Accountability Record to identify the resident's care needs and follow the plan of care. She added that the upper side-rails did not require a doctor's order because they were being used as a nursing intervention for positioning and that the side-rails should be down and not up during care giving. She also stated that the Bumper Guard was added after the incident. 415.12(h)(1)

Based on record review and staff interviews conducted during an abbreviated survey (NY 929), the facility did not ensure that an accident was thoroughly investigated. This was evident in 1 of 3 residents sampled (Resident #1) Specifically, on 01/22/2018 at 2:40 PM, Certified Nurse Assistant #1 (CNA #1) reported that Resident #1 was on the floor. Resident #1 was observed on the floor in her room face down at the bedside with bleeding and laceration to her chin. Resident #1 was transferred to the Hospital for fall, changes in mental status and laceration on her right chin. The facility did not obtain an interview or written statement from CNA #1 who found Resident #1 on the floor; the facility investigation did not rule out abuse, neglect or mistreatment. The findings include: The facility Policy and Procedure Incident Reporting dated 9/14/2017 documented that employee's supervisor will obtain written summary of statements made by the employees or witnessing employees. Interviews with staff involved in the event will be conducted. Resident #1 was initially admitted to facility on 10/05/2016 with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) dated 01/18/2018 assessed Resident #1 with long/short-term memory impairments. Review of the facility Occurrence Reporting Form dated 01/22/2018 documented that at 2:45PM Resident #1 was found on the floor, face down, near her bedside with laceration and minimal bleeding on the right chin and pressure applied to the wound. The Rapid Respond Team (RRT) responded and 911 called. Resident #1 was transferred to the Hospital (did not return to the facility). The facility Cause Analysis documented that Resident #1 was unable to tell how she fell . The facility investigation did not include a written statement or verbal report from Resident #1's assigned CNA #1, or any other staff member who were on the unit at the time CNA #1 reported finding Resident #1 on the floor. The investigation did not rule out abuse, neglect or mistreatment. Review of the nursing note dated 01/22/2018 at 5:18PM, by Registered Nurse (RN), revealed around 2:40 PM, Resident #1 was found on the floor face down near the bedside. Resident #1 was observed with a laceration to her right chin with minimal bleeding. The Medical Doctor (MD) and 911 called. Resident #1 left the unit at 3:45 PM in stable condition. The Discharge/Transfer Summary dated 01/22/2018 at 3:30PM documented that Resident #1 was discharge to the Hospital due to Fall, Change in Mental Status and Laceration on the right chin. The RN, who assessed Resident #1 was interviewed on 01/26/2018 at 2:23PM and stated that she was charge nurse on the unit at the time of the incident. CNA #1 reported to her that Resident #1 was on the floor during rounds. She observed Resident #1 on the floor next to her bed, face down with laceration on the chin and minimal bleeding. She evaluated Resident #1 and administered first aid by applying pressure to the chin and she call the MD, who was on the unit. The RN does not remember if she asked CNA #1 to write a statement and that a statement should have been written. The Associate Director of Nursing (ADN) was interviewed on 11/27/2018 at 10:23AM and stated, at the time of the incident, she was not the person responsible for conducting investigations. When an incident occurs, the charge nurse initiates the incident report, notify the doctor and collect statements from the staff. There was no interview or statement from Resident #1's assigned CNA who observed the resident on the floor. In a follow-up interview with ADN on 12/06/2018 at 10:00 PM, she stated that the Occurrence Reporting that she provided this surveyor, was the facility's completed Investigation. The Risk Manager (RM) was interviewed on 12/10/2018 at 10:43 AM and stated that the charge nurse on the unit is responsible for initiating the Occurrence Reports and the Assistant Director of Nursing Service (ADNS) collects the statements from the staff. He further stated, if the incident is not reportable New York State Department (NYS DOH), the ADNS finalizes the report. However, if the incident was reportable to DOH, the Risk Manager finalizes the investigation. A statement should have been collected from the staff who found the resident. The ADNS did not do a decent job documenting on the Occurrence Report. The RM added that he concluded that Resident #1 fell , it was not abuse, neglect or mistreatment. The outcome was not reflected on the Occurrence Report. 415.4 (b)

Based upon record review and interviews conducted during the recertification survey, the facility did not ensure that quarterly statements residents' personal funds were provided to the desginated representatives of non-interviewable residents. This was evident for 1 of 3 residents reviewed for Personal Funds (Resident #33). This is evidenced by the following: The facility policy and procedure for Securing Resident's Valuables and Clothing dated 4/1/13 documented the procedures for the resident accounts. The policy does not include procedures for the dissemination of quarterly statements. Resident #33 has several [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident's cognition was severely impaired. On 8/22/17 at 2:42PM, during Stage 1, the designated representative was interviewed and stated that they do not receive quarterly statements for the resident's personal account. There was no documented evidence that the resident's designated representative was sent a quarterly statement for the resident's personal funds. On 8/23/17 at 2:09PM, the Patient Property Assistant Coordinator (PPAC) was interviewed and stated that if the resident is non-alert, the facility does not send out the statements. The PPAC further stated that she did not know how the representatives get the balances, but the alert residents come to see her to inquire about their accounts and obtain funds. On 8/24/17 at 10:58AM, the Assistant Director (AD) was interviewed in the presence of the Controller and stated The statements for alert residents are given to the residents via intraoffice as it will go to the mailroom and will be delivered to that resident on the unit. There is no documented evidence that the resident received the quarterly statements as the social workers are not involved in this process. They further stated that the process for the non-alert residents is we do not send out the statements but the statements are kept on file. If the family representative wishes they can request the quarterly statements. 10 NYCRR 415.26(h)(5)

Based on observation, and interview the facility did not ensure that expired food items were removed from the emergency food supply stock room. Specifically, expired boxes of dried cereal were observed stored in the emergency food storage area. This was evident during the initial brief tour of the Kitchen. This resulted in no actual harm with potential for more than minimal harm. The finding is: During the initial tour of the kitchen conducted on 4/20/15 at 10:30 am, two (2) 24 ounce boxes of Gerber Rice Cereal were noted in the emergency food supply stock room located in the basement. The documented expiration date was December 2014. On 4/22/15 2:55 PM the Director of Food Services was interviewed and stated that the purchasing agent conducts weekly inventory of needed food items in the kitchen, including the emergency supplies. I do not know why those two boxes were left there. 415.14(h)

Based on observation, record review and staff interviews, the facility did not ensure that care was provided to maintain the residents dignity. Specifically, during the dining observation conducted on the 4th floor, three CNA's (Certified Nurse Assistant's) were observed standing over residents while they were being fed. This was evident on 1 of 5 resident units observed during the Dining Observation. (Unit 4) This resulted in no actual harm with potential for more than minimal harm. The findings is: During a dining observation conducted on 4/20/15 at 12:00 PM, the following was observed on the 4th floor unit: Three CNA's were observed standing over residents while the residents were being fed. Interviews were conducted on 4/21/15 at 2:30 PM with several CNA's: 1) CNA (#1) stated that she knew that she was not supposed to be standing up while feeding the residents and added that it was an oversight. 2) CNA #2 stated that the chairs available are too low and acknowledged that this should have been reported to the Head Nurse. An interview was conducted with the RN (Registered Nurse)/Nurse Manager on 4/21/15 at 3:30 PM. The RN stated that it is our practice to sit down when we are feeding the residents. The staff is provided with in service training for safe feeding practices at least once a year. The Policy and Procedure for "Oral Feeding" dated April 1, 2013 documented: " Feeder should sit and face resident while feeding to maintain eye level contact." 414.5(a)

Based on interviews and record review during an abbreviated survey, the facility did not develop a comprehensive care plan for a resident that included measurable objectives and timetables to meet the resident ' s medical and nursing needs. This was evident for 1 of 3 sampled residents (Resident #1). Specifically, the facility did not develop a plan of care for Resident #1 ' s use of a mouth guard. This resulted in no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. Complaint # NY 635 The findings include: Resident #1 was a [AGE] year old male admitted to the facility on [DATE]. Resident #1 ' s [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented that the resident ' s cognitive skills were severely impaired. The resident required total assistance in activities of daily living. The care plan for Dental/Oral Care initiated 1/10/13 documented that the resident was in a vegetative state and that his mouth opening was limited. The care plan documented that the resident ' s lower lip was fibrotic due to chronic lip biting. The facility ' s interventions included assessing and documenting mouth problems, referring to the dentist, providing oral care, and reporting any oral discomfort. A dentistry form titled " Prosthesis Post-Insertion Instruction " dated 3/25/13 documented that the resident received an upper mouth guard. The dentist instructed to apply the mouth guard "morning and night." The dentist instructed to wash and place the mouth guard in the mouth while wet. A dental treatment note dated 9/3/13 documented that the resident kept his teeth clenched and pursed his lips. The dentist documented that the resident ' s upper guard was in place. A dental treatment note dated 10/30/13 documented that the resident was seen for an emergency consult for a loose mouth guard. The note documented that the guard snapped into place and was not damaged. A review of the nurse ' s progress notes from March 2013 to August 2013 revealed no documentation related to the mouth guard. A review of the care plans from March 2013 to August 2013 revealed no documented evidence that a plan of care was developed for the use of the mouth guard. A review of the patient activity record (accountability record) from March 2013 to August 2013 documented that the resident was given oral care daily. The patient activity record had no documentation or instruction related to the care of the mouth guard. A physician ' s progress note dated 8/21/13 documented that Resident #1 was admitted to the hospital for shortness of breath and to rule [MEDICAL CONDITION] and pneumonia. A nurse ' s progress note dated 11/1/13 documented that the resident was readmitted to the facility from the hospital with a [DIAGNOSES REDACTED]. A review of the care plans for November 2013 revealed no documented evidence that a plan of care was developed for the use of the mouth guard. A review of the patient activity record for November 2013 documented that the resident was given oral care daily. The patient activity record had no documentation or instruction related to the care of the mouth guard. On 1/17/14 at 2:15 PM an interview was conducted with the dentist. The dentist stated that he initially inserted the mouth guard to the resident. He stated that he spoke with the nurse regarding the mouth guard and left written instructions on how to use the mouth guard. On 12/11/13 at 4:15 PM an interview was conducted with CNA #1, who was assigned to the resident during the day shift. CNA #1 stated that she provided oral care to the resident. She stated that she provided oral care by swabbing the resident ' s lips and teeth. She stated that it was difficult to provide oral care because the resident would not open his mouth. She stated that she had no knowledge of the resident ' s mouth guard. She stated that she was never informed of or instructed to care for the resident ' s mouth guard. On 4/2/14 at 11:00 AM an interview was conducted with CNA #2, who was assigned to the resident during the night shift. CNA #2 stated that he provided oral care to the resident. He stated that he had no knowledge of the resident ' s mouth guard. He stated that he was never instructed to care for the resident ' s mouth guard. On 8/20/14 at 11:00 AM a telephone interview was conducted with RN #6, who was on duty on 3/25/13. She stated that the resident had a dental consult on 3/25/13. She stated that the dentist gave a mouth guard to the resident. RN #6 stated that she did not develop a care plan for the mouth guard because the head nurse usually initiates care plans. On 8/20/14 at 10:30 AM a telephone interview was conducted with the Risk Manager (RM). The RM stated that all RNs could initiate care plans for residents. On 12/11/13 at 10:00 AM an interview was conducted with the Director of Nursing (DON). The DON stated that the facility did not have a policy and procedure in place for the care of residents with mouth guards. The DON stated that the staff was not in-serviced on caring for residents with mouth guards. The DON further stated that the nurses did not develop a care plan for the mouth guard for Resident #1. 415.11(c)(1)

Based on record review and interviews, the facility did not ensure that sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care was provided. This was evident for 2 of 26 sampled residents (Resident #s 1 and 18), residents in the Group Interview, and the Ombudsman Interview. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. The findings are: 1) On 7/1/14 at 11:00 AM, the Ombudsman was interviewed and stated that there have been many complaints and concerns about staffing. He stated that the facility is aware of the problem, and he has been informed that the process of hiring staff takes time. He further stated the facility had 22 hold over jobs, but there has been an approval to hire over 22 new staff members. He stated that, recently, there has been some decrease in the complaints about staffing. 2) On 7/3/14 at approximately 11 AM, the resident Group Interview was held with a total of 9 residents in attendance, including the Resident Council President. The Ombudsman, who was invited by the residents, was also in attendance. During the group, 7 of 9 residents expressed concerns of insufficient nurses' aide (CNA) staffing and their inability to deliver care timely. Group members gave examples of long delays in follow-up to initial call bell response and general concerns that staff are not available when needed. Members stated that frequently, the CNA staff would respond to call bells only to return hours later to render the desired care. 3) Resident #1 is a [AGE] year-old with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had intact cognition. The MDS further documented the resident required the extensive assist of one person for eating. On 7/1/14 at 11:00 AM, the Ombudsman was interviewed and stated that the resident made a complaint that he passed out from diabetic shock, that he did not get breakfast until 11:00 AM because no one helped him with the meal, and that he had a rash due to lack of showers. The Patient Relations Department Case Sheet dated 5/9/14 documented: "On 5/8/14, this writer interviewed (resident's name) who reported the following issues: On Friday (5/2/14) due to inadequate staffing between the hours of 4:30-5:30 his [MEDICAL CONDITION] bag burst and he was not cleaned until 9 PM...On 5/8 he did not have breakfast after lunch his blood sugar read 80...Resolution: 5/7/14...The delay of care complaint and meal is substantiated as a result to the unit staffing which Nursing administration was fully aware of as there was only 1 CNA (Certified Nursing Assistant) on the floor that evening. The exact time frame of the delay cannot be determined...His claim that his blood sugar dropped to 80 on 5/8/14 cannot be substantiated...Action Plan: Administration is reviewing staffing levels". A letter attached to the case sheet dated 5/9/14, written by the Licensed Practical Nurse (LPN) documented: "The date of May 2, 2014 is incorrect. This matter occurred on May 3, 2014. I am the nurse that (resident's name) voiced his concern about having his [MEDICAL CONDITION] bag changed. I explain to him that care will be provided for him but we only have one CNA to give care to the residents tonight. I also explained, she has to feed the residents at this time and I am helping her feed them. (Resident's name) stated "what does that have to do with me." I explained that the ADN (name) is aware that we only have one CNA on the floor to give care to 31 residents...After all residents were fed his [MEDICAL CONDITION] bag was changed by staff. The RN (Registered Nurse) working on the unit that night responded to the lack of staff on the floor by writing a protest of assignment". The undated Complaint Investigation attached to the case sheet documented: "LPN reported that there was one CNA on the unit and she told the resident that she was attending to the feeding of other residents. In addition, the ADN came to the unit to assist in the feeding. After the feeding the [MEDICAL CONDITION] bag was changed. It could not be determined what time the resident received breakfast. His blood sugar was 80, which is within normal range...Action Plan...Administration is reviewing staffing levels". The resident was unavailable for interview due to hospitalization on [DATE]. On 7/7/14 at 3:16 PM, the LPN was interviewed and stated that on 5/3/14, there was one regular CNA, one RN, and one CNA doing a 1:1 observation on the floor with her. She further stated that the food arrived on the floor and the bells were ringing with resident requests. She stated that Resident #1 rang the bell and asked to have his [MEDICAL CONDITION] bag changed because it was full, but the bag did not burst and was not leaking. The LPN stated that she explained to him that there was only one CNA, and he would be assisted after the meals were served. She stated that she checked in with him to make sure he was okay and knew they did not forget. The LPN stated that the CNA went to change him and clean him up around 5:45pm/6:00pm, before she started administering medications to the resident. She stated that she also followed-up with the resident after he was cared for to see if he was okay. The LPN further stated that there are usually 2 to 3 CNAs on the unit. 4) Resident #18 is a [AGE] year-old with [DIAGNOSES REDACTED]. The resident uses an oral device to call for assistance. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented the resident was cognitively intact and totally dependent on staff for all ADL (Activities of Daily Living). The MDS further documented the resident had bilateral upper and lower extremity range of motion limitations. On 7/8/14, at approximately 10:15AM, the resident and the resident's father were interviewed in her room. The resident was observed in bed, with her arms to her sides. She stated that she is unable to move all extremities and only able to move her head and neck. The resident stated that on several occasions, she utilized her oral device to call for assistance because she needed to be changed but was made to wait for hours prior to being changed. The resident stated that she expressed complaints to patient relations on several occasions, and her mother expressed similar complaints about the delays in her care. The resident stated that insufficient staffing was the issue, and the facility admitted to this being the reason for the delays. A Patient Relations Department Case Sheet dated 1/28/14 documented the resident's mother complained that she does not believe the unit has sufficient staffing to meet the needs of the resident due to delays in care, especially in the evenings and weekends because there are not enough nurses on the floor. The undated Complaint Response attached documented: "the unit is staffed based on the minimum staffing plan established by the facility. Action Plan... Administration is reviewing the acuity and staffing needs of the facility". A Patient Relations Department Case Sheet dated 5/16/14 documented that the resident complained that on 5/15/14 at approximately 4:40 PM, she rang her call bell to be changed, because she had a BM (bowel movement). The sheet further documented the resident stated that she was not cleaned until 8:30 PM, and the Certified Nursing Assistants (CNAs) gave her an attitude during care. A CNA Statement dated 5/16/14 documented the resident rang the call bell at approximately 4:45 PM. The statement documented the CNA assigned to the resident responded to the call and informed the resident that the food truck arrived to the unit and they are about to fee the residents. The statement documented that the resident was changed at 7 PM, and the CNAs found the resident had no BM. An undated Complaint Investigation attached to the case sheet documented: "Conclusion...There was a delay in checking the resident's diaper. Although she did not have a BM the CNAs should have checked her diaper before continuing with feeding...The way (CNA names) spoke to the resident cannot be conclusively characterized as giving "attitude" since the resident did not provide information about what she interprets as "attitude."...Action Plan...The named staff will be reminded about the importance of prioritizing reports of incontinence and checking the resident's diaper in a timely manner.". The 5th floor Nurse Manager was interviewed on 7/8/14 at approximately 10:40 AM. She stated that there are usually 2 to 3 CNAs available on the floor during any given shift for their resident pool of 40 residents. She stated that she is aware of the resident's complaints of delay in care but insists that they do their best. On 7/8/14 at 2:20 PM, the Director of Social Work was interviewed and stated that he was aware of concerns regarding inadequate staffing on the units. The information was brought to his attention via the family council group. He stated that 3-4 family members voiced their concerns and that information was then communicated to the Nursing Department and the Director of Nursing. The Chief Nursing Executive was interviewed on 7/8/14 at approximately 3:00 PM. She stated that she was in charge of nursing staffing and has been aware of staffing related concerns since February 2014. She stated that the facility census and complexity of resident care has increased since the time the facility opened in November 2013, and the facility is working on hiring more CNAs. She stated that the process to hire more CNAs began in April 2014 but has not yet been fully implemented because of the lengthy administrative process related to corporate requirements, union requirements and challenges of continued staff attrition. She stated that staff are sometimes borrowed when necessary from the "sister facility" of Henry J. Carter Specialty Hospital. On 7/8/14 at 2:00 PM, the Administrator was interviewed and stated that he was aware of the staffing problem which is due to various reasons. He explained the hiring process, and how it takes time to get new staff in the facility. He stated that since June there have been 34 Nursing staff hired to address staffing targets. 415.13(a)(1)(i-iii)

Based on observation, record review and interview, facility did not ensure that standards of practice were maintained . Specifically, medication was left unattended in a residents room. The nurses did not ensure that the resident took the medication before leaving the resident's room. This was evident for 1 of 26 sampled residents (Resident #3). This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. The findings are: Resident # 3 is a [AGE] year-old, admitted on [DATE], with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented the resident had intact cognition. On 7/2/14 at 9: 40 am, a medication cup, filled half-way with pills and a cup of water was observed on the resident's bedside table. On 7/2/14 at 9:42 am, the resident was interviewed and stated that she just woke up and will take her medications soon. She further stated that sometimes, the nurse leaves her medications on the table for her to take. The resident stated, "I guess the nurse didn't want to wake me up this morning." On 7/2/14 at 11 am, the Licensed Practical Nurse (LPN) was interviewed and stated that she left the medication cup on the bedside table this morning because she was called away by another staff member, and she forgot to return to the resident. She stated that, sometimes, the resident takes her medications by herself, but she should have remained with the resident to ensure that she took the medication. On 7/2/14 at 12:00 noon, the Registered Nurse (RN) Supervisor was interviewed and stated that no residents on the unit are self-administering medications. She further stated the nurse should never leave medication on the bedside table, which is an unacceptable practice. 415.11(c)(3)(i)

Based on record review and interview, the facility did not actively attempt to resolve a resident's grievance. Specifically, a resident complained that staff did not assist him with breakfast in a timely fashion. The facility did not thoroghly investigate this issue or keep resident appropriately informed about the investigative progress toward resolution. This was evident for 1 of 26 sampled residents (Resident #1) This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. The finding is: Resident #1 is a [AGE] year-old with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had intact cognition. The MDS further documented the resident required extensive assist of one person for eating. On 7/1/14 at 11:00 AM, the Ombudsman was interviewed and stated that the resident made a complaint that he did not get breakfast until 11:00 AM because no one helped him with the meal. The Patient Relations Department Case Sheet dated 5/9/14 documented: "On 5/8/14, this writer interviewed (resident's name) who reported the following... On 5/8 he did not have breakfast, after lunch his blood sugar read 80...Resolution: 5/7/14...His claim that his blood sugar dropped to 80 on 5/8/14 cannot be substantiated". There was no documented evidence that statements were taken from the nursing staff and dietary staff regarding when the breakfast was served, if the resident was assisted as needed or how much the resident consumed on 5/8/14. On 7/7/14 at 10:50 AM, the Patient Representative (PR) was interviewed and stated that she interviewed the resident about the concerns and provided the information to the Assistant Director of Nursing (ADN) so that an investigation could be initiated. She further stated that the ADN is responsible for getting statements from the staff, completing the investigation, and providing the findings to Patient Relations for review. The PR also stated that she reviewed the complaint with her supervisor and arrived at a conclusion. She stated that since there was an acknowledgement that the resident's other concerns were due to a staffing issue, she considered the investigation to be complete. She stated that she did ask the ADN about staff statements regarding the breakfast but was told that they were unable to be obtained because the staff on the unit did not know about the concern when it happened. The PR stated that Risk Management was informed of the concern but abuse and neglect were ruled out, and the issue attributed to a delay in service. On 7/7/14 at 3:50 PM, the Risk Manager (RM) was interviewed and stated that he did look into the investigation and determined there was no abuse, neglect, or mistreatment. He further stated that the resident did get his breakfast tray because the tray was delivered to the unit. He also stated that he did not feel it was necessary to get staff statements regarding what happened after the tray arrived to the unit. The RM stated the resident can feed himself and could always ask for food if he was hungry. 415.4(b)(1)(ii)

Based on observation, interviews and record review the facility failed to provide adequate supervision for residents that smoke. This was evident for 1 out of 8 sampled residents (Resident #1). Specifically, a quadriplegic resident who was a known unsafe smoker sustained a third degree burn on his left abdomen after an accident that occurred while he was smoking without adequate supervision in the smoke room. This resulted in actual harm to one resident (Resident #1) and the potential for serious harm to the 75 residents identified as smokers that is Immediate Jeopardy and Substandard Quality of Care. Complaint # NY 922 The findings include: Resident # 1 was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (a resident assessment tool) 3.0, dated 9/18/12 identified that the resident was cognitively intact. The Minimum Data Set documented that the resident required total assistance with all Activities of Daily Living (ADLs). The Comprehensive Care Plan (CCP), initiated on 4/3/12 identified that the resident was a smoker. The CCP documented that the resident was at risk for complications such as lung disease, burns and shortness of breath. The CCP identified that the resident used a " pipe device. " The interventions included providing education on the side effects of smoking, re-educating to smoke in designated areas, offering a smoking cessation program, allowing ventilation of feelings and ensuring that the pipe device was properly working. The CCP did not document whether the resident was considered a safe or unsafe smoker. The Caregiver Accountability Record, dated December 2012 identified in the section titled " Adaptive/Supportive Device " that the resident had a pipe smoking device. The Caregiver Accountability Record did not identify that the resident was at risk for complications related to smoking. The Occurrence Report, dated 12/8/12 documented that the resident reported on 12/6/12 he was in the smoke room when another resident took a cigarette from his mouth. The resident stated that the lit end of the cigarette fell on his stomach. He stated that he did not feel pain. The Occurrence Report documented that the resident sustained [REDACTED]. The Medical Doctor (MD) documented that the resident had a 3rd degree burn and he ordered treatment with bacitracin. The Job Description for the Institutional Aide/Smoke Watcher was reviewed. The Job Description did not document that the Institutional Aide/Smoke Watcher was responsible for identification or monitoring of unsafe smokers. The facility policy titled " Smoking Control Policy, " dated 4/26/2011 documented that residents who are assessed as unsafe smokers are not permitted to keep or maintain smoking products and " depending on the degree of impairment, may be prohibited from smoking or be permitted to smoke only under supervision. " The policy did not address specifics regarding monitoring of unsafe smokers or monitoring of the smoke room. On 12/27/12 at 2:00PM a smoke room observation was conducted. The smoke room is approximately 30 feet x 40 feet. There are two windowed doors to the smoke room. Each window is approximately 24 inches x 30 inches. One door to the smoke room is located across from where the Smoke Watcher is positioned. The Smoke Watcher is located in the hallway. The Smoke Watcher is seated at a small desk that is approximately 4 ft across the hallway from the smoke room door. The second smoke room door is located on the adjacent wall approximately 12 feet away from the first door. The Smoke Watcher does not have line of sight access to the entire smoke room. There was a video surveillance monitor positioned on the wall above the Smoke Watcher ' s desk. The monitor displays a split screen with 4 views. Two of the views are of the smoke room. The monitor does not have an adequate or clear view of the entire smoking room. There were 17 residents observed smoking in the smoke room. Residents were observed ashing cigarettes on the floor. A subsequent observation on 12/27/12 at 4:00PM revealed burn marks on chairs in the smoke room. There were 10 cigarette butts noted on the floor. The Smoke Watcher was not observed intervening at any time during the smoke room observation. Resident # 1 was interviewed on 12/26/12 at 12:05PM. Resident #1 stated that he is able to smoke with the use of a smoking device that was provided by the Occupational Therapist. He has been using this device for 3.5 years. Resident #1 stated that none of the staff have ever checked the functioning of his smoking device. Resident # 1 stated that around 10/14/12, the tubing on his smoking device started slowly breaking. He stated that he stopped using the smoking device. He has been smoking through his mouth with the assistance of other residents in the smoke room to place the cigarette in his mouth, light the cigarette and ash the cigarette for him. He stated that only residents are inside the smoke room and that there is a staff member outside to check if everything is alright. He stated that on 12/6/12 at about 3:30PM he was smoking when another resident asked for his remaining half lit cigarette When the other resident took the cigarette from his mouth, the lit end of the cigarette fell on his clothes. He was not aware that he had a burn. The Occupational Therapist (OT) was interviewed on 12/26/12 at 2:50PM. She stated that the resident has a hands free smoking device. The device allows the resident to smoke through a tube, which is attached to a cigarette that is positioned directly over a weighted ashtray. The ashes go directly to the ashtray. The OT stated that prior to the incident on 12/6/12, there was no protocol established to check the smoking device for functioning. She stated that she was not aware if a staff member or peer applied and removed the smoking device from the resident. On 12/26/12 at 3:25PM an interview was conducted with Certified Nursing Aide (CNA) #1 who was assigned to the resident on 12/6/12 from 3:30PM- 12:00AM. CNA #1 stated that he was aware that the resident smokes. He stated that he was not responsible to check the resident ' s smoking device. CNA #1 did not indicate that he provided any specific monitoring related to the resident ' s status as an unsafe smoker. On 12/26/12 at 4:00PM an interview was conducted with CNA #3 who worked with the resident on 12/7/12 from 3:30-12:00AM. CNA #3 did not indicate that Resident #1 was an unsafe smoker or that she had been providing any additional monitoring related to the resident ' s smoking status. She stated that she did not check the functioning of the smoking device. On 12/27/12 at 11:20AM an interview was conducted with CNA #4 who worked with Resident #1 on 12/7/12 from 11:45PM-7:45AM and on 12/8/12 from 7:45AM-4:00PM. CNA #4 was asked about supervision of the resident during smoking. She stated that hospital police are located outside the smoke room and are trained to supervise the smokers. She stated that sometimes a CNA monitors the smokers. She stated that she had never seen Resident #1 ' s smoking device. On 12/26/12 at 4:10PM an interview was conducted with the Registered Nurse (RN) #1 who worked the 3:30PM - 12:00AM shift. The RN stated that she was not aware that Resident #1 was a smoker. On 12/26/12 at 1:55PM an interview was conducted with RN #3 who worked the 7:30AM - 4:00PM shift. She stated that Resident # 1 is high risk for burns secondary to his [DIAGNOSES REDACTED]. RN # 3 stated that usually another resident helps him to put the pipe in his mouth. She stated that he did not have a smoking apron. The resident did not report that the smoking device was not functioning properly. She did not indicate if a staff member was responsible for checking functioning of the resident ' s smoking device. On 12/26/12 at 3:40PM an interview was conducted with RN #4 who worked the 3:30PM- 12:00AM shift. RN #4 stated that she was aware that the resident was a smoker, but she had not seen the resident ' s smoking device. RN #4 did not indicate if there was staff member responsible for checking functioning of the smoking device. RN #4 did not identify any specific additional monitoring related to the resident ' s smoking status. On 12/27/12 at 10:05AM an interview was conducted with RN #5 who worked the 7:30AM - 4:00PM shift. She stated that it is the facility policy to assess the smokers ' safety based on decisional capacity and then provide education. RN #5 stated that the residents purchase their own cigarettes, matches and lighters. According to RN #5, the assigned CNA on the 7:30AM -4:00PM shift is responsible for checking Resident #1 ' s smoking device for functioning. On 12/27/12 at 3:15PM an interview was conducted with RN #6 who worked 7:30AM-4:00PM. She stated that she was not aware if any of the staff was checking the resident ' s smoking device for functioning. She was not aware if staff or peers assist him with smoking. RN #6 did not indicate if she was aware if the resident was a safe or unsafe smoker. On 12/31/12 at 2:00PM a telephone interview was conducted with the Assistant Director of Nursing (ADON) #3 who was assigned to the resident ' s unit. She stated that she had not seen the resident ' s smoking device. According to ADON #3, it is the responsibility of the head nurse to check the resident ' s smoking device for functioning. On 12/26/12 at 1:30PM an interview was conducted with the Smoke Watcher # 1 who worked the 7:30AM - 4:00PM shift. The Smoke Watcher stated that he was working on 12/6/12. He stated that his duties included watching the smokers through the glass windows of the 2 doors to the smoke room. He stated that he monitors for drug activities, resident to resident fighting, falls or residents getting sick. He stated that he did not know which residents were considered unsafe smokers. He does not have a list of smokers who are at high risk for burns. He stated that he only goes inside the smoke room during an emergency. Smoke Watcher # 1 stated that the residents light their own cigarettes or light them for each other. He stated that on 12/6/12 he did not notice anything unusual in the smoke room. A follow-up interview was conducted with Smoke Watcher # 1 on 12/31/12 at 12:05PM. He was asked about monitoring the smoke room via the camera monitors. He stated that he has nothing to do with the monitor on the wall. He stated that he does not monitor smokers using those monitors and that it was not his job to look at those monitors. On 12/27/12 at 4:20PM an interview was conducted with Smoke Watcher # 2 who works 3:30PM- 12:00AM. He stated that the smoke room is open 24 hours. He was not aware of which residents were unsafe smokers. He stated that he does not have a list of safe and unsafe smokers. He stated that he monitors the smoke room for drug activities, altercations or other emergencies. On 12/27/12 at 3:15PM an interview was conducted with the Director of Hospital Police, who is also the Smoking Control Officer. He stated that the role of the Institutional Aides/Smoke Watchers is to intervene during medical emergencies, resident to resident altercations and possible sales of illegal substances. The facility implemented corrective actions to remove the immediacy prior to the team exit resulting in an IJ Removed designation. The facility implemented an interim plan to remove the immediacy that included the identification of 5 unsafe smokers. The care plans of the 5 unsafe smokers have been updated to include the use of smoking aprons. Five out of five nursing staff interviewed had been in-serviced on new interventions for unsafe smokers. Two out of two Institutional Aides/Smoke Watchers that were interviewed over 2 shifts had been inserviced on new responsibilities for monitoring the smoke room. Interviews with Institutional Aides/Smoke Watchers were able to identify unsafe smokers and the need to maintain line of sight supervision on all unsafe smokers. 415.12(h)(1)(2)

Based on observation, interviews and record review, the Administrator failed to ensure that systems were in place to adequately monitor and supervise residents while smoking. The administrator failed to ensure that appropriate policies and procedures related to resident smoking practices were implemented. This was evident for 1 out of 8 sampled residents (Resident #1). Specifically, a Quadriplegic resident who was known to be an unsafe smoker sustained a third degree burn on his left abdomen after an accident occurred while he was smoking without adequate supervision in the smoke room. This resulted in actual harm to one resident (Resident #1) and the potential for serious harm to the 75 residents identified as smokers that is Immediate Jeopardy and Substandard Quality of Care. Complaint # NY 922 The findings include: The Administrator was interviewed on 12/28/12 at 10:45AM. The Administrator stated that nursing identifies residents who smoke and along with the hospital police, they monitor for unsafe smoking practices. The Administrator stated that the role of the Smoke Watcher is to watch and observe the safety of those in the room. They intervene in any situation he would deem unsafe. The Administrator stated that he was not aware that the Smoke Watcher did not have a list of residents who would require additional monitoring while smoking. See F 323 K 415.26