Every finding on record at Highpointe on Michigan Health Care Facility

Based on observation, interview, and record review conducted during a survey the facility did not ensure the resident's right to be free from neglect for twenty two (22) (Residents #1, 2, 3, 7, 8 ,9 ,10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, and 25) of twenty two (22) residents reviewed. Specifically, on 08/18/2025, 08/27/2025, 08/28/2025, and 12/04/2025 staff did not provide incontinent rounds and/or care every two (2) to three (3) hours per the residents' plan of care and safety checks.The findings are but not limited to: The policy titled Identification and Reporting of Abuse, Neglect, Exploitation, or Mistreatment of a Skilled Nursing Facility Resident, as per Public Health Law Section 2803-d revised 10/22/2024 documented that resident abuse and neglect, will not be tolerated. Any staff member or volunteer shall not physically, mentally, sexually or emotionally abuse, mistreat or neglect a resident. Neglect is defined as the failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The policy titled Incontinent Care, Long Term Care revised 11/03/2025 documented that certified nurse aides will be responsible for providing incontinent care and/ or toileting their assigned residents every two (2) to four (4) hours and as needed or as specified per the plan of care. Purposeful rounding is not just a check-in; it's an opportunity to ask open-ended questions and to listen deeply to what matters most to each resident so we can hear their wishes. Long Term Care Certified Nurse Aide Shift Tasks is what is expected of you during your shift but are not limited to: Get report from previous shift nurses; Perform safety rounds, check on your residents to make sure everyone is safe and not on the floor; Answer resident call lights and round on all residents at least every one (1) to two (2) hours. Rounding includes checking that all residents are dry and toileted appropriately. 1. Resident #1 had diagnoses that included quadriplegia (paralysis of all four limbs), diabetes mellitus, and neuropathic bladder (bladder with diminished sensation). The Minimum Data Set (a resident assessment tool) dated 06/15/2025 documented Resident #1 had moderate cognitive impairment and was dependent on staff for toileting and was always incontinent of bowel and bladder. The comprehensive care plan revised on 03/24/2025 documented that Resident #1 was incontinent of bowel and bladder. The plan included to toilet every morning, after meals and at the hour of sleep (bedtime). Check for incontinence and provide care every two (2) to three (3) hours and as needed. Resident #1 required extensive assistance of one (1) staff member for peri-hygiene and clothing management. The Kardex Report dated 08/27/2025 documented Resident #1 was on a toileting plan which included toileting every morning, after meals and at bedtime. Resident #1 was to be checked for incontinence and provided care every two (2) to three (3) hours and as needed. Review of the Complaint/Incident Investigation Report received by the Department of Health on 09/28/2025 documented on August 28th, 2025 that a complaint was made to the social worker stating that Resident #1's family member stated that on 08/18/2025, 08/27/2025, and 08/28/2025 they found Resident #1 with urine-soaked bed linens and T-shirt in bed. The spouse additionally reported that on 08/18/2025 Resident #1 was drenched with urine through their brief, chucks pad (paper pad), cloth pad, and the fitted sheet. Review of Nursing Home Investigative Report completed by the Assistant Director of Nursing #1 on 10/01/2025/25 at 1:24 PM, documented they verified neglect had occurred for not following Resident #1's plan of care. Certified Nurse Aides #1 and Certified Nurse Aide #2 were terminated. Review of the facility investigation dated 10/01/2025 documented that video footage from 08/18/2025, 08/27/2025, and 08/28/2028 from 11:00 PM to 5:30 AM was reviewed. During the investigation it was found that on 08/18/2025 Certified Nurse Aide #2 did not enter Resident #1's room at all from 11:00 PM to 5:30 AM. On 08/27/2025 and 08/28/2025 Certified Nurse Aide # 1 only entered Resident #1's room once during 11:00 PM and 5:30 AM. During an interview on 02/17/2026 at 2:30 PM, Assistant Director of Nursing #1 stated they viewed the entire video footage from 08/17/2025, 08/27/2025 and 08/28/2025 between the hours of 11:00 PM to 5:30 AM and created a timeline of events. On 8/17/2025 a nurse went in Resident #1's room with medications at 4:22 AM and left the room at 4:26 AM. No other staff checked on Resident #1 during the entire shift. On 08/27/2025, Certified Nurse Aide #2 entered Resident #1's room once at 3:45 AM and exited the room at 3:49 AM and left with no soiled linens. On 8/28/2025 Certified Nurse Aide #2 entered Resident #1's room at 3:37 AM and left out of the room at 3:39 AM empty handed. The Assistant Director of Nursing #1 stated according to the video footage there seemed to be neglect and they reported it. Certified Nurse Aide #1 and Certified Nurse Aide #2 should have completed rounds every two (2) to three (3) hours and checked and provided incontinent care per the care plan. The Assistant Director of Nursing #1 verified that the following Residents #12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, & 25 were also involved based on review of the camera footage. During observation on 02/18/2026 at 9:30 AM Resident #1 was well-groomed with no evidence of incontinence. Resident #1's family member stated that they come in daily at 5:30 AM and provide care. On 08/18/2025, 08/27/2025 and 08/28/2025 at 5:30 AM Resident #1 was soaked with urine, had brown rings on their brief, the incontinent pads, the bed linens, and the mattress were saturated with urine. During an interview at the time of the observation, the family member stated they spoke Certified Nurse Aide #2, and the aide replied that Resident #1 was a heavy wetter and urinated again after changing them. Resident #1 and their family member both stated no one would enjoy lying in a wet bed and further stated it was undignified and neglectful. During a telephone interview on 02/18/2026 at 2:38 PM, Certified Nurse Aide #2 stated they did not remember Resident #1 on their assignment on 08/18/2025. Certified Nurse Aide #2 stated Resident #1 was well taken care of by them. They completed incontinent rounds every two (2) to three (3) hours. Not everyone required incontinent care and don't like to be bothered. During a telephone interview on 02/18/2025 at 2:42 PM, Certified Nurse Aide #1 stated they checked on Resident #1 twice each night on 08/27/2025 and 08/28/2025. They knew they were held up with another resident on 08/27/2025 and could not provide care by 5:30 AM and left Resident #1 wet. They could not recall a reason on 08/28/2025. Certified Nurse Aide #1 stated they should have asked for help from a nurse and stated their actions were negligent. During an interview on 02/19/2026 at 2:40 PM, Licensed Practical Nurse #3 Unit Manager would expect that Certified Nurse Aide #1 and Certified Nurse Aide #2 would get report for the unit and do safety checks within the first hour. They expected residents to be checked every two (2) hours not just for incontinence but for safety. Leaving Resident #1 lying there in bed wet was mistreatment and morally corrupt. During an interview on 02/19/2026 at 3:45 PM, the Director of Nursing stated Certified Nurse Aide #1 and Certified Nurse Aide #2 did not follow Resident #1's care plan. They were expected to do rounds and to check on every resident on their assignment. Not all residents were wet but needed to be checked for safety. Those residents who could not make their needs known should have been physically checked for incontinence. During an interview on 02/19/2026 at 4:15 PM, the Administrator stated Resident #1's family member's complaint was substantiated. Multiple residents were involved. Not providing care per the care plan was neglectful. 2. Resident #2 had diagnoses that included hemiplegia (paralysis on one side of the body), diabetes mellitus, and urinary tract infection. The Minimum Data Set, dated [DATE] documented Resident #2 had severe cognitive impairment. Resident #2 was dependent on staff for toileting and was frequently incontinent of bladder and always incontinent of bowel. The comprehensive care plan revised on 02/20/2025 documented that Resident #2 was incontinent of bowel and bladder. The plan included providing incontinent care every three (3) to four (4) hours and as needed. Resident #2 required an extensive assist of two (2) staff members for toileting and clothing management. The Kardex Report dated 12/4/2025 documented Resident #2 was required to have incontinence care provided every three (3) to four (4) hours and as needed. Resident #3 had diagnoses that included cerebral palsy (CP) (neurological disorder that affects movement, posture, and muscle tone), diabetes mellitus, and seizures. The Minimum Data Set, dated [DATE] documented Resident #3 had severe cognitive impairment. Resident #3 required substantial/maximal assistance for toileting hygiene. Resident #3 was always incontinent of bowel and bladder. The comprehensive care plan revised 01/16/2026 documented that Resident #3 was incontinent of bowel and bladder and required incontinent care every four (4) hours and as needed. The plan included to offer assistance to the bathroom before and after meals and at bedtime. The Kardex Report dated 12/4/2025 documented Resident #3 documented to offer toileting every three (3) hours and as needed and to keep their skin clean and dry. Review of the Complaint/Incident Investigation Report received by the Department of Health on 12/19/2025 documented the Administrator was made aware that on 12/04/2025 there was reason to believe neglect occurred. Assistant Director of Nursing #1 received a complaint that residents on the Kensington A-pod (resident unit) appeared to be soaked and had not changed during the night shift 12/04/2025 to 12/05/2025. It was noted that Certified Nurse Aide #4 did not change anyone except two (2) of the 15 (fifteen) residents in the timeframe from 11:00 PM until 5:15 AM. The Nursing Investigative Report completed by Assistant Director of Nursing #1 on 12/23/2025 documented the residents did not recall the incident and there were no signs of psychosocial distress. The conclusion verified neglect. Certified Nurse Aide #4 would be terminated. Review of Licensed Practical Nurse #4 signed statement dated 12/05/2025 at 12:00 PM documented they walked onto the Kensington A-pod (resident unit) at 7:05 AM on 12/05/2025 and immediately smelled a foul odor as the certified nurse's aides were bringing to their attention that none of the residents were touched from the 11:00 PM to 7:00 AM shift, and Resident # 2 was covered in feces. Review of Certified Nurse Aide #4 signed statement dated 12/12/2025 at 3:40 PM documented they could not recall the night of 12/04/2025 from 11:00 PM to 7:00 AM. When they first came in, they normally did a walk through on the pod (resident unit) that they were working. During that time, they checked to see who needed to be changed. They started their second set of rounds at 1:30 AM to 2:00 AM and then a final round at 4:00 AM. Certified Nurse Aide #4 documented they did not sit or sleep at the nurse's station. During an interview on 02/19/2025 at 10:28 AM, Assistant Director of Nursing #1 stated they requested video footage from 12/04/2025 to 12/05/2025 on 12/08/2025 from security and received it on 12/18/2025. After reviewing the entire video footage, employee statements, and documenting a timeline there was concern of neglect. Certified Nurse Aide #4 did not provide care to the residents on the A-pod (resident unit) on the Kensington unit on 12/04/2025 to 12/05/2025 on the 11:00 PM to 7:00 AM shift. The Assistant Director of Nursing #1 stated other residents were involved including Resident #'s 7, 8, 9, 10, and 11. During a telephone interview on 02/19/2025 at 10:01 AM, Certified Nurse Aide #5 stated that not checking or changing your residents was neglectful and was our jobs as aides to help them, that's why they were here. Residents with dementia cannot tell us if they need to be changed. That's why it's important to ensure they are dry and comfortable. During a telephone interview on 02/19/2025 at 10:53 AM, Certified Nurse Aide #7 stated they viewed the video footage from 12/04/2025 in its entirety on 12/12/2025 in the presence of the Assistant Director of Nursing #1. They saw Certified Nurse Aide #4 in the secretary's desk when the call lights were going off. Certified Nurse Aide #4 did not provide incontinent care and if they did enter a resident room they would come right back out with no soiled linens. Certified Nurse Aide #7 verified that Certified Nurse Aide #7 did not provide care and was considered neglect. During a telephone interview on 02/19/2025 at 11:37 AM, Certified Nurse Aide #4 stated they had a bad night and was accused of sleeping and not providing care on 12/04/2025. They told me that I did not go into any rooms with linens, and they told me I was asleep at the nurse's station, which was a lie. They told me, I took a break for one hour and thirty minutes, which I'm guilty of but they worked from 3:00 PM to 11:00 PM and did not get to take a break. Certified Nurse Aide #4 then stated some residents were heavy wetter's and it may look like they were not touched even after changing them. Certified Nurse Aide #4 further stated, not conducting rounds was neglectful. During an interview on 02/19/2026 at 3:45 PM, the Director of Nursing stated Certified Nurse Aide #4 left residents wet and not appropriately cared for the residents per the care plan. Certified Nurse Aide #4 was expected to do their job and know their limitations. They should have asked for help if they felt overwhelmed. Failure to follow the care plan was misconduct and was not up to our standards of care at the facility and was neglect. During an interview on 02/19/2025 at 4:15 PM, the Administrator stated they would have expected Certified Nurse Aide #4 to complete every two (2) to three (3) hour rounding. No residents should ever be untouched for eight (8) hours and that was unacceptable. 10 New York Code Rules Regulations 415.4(b)(1)(i)

Based on interview, observation, and record review conducted during a survey, the facility did not ensure that each resident received adequate supervision and assistive devices to prevent accidents for two (2) (Residents #4 and #5) of three (3) resident reviewed for accidents. Specifically, the facility did not ensure that Resident #4, who was severely cognitively impaired and at risk for elopement, was adequately supervised to prevent them from exiting through a stairwell door and they were found in the stairwell; the facility did not ensure Resident #5 was reassessed for elopement risk or had interventions in place to prevent/address exit seeking behavior when they had improvement in their functional levels and the resident was found on the sidewalk next to the building by staff. The findings are:The policy titled Elopement Long Term Care/ Missing Person, last revised 12/08/2025, documented it was required and desired for the facility to provide a safe environment for all residents. The facility would properly assess residents and plan their care to prevent accidents related to unsafe behavior and/or elopement. All staff were to know which residents were at risk for elopement and what interventions were needed to minimize the risk of an elopement.The policy titled Wander Guard, last revised 10/27/2022, documented the facility recognized the need to provide a safe and secure environment for residents whose wandering may place them at risk for elopement. The wander guard system in place at the facility was a selective alarm system that was installed on exterior doors and stairwells. The system alarmed when residents wearing a bracelet signaling device attempted to pass through a monitored area.1.Resident #4 had diagnoses including hemiplegia and hemiparesis (paralysis and weakness) following cerebral infarction (stroke), and macular degeneration (loss of the central field of vision as a result of deposits of the retina). The Minimum Data Set (a resident assessment tool) dated 09/21/2025 documented Resident #4 was severely cognitively impaired, usually understands, was usually understood by others, and exhibited wandering behavior one (1) to three (3) in the last seven (7) days.Review of Elopement Risk Scale dated 09/18/2025 documented that Resident #4 was self-ambulatory (could move) with or without a device or self-mobile in wheelchair; was cognitively impaired, with poor decision making skills, and/or with pertinent diagnosis; had a recent history of wandering; had wandered off the unit in the past three (3) months; the wandering was non purposeful; instructions for staff were to care plan Resident #4 for elopement or wandering, educate staff and enter interventions on the interim Care Guide, provide picture of the Resident, distribute the updated poster to all nursing units/floors, departments and switchboard operators when applicable, and had a wander guard in place.The comprehensive care plan, dated 07/27/2024, documented Resident #4 was at risk for elopement with an intervention initiated on 10/17/2024 that staff would need to monitor Resident #4's whereabouts at all times; wander guard was in place and their picture was placed throughout the facility. Resident #4 was a high-risk for falls with intervention that they would be in the common area for close monitoring while awake.The Kardex Report (a guide used by staff to provide care) dated 11/17/2025 documented Resident #4 was able to self-propel their wheelchair short distances with supervision; staff were to propel otherwise.Review of Incident Abstract Report dated 12/01/2025 at 5:43 AM, Security Officer #1 documented on 11/29/2025 Licensed Practical Nurse #6 was doing their routine rounds, they walked through A pod, then B pod on the Coldspring unit, entered the second-floor stairwell E at 3:30 AM and found Resident #4 at the landing of the first-floor stairway with their wheelchair on top of them. Registered Nurse #4 Nursing Supervisor was called, assessed Resident #4 and stated all vitals were stable; Resident #4 had a gash to their right hand and left side of forehead, and an abrasion on their right knee. The ambulance was called, and Resident #4 was sent to the hospital to be evaluated. Security Officer #1 documented they reviewed security camera footage which revealed Resident #4 had exited their room at 2:40 AM and attempted to open other residents' doors and stairwell E door but was unable to. At 2:50 AM, Resident #4 was able to kick open stairwell E door and passed through to the stairwell. At 3:34 AM, Licensed Practical Nurse #6 was seen going through the door. Registered Nurse #4 and Licensed Practical Nurse #6 opened stairwell E door multiple times to test the alarm and both stated it only activated once. Review of written statements from staff working at the time of Resident #4s elopement on 11/29/2025 documented as part of the facility's investigation revealed the following:-Licensed Practical Nurse #6 documented they did not witness the fall, they entered stairwell E and found Resident #4 at the bottom of the stairs, alerted Registered Nurse #4.-Certified Nurse Aide #8 (Resident #4s assigned aide) documented they did their rounds at 1:00 AM and Resident #4 was in their bed. Certified Nurse Aide #8 documented they sat in the middle of the two pods to listen for lights on both sides because Certified Nurse Aide #9 was gone for a while.-Licensed Practical Nurse #1 documented they were notified by Certified Nurse Aide #8 that they completed their rounds at 1:00 AM and Resident #4 was in bed. At 3:30 AM, Licensed Practical Nurse #6 alerted them to Resident #4 being in the stairwell.The Work Order Details form dated 11/29/2025 at 5:32 AM revealed Registered Nurse #4 submitted a work order for stairwell E due to security door alarm malfunctioning. A resident was able to get out of the door. There was no prior work orders submitted for the stairwell E door.During an observation of A pod stairwell E on 02/18/2026 at 3:40 PM, Licensed Practical Nurse #7 pushed the door handle and opened the stairwell door, the alarm sounded. The alarm was loud and there was no wander guard alarm.During intermittent observations from 02/18/2026 to 02/20/2026 between 8:00 AM and 4:00 PM, Resident #4 was lying in their bed in their room. Resident #4 was noted to have a wander guard to their left wrist. There were no observations that the resident had exit seeking behavior.During an interview on 02/18/2026 at 1:39 PM, Registered Nurse #4 Nursing Supervisor stated they were alerted to Resident #4 being in the stairwell on 11/29/2025, they assessed Resident #4 who had no complaints, just wanted to go to work. They stated Resident #4 had a wander guard on, but security did not receive an alert that Resident #4 had exited through the door; they tested the door following the incident multiple times, and it only alarmed once. They put in a work order that morning for the door to be checked. Registered Nurse #4 stated Resident #4 returned from the hospital the same day and was placed on the third floor, which was a more secure unit, had not had any elopements since their return.During a telephone interview on 02/18/2026 at 2:08 PM, Certified Nurse Aide #8 (Resident #4's assigned aide) stated they worked on 11/29/2025 and were assigned to the B pod. They stated the double doors were closed entering B pod from A pod at the beginning of the shift, they did not know why, so they remained closed. They stated they did their checks on residents every two (2) hours, and sat at the desk in between the two pods, outside the double doors, throughout the night. Certified Nurse Aide #8 stated they last saw Resident #4 at 1:00 AM in bed sleeping. Certified Nurse Aide #8 stated a call light went off at 2:00 AM so they went to assist a resident on A pod and then returned to the desk in between the pods. Certified Nurse Aide #8 stated they did not hear a door alarm go off, but it was possible they could not have heard it because they were on the opposite end of the unit, the double doors were closed, and another call light was ringing.During a telephone interview on 02/18/2026 at 2:19 PM, Certified Nurse Aide #9 stated they worked on 11/29/2025, did not hear any alarms go off and did not provide care for Resident #4 at all.During an interview on 02/19/2026 at 10:02 AM, Licensed Practical Nurse #3/ Unit Manager stated there was an incident in November where Resident #4 had gotten into the stairwell through the stairwell E exit. They stated the doors on the second floor did not have badge access swipes to get through them, so they did not alarm when a resident with a wander guard passed by or through them, and did not alert security when a door alarm went off; the doors would alarm when opened without pushing the two red buttons located at the top of the door. They stated Resident #4 was always busy and had multiple falls due to self-transferring, but no prior elopement attempts. Licensed Practical Nurse #3 stated they do not know why the double doors were closed, would have expected staff to open them so they could keep eye on all residents if needed.During an interview on 02/19/2026 at 12:34 PM, the Director of Nursing stated they were not aware of any complaints about the door alarm to stairwell E malfunctioning until after Resident #4 eloped through it, and even after that there was not anything wrong with the system. The Director of Nursing stated the stairwell doors on the second floor did not have badge swipes, magnetic locks, or wander guard alert systems on them; only doors with magnetic locks would alert security if accessed without a badge swipe.During an interview on 02/19/2026 at 2:00 PM, the Director of Nursing stated they reviewed the surveillance footage from 11/29/2026 and they were unable to determine if the door alarm sounded or not, there was no audio to the video.During a telephone interview on 02/19/2026 at 2:40 PM, Licensed Practical Nurse #1 stated during the 11:00 PM to 7:00 AM shift on 11/28/2025 they primarily worked on A pod throughout the shift. They stated that around 2:00 AM they were assisting residents on A pod with Certified Nurse Aide #8. Licensed Practical Nurse #1 stated they did not hear a door alarm sound. Licensed Practical Nurse #1 stated Licensed Practical Nurse #6 passed by the nurses' station and then shortly after they came back and let them know Resident #4 was in the stairwell.During an interview on 02/19/2026 at 3:35 PM, Licensed Practical Nurse #6 stated they entered stairwell E while coming back from their break and found Resident #4 lying at the bottom of the stairwell with their wheelchair on top of them; they stated Resident #4 said they were going to work and could not be late and did not complain of any pain. Licensed Practical Nurse #4 stated they called Registered Nurse #4 Nursing Supervisor, who came and assessed the resident. After Resident #4 was taken to the hospital, Licensed Practical Nurse #4 stated they opened the door by pushing on the handle with Registered Nurse #4 Nursing Supervisor present multiple times and the door alarm only sounded once.During an interview on 02/20/2026 at 8:44 AM, the Director of Nursing stated they determined Resident #4 was able to get into the stairwell and fall down the stairs because the staff assigned to care for them was caring for other residents. They stated they determined through surveillance footage that the double doors were closed in between A and B pod, so there was a possibility the door alarm was not heard because staff were in a resident's room, but they could not say for sure. The Director of Nursing stated they would have expected for staff to have had the double doors open at the beginning of the shift so they could hear anything that was going on in either pod; it was important to ensure residents safety.During an interview on 02/20/2026 at 9:14 AM, the Administrator stated the door alarms only sounded locally on the second floor; they would expect it to be difficult to hear the door alarm sound on the second floor if staff were in the other pod with the double doors closed, especially on the overnight shift because there were less staff present. That was one reason they requested magnetic locks on those doors. The Administrator stated they would have expected staff to communicate and monitor the residents.During a telephone interview on 02/20/2026 at 12:03 PM, the Manager of Physical Environment Compliance stated following the elopement on 11/29/2025, a work order was placed regarding stairwell E door on the second floor. The door was assessed and it was determined it was not an alarm issue. The following day a carpenter was called out and inspected the door and said the door was working as designed.During a telephone interview on 02/20/2026 at 1:19 PM, Nurse Practitioner #1 stated they saw Resident #4 when they returned from the hospital after falling in a stairwell. They stated upon their assessment Resident #4 had some scabbed areas and was not complaining of any pain. Nurse Practitioner #1 stated they would have expected staff to do routine rounding, hourly if possible, to make sure all residents' needs were met. They stated if a resident had any concern with prior elopement attempts, they expected staff to check on them frequently.2. Resident #5 had diagnoses including congenital alveolar hypoventilation syndrome (rare neurological disorder characterized by inadequate breathing during sleep), epilepsy (seizures), and tracheostomy status (surgical intervention that establishes an airway through an incision in the neck into the trachea). The Minimum Data Set, dated [DATE] documented Resident #5 was severely cognitively impaired, was rarely/never understood, rarely/never understands, and did not exhibit wandering behavior.The comprehensive care plan dated 01/16/2025 documented Resident #5 was to be supervised in their room and on the unit when ambulating. There was no documentation that the resident had exit seeking behaviors or was at risk for elopement.Review of the Kardex Report dated 05/04/2025 documented Resident #5 was independent for bed mobility and required supervision from staff for ambulation (walking), Resident #5 received schooling weekly when school was in session; staff were to anticipate and meet the resident's needs.Review of weekly rounding progress note dated 03/04/2025 at 3:22 PM, the Medical Director documented Resident #5's behaviors off their ventilator had been a concern, was noted to be out of their room twice over the previous weekend. The plan was to continue to monitor behaviors closely and assess any additional safety measures that need to be put into place.Review of a Plan of Care note dated 03/05/2025 at 11:28 AM, Social Worker #1 documented therapy staff had stated Resident #5 was more engaged in therapy and their legs were becoming more stable.Review of nursing progress note dated 04/22/2025 at 6:05 AM, Registered Nurse #8 documented Resident #5 pulled off their sensor (an electronic health monitoring system) and attempted to run off the unit during evening rounds the evening prior (04/21/2025). Resident #5 was seen by staff and redirected back to their room without incident. The door to the unit had not been latching completely, Plant Operations were notified via work order.Review of 24-hour report sheets dated 04/21/2025 to 05/03/2025 revealed no documentation that staff were monitoring Resident #5 for exit seeking behavior.Review of interdisciplinary progress notes dated 04/23/2025 to 05/03/2025 revealed no documented evidence of exit seeking or wandering behavior for Resident #5.Review of Resident #5's Elopement Risk Scales documented on 02/15/2025 Resident #5 was not at risk for elopement. There was no documented evidence that a new elopement risk scale was completed for Resident #5 following the exit seeking behavior on 04/21/2025 and prior to their elopement on 05/04/2025.Review of the facility Investigation Report dated 05/04/2025 at 9:30 AM documented Resident #5 left the building at 9:19 AM through the same double door they used to get to the school bus. Environmental Service Staff #1 was coming back from their break and saw Resident #5 go through the doors. Environmental Service Staff #1 ran to Resident #5, who was on the sidewalk near the building; brought Resident #5 back into the building through the front door, and they were back on their unit by 9:21 AM. A wander guard was immediately placed on Resident #5, and they were placed on 1:1 monitoring for three days. A cover was to be placed over the push button to deter all ambulatory residents from easily assessing the push button for the double doors.Multiple observation from 02/18/2026 to 02/20/2026 from 8:00 AM to 4:00 PM, Resident #5 was in their room lying in bed and walking around their room; their wander guard was noted to their right wrist.During an interview on 02/19/2026 at 10:17 AM, Registered Nurse #9 (Resident #5's assigned nurse) stated they were on their break when Resident #5 went through the double doors. They stated the resident was lying in their bed when they saw them 15 minutes prior to taking their break. They had no knowledge of any prior exit seeking behavior. During a telephone interview on 03/05/2026 at 9:53 AM, Registered Nurse #8 stated they recalled on 04/21/2025 at the start of the evening shift (6:00 PM) one of the double doors to the unit was propped open because the buzzer that went off when the door opened was beeping nonstop. They asked if anyone had put a work order in for the malfunctioning door and then shut the door. They stated it was not safe to have the door propped open. Registered Nurse #8 stated the shift had just started, and they had just gotten report from the outgoing nurse and was in another resident's room. They heard the beeping indicating that someone was not connected to their sensor (electronic health monitoring system), came out of the room, looked down at the hall and saw Resident #5 running towards the door to exit the unit. Certified Nurse Aide #17 was standing near the doors and redirected Resident #5 back to their room, they never made it off the unit. Registered Nurse #8 stated it was a new behavior for Resident #5 as they were recently transitioned into a regular floor bed from a Posey bed (special fully enclosed hospital bed) and had been making progress with walking; was learning new skills in school and with therapy. Registered Nurse #8 stated they updated Registered Nurse #10/Nursing Supervisor, documented it in the progress notes, and thought they added it to the 24-hour report sheet. They stated they verbally updated on coming shift at 6:00 AM on 04/22/2025. Registered Nurse #8 stated they put a work order into Plant Operations regarding the door not latching and making a beeping noise. Someone from Plant Ops came out and serviced the door in the middle of the night but stated they needed to order a part. They stated Resident #5 was given their medication shortly after rounds and slept throughout the night without incident. Registered Nurse #8 stated typically after a resident made an elopement attempt a wander guard would be placed, and that did not happen.During a telephone interview 03/05/2026 at 11:39 AM, Registered Nurse #6 (oncoming nurse on 04/22/2025) stated they remembered being told Resident #5 had an elopement attempt on 04/21/2025 and there was a work order placed for the door during rounds on 04/22/2025 at 6:00 AM. They stated there was not a Unit Manager on the unit at the time of the elopement attempt, so the Nursing Supervisor would have been responsible for initiating any interventions and completing a new elopement risk scale. Registered Nurse #6 stated they did not recall any new intervention put into place following Resident #5's elopement attempt on 04/21/2025 and could not recall if the provider was made aware. Registered Nurse #6 stated Resident #5 should have had a wander guard placed for their safety after their exit seeking behavior on 04/21/2025, it could have prevented them from eloping on 05/04/2025. During a telephone interview on 03/05/2026 at 11:53 AM, the Former Assistant Director of Nursing/Former Interim Unit Manager stated they were on vacation until 04/23/2025 and upon their return were not made aware of Resident #5's exit seeking behavior. They stated if they would have been made aware they would have placed a wander guard on Resident #5 and completed a new elopement risk scale; the wander guard could have prevented Resident #5's elopement on 05/04/2025 from occurring. They stated since they were not there the incident should have been reported to the Nursing Supervisor or Director of Nursing so that appropriate interventions could have been put into place.During an interview on 03/05/2026 at 12:02 PM, the Director of Nursing reviewed Resident #5's electronic medical record including their progress notes from 03/04/2025 to 05/04/2025, comprehensive care plan, and elopement risk and they were not made aware of Resident #5's elopement attempt in April; they would have expected staff to document it on the 24-hour report sheet so that oncoming staff were aware, report it to their unit manager or nursing supervisor so they could follow up, and let security know so they could have placed a wander guard. The Director of Nursing stated if Resident #5 was wandering and trying to get through doors, an elopement assessment and a wander guard placement would be expected. They did not see any new interventions put into place and did not see an elopement risk scale completed after the elopement attempt on 04/21/2025, and there should have been. It was important to ensure residents' safety and could have possibly prevented any further elopements. During an interview on 03/05/2026 at 1:36 PM, Respiratory Therapist #1 stated (on 05/04/2025) they were in the back of the unit, heard the system alert and it showed Resident #5 was disconnected from their sensor. They stated they went to Resident #5s room and saw they were not in their room. They started walking towards the doors and saw Environmental Service Staff #1 walking Resident #5 back onto the unit.During an interview on 03/05/2026 at 1:18 PM, Social Worker #1 stated Social Workers were responsible for completing elopement risk scales annually, quarterly, and as needed; they were not made aware of any elopement attempt from Resident #5 in April of 2025 and would have completed a new assessment if they were made aware. They did recall Resident #5 having new behaviors due to learning new skills with school and therapy, they were progressing very fast. They stated Administration should have been made aware of the elopement attempt and a wander guard should have been applied after that attempt, that would have triggered them to complete the assessment. Social Worker #1 stated it was important to ensure the safety of residents; Resident #5s elopement on 05/04/2025 could have been avoidable if the wander guard was placed when the wandering behaviors started (on 04/21/2025).During an interview on 03/05/2026 at 1:45 PM, the Director of Nursing stated Resident #5 was hooked up to the sensor, so when the sensor was removed or detached, it would alarm at a computer screen at the nurses station and staff were trained to run when it went off, so there was a way for staff to be aware Resident #5 was out of their room.During a telephone interview on 03/05/2026 at 1:47 PM, the Medical Director stated they were noticing Resident #5 was gaining new skills and staff knew to monitor them, so the note from 03/04/2025 was referring to that. They stated if a wander guard was applied after their attempt to leave the unit (on 04/21/2025), it possibly could have prevented the elopement on 05/04/2025. They stated Resident #5 was always attached to their sensor due to their underlying genetic disorder which affects their respiratory system, so if they removed the sensor, it would alert staff to run.During a telephone interview on 03/05/2026 at 2:54 PM, Registered Nurse #10 stated they were the Nursing Supervisor working on 04/21/2025 from 6:00 PM to 6:00 AM, and on 04/22/2025 from 2:00 PM to 10:00 PM; did not recall being made aware of Resident #5 having an elopement attempt or exit seeking behavior. They stated if they were made aware they would have assessed Resident #5, placed them on 1:1 supervision, completed an elopement risk scale, and likely would have applied a wander guard.10NYCRR 415.12(h)(1)

Based on interview, and record review conducted during the Abbreviated Survey (Complaint #NY00376929) the facility did not ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for one (1) (Resident #1) of three (3) reviewed. Specifically, a BiPAP machine (Bilevel Positive Airway Pressure machine used as a non-invasive respiratory support) was not provided until five days after admission to the facility. The finding is: The policy and procedure titled Resident Assessment Process revised 12/2022 documented the external data collection of medical documents begins at the time of admission from transferring institutions. These documents will assist the interdisciplinary team in the development of the comprehensive assessment. Data will be collected from various sources, not limited to hospitals. The internal collection process was conducted simultaneously of gathering information to validate, develop and assess the resident's current needs. The accumulation of medical information will allow the development of a Comprehensive Assessment Plan which will assist the resident to maintain his/her highest practical level of care and enhance the resident's quality of life. The policy and procedure titled admission Policy, Long Term Care revised 1/2024 documented an assessment of the resident's level of care needs will be performed prior to admission by or on behalf of the agency or person seeking admission for the resident. Resident #1 was admitted to the facility with diagnoses including chronic obstructive pulmonary disease, diabetes mellitus, and anxiety. The Minimum Data Set (a resident assessment tool) dated 3/30/24 documented that Resident #1's memory was ok and an independent decision maker. The Minimum Data Set did not document the use of a BiPAP machine. The admission pre-screen with a locked date of 3/25/25 documented respiratory treatment/therapy that included the use of a BiPAP. The discharge planning note within the admission pre-screen documented Resident #1's baseline oxygen was maintained on five (5) liters of oxygen via nasal cannula and a BiPAP machine every night. The Hospital Discharge summary dated [DATE] documented chronic hypoxic hypercapnic (too much carbon dioxide in the blood stream) respiratory failure due to chronic obstructive pulmonary disease. BiPAP every night with settings 5 expiratory positive airway pressure (epap) and 12 inspiratory positive airway pressure (ipap). The Skilled Nursing Facility admission Data Sheet signed, completed at 6:20 PM on 3/25/25 by Registered Nurse #3 documented oxygen use at five (5) liters via nasal cannula. There was no documented evidence Resident #1 required a BiPAP. The Baseline Resident Care plan with an effective date of 3/25/25 revealed a respiratory section which included boxes for BiPAP and oxygen. The boxes were blank. Nursing Progress Note dated 3/25/25 at 6:53 PM, Registered Nurse #3 documented Resident #1's respirations were full and easy on five liters of oxygen via nasal cannula. There was no documented evidence Resident #1 used a BiPAP machine. Nurse Practitioner #2's Progress Note dated 3/26/25 documented they ordered a BiPAP at night and as needed for sleep during the day. Review of the Order Summary Report revealed an active physician's order dated 3/26/25 for the BiPAP at night and as needed during the day. The settings were 5 expiratory positive airway pressure (epap) and 12 inspiratory positive airway pressure (ipap). There was no physician's order for the BiPAP upon the resident's admission to the facility. Review of the March 2025 Medication Administration Record revealed an active physician's order dated 3/26/25 for the use of a BiPAP machine at night and as needed during the day. On 3/26/25, 3/28/25, and 3/29/25 at 9:00 PM the number nine (9) was documented and referred to see the progress notes. On 3/27/29 the medical record was inaccurately documented as the BiPAP machine was not available in the facility until 3/30/25. Review of the Nursing Progress Notes dated 3/26/25 at 8:53 PM and 3/29/25 at 10:03 PM, Licensed Practical Nurse #1 documented Resident #1's BiPAP machine was not available. On 3/28/25 Licensed Practical Nurse #3 documented at 8:22 PM that Resident #1 did not have a BiPAP machine. The Nursing Progress Notes dated 3/30/25 revealed Resident #1 received the BiPAP machine at 12:00 PM. Resident #1 was lethargic and only opened their eyes to verbal stimuli. Resident #1 was transferred to the hospital on 3/30/25 at 3:05 PM for evaluation. During a telephone interview on 4/8/25 at 11:54 AM, admission Screener #1 stated they confirmed with the hospital social worker during their screening process and relayed to the facility via an email on 3/25/25 at 11:35 AM that Resident #1 required a BiPAP machine while at the facility. An email was sent as a notification to the Director of Nursing, the Long-Term Care Health Information Manager, and the Administrator and then forwarded on to the Unit Manager. The facility was responsible to ensure the facility ordered the equipment from the vendor. Review of an email provided on 4/8/25 at 1:10 PM by admission Screener #1 revealed they had informed the Director of Nursing, the Long-Term Care Health Information Manager, and the Administrator at 11:35 AM on 3/25/25 that Resident #1 was being admitted into the facility on 3/25/25 and required a BiPAP machine and documented the required settings. During a telephone interview on 4/8/25 at 11:23 AM, Nurse Practitioner #1 stated they expected the hospital discharge summary be followed and the BiPAP equipment to have been available for Resident #1 upon admission. Registered Nurse #3 should have noticed there was no equipment and should have contacted the provider for further instructions. Resident #1 could have retained carbon dioxide and decompensated. Nurse Practitioner #1 stated they would have ordered additional pulse oximetry readings and monitored frequently throughout the night for respiratory distress. During a telephone interview on 4/8/25 at 11:58 AM, Licensed Practical Nurse #1 stated they documented in the Nursing Progress Notes BiPAP was unavailable on 3/26/25 and they verbally told Registered Nurse #4 that Resident #1 needed the BiPAP. Licensed Practical Nurse #1 stated the machine was still unavailable on 3/29/25. During a telephone interview on 4/8/25 at 3:50 PM, Registered Nurse #3 stated they worked together with Registered Nurse #4 on Resident #1's admission. Registered Nurse #4 completed the orders and confirmed them with the physician and completed the assessments and the paperwork. Registered Nurse #3 stated they were unaware that Resident #1 required a BiPAP. Nurses were never responsible for ordering equipment; it was the responsibility of the Unit Manager. During a telephone interview on 4/9/25 at 7:52 AM, Nurse Practitioner #2 stated it was blatant per the hospital discharge summary that the BiPAP should have been ordered upon admission, it was not ordered, so they ordered it on 3/26/25. Nurse Practitioner #2 was not sure if Resident #1 would be compliant with the equipment but they would have expected at the least to have it in the building. During a telephone interview on 4/9/25 at 9:08 AM, the Medical Director stated they confirmed the orders on 3/25/25 over the telephone. It was not brought to their attention the need for the BiPAP until 3/29/25 when they found out that Resident #1 did not have one. The Medical Director stated they reviewed Resident #1's history and physical from their most recent hospital stay on 3/30/25 which said Resident #1 did not receive their BiPAP while at the nursing home and that was concerning. During a telephone interview on 4/9/25 at 9:51 AM, Registered Nurse #4 stated the admission screener ordered equipment prior to admission into the facility. There was no physicians order on the hospital Discharge summary dated [DATE] for the BiPAP, and they must have overlooked it. During an interview on 4/24/25 at 9:30 AM, Registered Nurse #1 stated Resident #1 was admitted with a respiratory diagnosis, and the need for the BiPAP was documented in the meat of discharge summary. If one was used it in the hospital, they would have expected the resident to have one ready to go in the facility. Licensed Practical Nurse #1 verbally communicated there was no equipment to Registered Nurse #4. Registered Nurse #4 should have informed the Nursing Supervisor or the Director of Nursing who could have contacted the vendor. During an interview on 4/24/25 at 2:53 PM, the Director of Nursing stated someone on the unit should have been notified and ordered the equipment. Resident #1 used BiPAP in the hospital, and it should have been available. The Director of Nursing stated they did receive an email dated 3/25/25 from admission Screener #1 but did not read it. During an interview on 4/24/25 at 3:15 PM, the Administrator stated the email from admission Screener #1 on 3/25/25 was for notification purposes. It would have been prudent to have a BiPAP machine prior to Resident #1 coming into the facility. In addition, the Administrator stated there was no policy specifically for use of BiPAP machines. 10 NYCRR 415.12(k)(6)

Based on observations, interviews and record reviews conducted during a complaint investigation (#NY00330798 and #NY00325133) during an extended standard re-certification survey from 9/3/2024 to 9/16/2024, the facility failed to protect the residents' right to be free from sexual abuse by a resident for three (Residents #33, #50, #208) of ten residents reviewed. Specifically, the facility failed to implement safeguards that resulted in repeated instances of sexual abuse with residents that had impaired cognitive status and lacked the ability to consent. This resulted in and had the likelihood for psychosocial harm that is Immediate Jeopardy and Substandard Quality of Care for Residents #33, #50, #208 with the likelihood to affect all residents (census 265) in the facility. The findings are: The policy and procedure titled Identification and Reporting of Abuse, Neglect, Exploitation, or Mistreatment of a Skilled Nursing Facility Resident revised on 9/12/2024 documented any resident abuse will not be tolerated. When a suspicion of abuse, mistreatment, or neglect becomes known, necessary steps will be taken to protect the residents involved and any other vulnerable residents in the facility. Resident #226 had diagnoses of stroke (loss of blood flow to part of the brain or bleeding in the brain) and type 2 diabetes mellitus. The Minimum Data Set (a resident assessment tool) dated 9/24/2023 documented Resident #226 was cognitively intact. The comprehensive care plan dated 7/21/2023 documented staff should check Resident #226's whereabouts on rounds, change of shift, and after meals due to wandering behaviors. Resident #208 had diagnoses of Alzheimer's disease and depression. The Minimum Data Set, dated dated dated [DATE] documented Resident #208 was severely cognitively impaired. The comprehensive care plan dated 4/5/2024 documented Resident #208 had impaired cognitive function, was non-verbal and dependent on staff for meeting emotional, intellectual, physical, and social needs. Review of the care plan revealed there were no revisions documented since August of 2022. A nursing progress note dated 9/3/2023 written by Licensed Practical Nurse #3 documented Resident #226 was in the common area rubbing the leg of Resident #208. During a telephone interview on 9/9/2024 at 8:18 AM, Licensed Practical Nurse #3 stated they heard an aide say, uh, uh, don't do that, looked over and Resident #226 was rubbing Resident #208's lower leg. They reported it to Registered Nurse Unit Manager #7 and was told to keep Resident #226 and Resident #208 apart. Licensed Practical Nurse #3 stated they were not instructed to put Resident #226 on 1:1 supervision or to put Resident #226 on 15-minute visual checks. A nursing progress note dated 9/24/2023 written by Licensed Practical Nurse #1 documented Resident #226 was observed crawling under a table by Resident #208's knees. Resident #208 was moved to another area away from Resident #226. During a telephone interview on 9/6/2024 at 9:01 AM, Licensed Practical Nurse #1 stated they had witnessed Resident #226 on 9/24/2023 trying to crawl under the table and was by Resident #208's knees. Licensed Practical Nurse #1 stated they had asked Resident #226 what they were doing and documented the behavior in the progress notes. They stated they had reported Resident #226's behavior to the former Unit Manager, Registered Nurse #7. Review of an investigation and witness statements dated 9/29/2023 documented Licensed Practical Nurse #16 was answering a call light in Resident #208's room when they found Resident #226 in Resident #208's room standing next to the bed with their arms at their side Resident #208's breasts were exposed, and Resident #226 was staring at Resident #208. Resident #226 had denied touching Resident #208. When asked what they were doing, Resident #226 responded nothing, nothing and walked out of the room. It was documented that Resident #208 was asked what happened but did not respond. Resident #81 (roommate of Resident #208) stated that someone had come into the room, but the curtain was pulled so they could not see what had happened and did not hear any noises from Resident #208's side of the room. Review of security video footage dated 9/29/2023 revealed that at 3:49 PM Resident #226 went into Resident #208's room. At 4:04 PM, the call light began to blink outside Resident #208's room. At 4:12 PM, Licensed Practical Nurse #16 entered Resident #208's room and Resident #226 was then seen leaving the room. Review of the 24-Hour Nursing Reports dated 9/29/2023, 9/30/2023, 10/1/2023, 10/2/2023, and 10/3/2023 documented staff were to watch Resident #226 to keep them away from Resident #208. There was no documented evidence indicating specific instructions for watching Resident #226. During a telephone interview on 9/6/2024 at 9:01 AM, Licensed Practical Nurse #1 stated they regularly worked on the unit and saw Resident #208 after the incident on 9/29/2023. They stated Resident #208 had tears in their eyes and would open their mouth and cry out, so Licensed Practical Nurse #1 stated they knew there was something wrong. Licensed Practical Nurse #1 stated Resident #226 did not have a room change right away and they were not put on 1:1 supervision. During a telephone interview on 9/9/2024 at 10:18 AM, Registered Nurse Supervisor #1 stated they had notified Assistant Director of Nursing #1 of the 9/29/2023 incident. Registered Nurse Supervisor #1 stated the Assistant Director of Nursing did not instruct them to put Resident #226 on a 1:1 supervision or to initiate 15-minute checks. During an interview on 9/9/2024 at 3:06 PM, Social Worker #1 stated Resident #226 was moved to the dementia unit four days after the 9/29/2023 incident with Resident #208 because there was not a long term care room available. Social Worker #1 stated they spoke with Resident #226 after the incident and educated them to keep their hands to themselves and not to make inappropriate comments to females. There was no documented evidence of a medically necessary reason to move Resident #226 to the dementia unit. During an interview on 9/10/2024 at 4:55 PM, Assistant Director of Nursing #1 stated Resident #226 was moved to the dementia because there was not another room available. Assistant Director of Nursing #1 stated no one witnessed Resident #226 touching Resident #208 so Resident #226 was not put on 1:1 supervision or 15-minute visual checks. During a telephone interview on 9/10/2024 at 6:23 PM, Licensed Practical Nurse #17 stated after the 9/29/2023 incident they were told by Registered Nurse Unit Manager #7 to keep Resident #226 away from Resident #208. They were supposed to keep Resident #226 in sight while they were awake but there was no official documentation, and the resident was not on 1:1 supervision. During an interview on 9/11/2024 at 8:07 AM, the Director of Nursing stated Resident #226 was moved to the dementia unit because there was not another room available, and they increased monitoring of Resident #226 whereabouts. The Director of Nursing stated the nurses should have documented Resident #226's whereabouts but there was not a formal 15-minute check started or 1:1 supervision. The facility daily census reports dated 9/29/2023 through 10/3/2023 revealed available beds within the facility: -Rehabilitation Unit - 3 empty beds available on 9/29/2023 and 9/30/2023 5 empty beds available on 10/1/2023 and 10/2/2023. 3 empty beds available on 10/3/2023. -Long-Term Care Unit had one bed available on 9/29/2023 and 9/30/2023, 2 beds available on 10/1/2023, 10/2/2023 and 10/3/2023. In addition, the facility had a closed (POD, unit) leaving the following beds empty 480 - 490 9/29/2023 through 10/3/2023. During an interview on 9/11/2024 at 10:11 AM, the current Administrator stated they did not know why Resident #226 was not moved sooner to another room after the incident on 9/29/2023. They stated Resident #226 should have been placed on 1:1 supervision at that time to ensure they did not go into Resident #208's room or anyone else's room. During an interview on 9/12/2024 at 8:55 AM, Medical Doctor #1 stated the incident on 9/29/2023 was highly suspicious and could have been abuse. Resident #226 should have been put on 1:1 supervision on 9/29/2023. 2. Resident #226 was moved to the dementia unit on 10/3/2023. Resident #50 had diagnoses of dementia, arthritis, and seizure disorder. The Minimum Data Set, dated dated dated [DATE] documented Resident #50 was severely cognitively impaired. The comprehensive care plan dated 9/10/2019 and in place in 11/2023 documented Resident #50 was cognitively impaired, preferred to be in bed after dinner, and staff were to check at least every 2-3 hours for incontinence. Resident #33 had diagnoses of dementia and anxiety disorder. The Minimum Data Set, dated dated dated [DATE] documented Resident #33 was severely cognitively impaired. The comprehensive care plan dated 3/15/2017 and in place 11/2023 documented Resident #33 had dementia. The 24-Hour Nursing Reports dated 11/10/2023, 11/11/2023, and 11/12/2023 documented Resident #226 was found in Residents #50 and #33's shared room. Review of Resident #226 nursing progress notes revealed the following: 11/9/2023 at 10:57 PM, Registered Nurse Nursing Supervisor #1 documented resident was observed by staff standing in the common area with their genitals out of their pants. Resident #50 and another resident (#33) were in the common area. Resident #226 denied that they had their genitalia exposed. 11/10/2023 at 8:22 PM, Licensed Practical Nurse #5 documented resident was found by staff in Resident #50's room. 11/11/2023 at 9:22 PM, Licensed Practical Nurse #6 documented resident was found in Resident 50's room again and this was the third instance. 12/11/2023 Licensed Practical Nurse #18 documented resident was in Resident 50's room. The Nursing Supervisor and the Nurse Practitioner were notified. Review of security video footage dated 11/10/2023 revealed Resident #226 entered Resident 50's room at 7:19 PM and was spotted by Certified Nurse Aide #3 at 7:23 PM and was removed from the room. Review of security video footage dated 11/11/2023 at 7:28 PM revealed Resident #50 was brought by a staff member to their room. At 7:53 PM, Resident #226 entered Resident #50's room and left the room at 8:19 PM. At 8:39 PM, Resident #226 re-entered Resident 50's room. At 8:56 PM, Certified Nurse Aide #3 ran into Resident #50's room and left. At 9:16 PM, Certified Nurse Aide #3 re-entered Resident 50's room. At 9:18 PM, an unidentified nurse entered Resident 50's room. At 9:20 PM, Certified Nurse Aide #3 and Resident #226 left Resident 50's room. During an interview on 9/11/2024 at 1:27 PM, Certified Nurse Aide #3 stated on 11/11/2023 they saw Resident #50 had thrown up on themselves and Certified Nurse Aide #3 ran to get the nurse. They stated they were so focused on Resident #50 throwing up that they did not see Resident #226 in the room the first time. Certified Nurse Aide #3 stated they removed Resident #226 from Resident #50's room after discovering the resident in that room. They stated Resident #50 was dressed in a hospital gown but was not exposed in any way. Review of security video footage dated 12/11/2023 revealed Resident #226 entered Resident #50's room at 7:16 PM. At 7:22 PM, Certified Nurse Aide #1 walked by Resident 50's room, looked in, walked away, and returned to the room and entered. At 7:23 PM, Resident #226 was seen leaving Resident #50's room. Review of the 24-Hour Nursing Reports for December 2023 revealed there was no documentation regarding Resident #226 being in Resident #50's room. Review of an investigation along with Licensed Practical Nurse #13 and Certified Nurse Aide #4 witness statements dated 12/29/2023 documented Resident #226 was found kneeling at the bedside of Resident #50. Resident #226 was fondling their own genitals and had their other hand in the incontinence brief of Resident #50. Review of security video footage dated 12/29/2023 revealed at 9:47 PM, Resident #226 walked around the corner with their incontinence brief around their ankles. At 9:48 PM, Resident #226 walked into Resident #50's room wearing only a hospital gown. From 9:48 PM to 11:23 PM, Resident #226's walker and brief were observed on the floor outside of Resident 50's room. At 11:23 PM, Certified Nurse Aide #4 entered Resident 50's room and hurriedly left the room. At 11:24 PM Licensed Practical Nurse #13 entered Resident #50's room and Resident #226 was removed from the room. During a telephone interview on 9/6/2024 at 8:18 AM, Certified Nurse Aide #4 stated they witnessed Resident #226 in Resident 50's room fondling themselves and their other hand was inside Resident #50's brief. Certified Nurse Aide #4 stated they ran to get the nurse. During a telephone interview on 9/9/2024 at 4:57 PM, Certified Nurse Aide #1 stated approximately two weeks before the 12/29/2023 incident they had found Resident #226 in Resident #50's room. Resident #226 had their pants and their incontinence brief down. Certified Nurse Aide #3 stated they got the nurse and Resident #226 was removed from the room. During a telephone interview on 9/16/2024 at 2:04 PM, Licensed Practical Nurse #13 stated they found Resident #226 next to Resident #50's bed masturbating and their other hand was inside Resident #50's incontinence brief. During an interview on 9/10/2024 at 9:26 AM, Licensed Practical Nurse #18 stated the aides had reported Resident #226 was found in Resident #50's room on 12/11/2023. Licensed Practical Nurse #18 stated they documented it in the progress notes and had reported it to the nursing supervisor and a nurse practitioner but, did not recall which supervisor or which nurse. They stated they were asked by Assistant Director of Nursing #1 to write a witness statement and to initiate an investigation. During an interview on 9/10/2024 at 10:04 AM, Assistant Director of Nursing #2 stated there were no other investigations for any incidents between Resident #226 and Resident #50 and #33. During an interview on 9/10/2024 at 12:07 PM, Nurse Practitioner #1 stated they were never notified of any allegations of abuse between Resident #226 and Resident #50. Nurse Practitioner #1 stated they did not think Resident #226 was appropriate for a dementia unit. During an interview on 9/10/2024 at 12:31 PM, Nurse Practitioner #2 stated they were never notified about Resident #226 exposing themselves or any type of sexual abuse between residents. During an interview on 9/11/2024 at 1:00 PM, the Director of Nursing stated that what happened to Resident #50 was abuse. During an interview on 9/11/2024 at 2:43 PM, the [NAME] President of Long-Term Care (former Administrator) stated it was not an effective plan to move Resident #226 to another unit. The [NAME] President stated they were not aware Resident #226 was entering other resident rooms and if they had been aware, they would have initiated 1:1 supervision earlier to prevent any events and protect all vulnerable residents. The [NAME] President of Long-Term Care stated this situation should have risen to the administrative level for further review. During an interview on 9/12/2024 at 10:07 AM, the Director of Nursing stated they should have been notified by staff of Resident #226's behavior so that additional interventions could have been put into place to prevent sexual abuse. I believe we were not as prudent as we should have been to maintain the safety of all our residents. During an interview on 9/12/2024 at 8:55 AM, Medical Doctor #1 stated they were not aware of any incidents between Resident #226, Resident #50, and Resident #33 that occurred in November 2023. They would have expected staff to report any incidents of possible sexual abuse to themselves and the Director of Nursing. After the incident on 12/29/2023 they called the Special Victims Unit because this was sexual abuse. Medical Doctor #1 stated they assessed both Resident #50 and #226. Resident #226 was assessed for insight, judgement, and determined that Resident #226 was alert and oriented. Medical Doctor #1 stated, had Resident #226 been placed on 1:1 supervision on 9/29/2023, then any other incidents of sexual abuse could have been prevented. They stated there was room for improvement when it comes to sexual abuse education for staff. Based on observations, staff interviews, and record review the facility removed the immediacy as of 9/13/2024 at 11:15 PM: 12/29/2023 the facility placed Resident #226 on 1:1 supervision and remains on 1:1. 9/11/2024 the facility conducted a Quality Assurance and Performance Improvement meeting; completed a root cause analysis; conducted record reviews and resident interviews and began staff education with a specific focus on sexual abuse, recognition, prevention, and reporting. 9/12/2024 the facility conducted a second Quality Assurance and Performance Improvement meeting, reviewed the facility abuse policies, and education continued for all staff with a focus on sexual abuse. The Director of Nursing, Assistant Directors of Nursing and Registered Nurse Supervisors were educated on conducting abuse investigations. As of 9/13/2024 at 11:15 PM 86 % (percent) of all staff were educated. NYCRR 10 415.4(b)(1)(ii)

Based on observations, interviews, and record review completed during complaint investigations (Complaint #NY00345300 and #NY00324827) during an extended recertification survey, the facility failed to ensure that each resident received adequate supervision to prevent accidents and elopement for two (Resident #20 and #228) of ten residents reviewed. Specifically, Resident #228 required 1:1 (one to one) supervision for safety and had an unwitnessed fall, sustaining a right hip fracture. In addition, on 9/24/2023 at 1:25 PM Resident #189 eloped through the front door of the facility. This resulted in actual harm to Resident #228 that was not Immediate Jeopardy. The findings are: 1. During an interview on 9/11/2024 at 12:39 PM both the Director of Nursing and the Administrator stated there was no policy for 1:1 supervision. Review of the Role of the Sitter and Sitter Safety in the Acute Healthcare Setting education revealed the definition of 1:1 is constant observation, meaning a situation in which a staff member is responsible for maintaining continuous watch of a single patient, with eyes on the patient at all times and within arm's length of the patient. Resident #228 had diagnoses including unspecified dementia with agitation, delirium (confused thinking, with reduced awareness of surroundings), and history of traumatic fracture to their left hip. The Minimum Data Set (a resident assessment tool), dated 4/26/2024, documented Resident #228 was moderately cognitively impaired, usually understood, and sometimes understands. Resident #228 was dependent for bed mobility and transfers and used a wheelchair. Resident #228 had a fall prior to admission and two or more falls with injury since admission which included surgery (fractured left hip repair) requiring active skilled nursing care. Review of the Comprehensive Care Plan dated 5/3/2024 revealed Resident #228 required 1:1 supervision around the clock for safety; was a fall risk due to recent frequent falls and delirium; required their bed in the lowest position with fall mats to both sides of their bed. In addition, Resident #228 had behaviors such as rolling out of bed and attempting to self-ambulate. Review of the Kardex (a resident care guide) dated 5/24/2024 revealed Resident #228 required 1:1 supervision around the clock for safety. Review of the nursing progress notes from 4/19/2024 - 5/3/2024 revealed Resident #228 had multiple unwitnessed falls with minor injuries. The Internal Quality Review/Investigation Worksheets dated 4/19/2024, 4/20/2024 and 4/23/2024 revealed multiple falls on the floor. On 4/23/2024, one-to-one observation was initiated for the resident, which was not placed on their comprehensive care plan until 5/3/2024. The Internal Quality Review/Investigation Worksheet dated 5/24/2024 documented at 8:45 AM Resident #228 was found sitting on their buttocks on their roommate's side of the room. No injuries noted. The form documented the 1:1 had been discontinued on 5/24/2024 by the Physician. Review of the attached Kardex dated 5/24/2024 documented Resident #228 required 1:1 observation around the clock for safety. The attached assignment sheet labeled [NAME] Park, the resident's unit, dated 5/24/2024 for 7:00 AM- 3:00 PM shift documented there was no aide assigned as a 1:1 for Resident #228 that shift. The Physician/Nurse Practitioner/Physician Assistant note dated 5/24/2024 at 8:57 PM completed by Medical Director #1 documented 1:1 supervision was reinstated for Resident #228 due to recent frequent falls. The Internal Quality Review/Investigation Worksheet dated 5/26/2024 documented at 1:10 PM Resident #228 was found on the floor in the common area lying on their right side. Staff were attending to other residents at the time. An X-ray was ordered, and results showed a fractured right hip. The attached Kardex dated 5/24/2024 documented Resident #228 required 1:1 observation around the clock for safety. The attached assignment sheet labeled [NAME] Park dated 5/26/2024 for 7:00 AM- 3:00 PM shift documented there were two residents requiring 1:1 that shift. Only one aide was assigned as a sitter (staff assigned to 1:1 for a resident) but was not assigned to Resident #228. During an observation on 9/6/2024 at 10:30 AM with Security Officer #1 present, the facility video surveillance footage for 5/26/2024 at 12:46 PM revealed Resident #228 was left unattended in the common area on the [NAME] Park unit. At 12:46 PM, Resident #228 stood up and fell to the floor onto their right side. At 12:48 PM Licensed Practical Nurse #11 came into view, saw the resident, and went to the telephone. The Ultrasound Report dated 5/26/2024 documented an exam of the right hip with pelvis X-ray which revealed an acute right hip fracture. The Radiology Results Report dated 5/26/2024 documented an acute intertrochanteric (upper part of the thigh bone between the two ends that stick out, where the muscle is attached) hip fracture. The hospital Discharge Summary dated 6/4/2024 documented Resident #228 had a closed reduction internal fixation (surgical repair) of the right hip intertrochanteric fracture on 5/28/2024. During an interview on 9/6/2024 at 8:57 AM, Licensed Practical Nurse #10 stated 1:1 supervision meant a staff member would be assigned to the resident and they would be with that resident the entire shift, getting relieved for breaks. They should stay close enough to the resident so they could catch them if they were to try to stand and fall. During a telephone interview on 9/9/2024 at 9:52 AM, Certified Nurse Aide #8 stated Resident #228 was made a 1:1 because they were always trying to get themselves up and they fell a lot. Certified Nurse Aide #8 stated they know if a resident is 1:1 by checking the care plan, and they check that every day in case there are changes. During an interview on 9/9/2024 at 10:20 AM, Certified Nurse Aide #10 stated they were assigned as a sitter on [NAME] Park on 5/26/2024 for the 7:00 AM-3:00 PM shift, but not for Resident #228. They recalled they were in the other resident's room who was a 1:1 for that shift. They looked at the assignment sheet for [NAME] Park unit dated 5/26/2024 for 7:00 AM-3:00 PM shift and noted there were two residents on 1:1, but they were the only sitter assigned. Certified Nurse Aide #10 stated that by not providing Resident #228 with a sitter, it was a break in their care plan. They stated Resident #228 was a 1:1 because they tried to stand and fell a lot. During an interview on 9/9/2024 at 2:34 PM, Assistant Director of Nursing #4 stated they did not know why Resident #228 was not assigned a sitter on 5/26/2024. Resident #228's care plan and Kardex documented they required 1:1 supervision, around the clock, for safety. By not having an assigned 1:1 sitter, and the resident falling and breaking their hip, it was a break in their care plan that led to harm to the resident. During an interview on 9/9/2024 at 3:09 PM, the Director of Nursing stated according to their care plan and Kardex, Resident #228 should have been assigned a sitter on 5/26/2024, but they were not, and they fell and fractured their hip. By not assigning a sitter, it was a break in the resident's care plan that led to harm of the resident. During an interview on 9/10/2024 at 10:03 AM, Medical Director #1 stated Resident #228 was put on 1:1 because they were very active and difficult to redirect. Resident #228 was always trying to get up on their own. Medical Director #1 stated it was possible the fall could have been prevented if they were provided the 1:1 at the time of the incident. The fall resulted in a fractured hip, which was a major injury that did result in harm to the resident. During an interview on 9/10/2024 at 12:42 AM the Administrator stated, if Resident #228 was care planned to have 1:1 supervision around the clock and they were not provided 1:1 supervision, had a fall, and fractured their hip, then that was a break in the care plan that led to harm to the resident. During an interview on 9/11/2024 at 9:05 AM the Clinical Educator stated that 1:1 meant there should always be an aide with the resident within arm's reach. 1:1 supervision was not taught during orientation nor during annual in-services. The Clinical Educator stated they should probably include that in their orientation because they did have residents that required 1:1 supervision. During an interview on 9/11/2024 at 9:06 AM, Physical Therapist #1 stated the therapy department is not involved in 1:1 education or recommendations, but it is the nursing department's responsibility. They stated 1:1 meant an aide should be no more than 6 feet away from the resident and always have them in site. Physical Therapist #1 stated 1:1 in the nursing home was usually used for safety of residents that tried to stand and fell a lot. 2. The policy titled Elopement Long Term Care/Missing Person last revised 10/27/2022 documented resident elopement is defined as when a cognitively impaired resident leaves a facility without staff observation or knowledge of the resident's departure. Any staff member observing a confused or previously identified wandering resident attempting to leave the premises, shall attempt to redirect the resident to the facility. Upon notification that a resident is missing, a thorough search of the facility and the premises for the missing resident will be conducted. Outside search will be coordinated with Site Leadership, Nursing Supervisor, and Security. The policy titled Wander Guard last revised on 10/27/2022 documented the wander guard system alarms when residents wearing a bracelet signaling device attempts to pass through a monitored area. Residents identified as at risk for elopement will have a bracelet signaling device applied to their wrist. Resident #189 had diagnoses that included unspecified dementia, polyneuropathy (damaged peripheral nerves) and type 2 diabetes mellitus (problem with the way the body regulates the uses of sugar as a fuel). The Minimum Data Set, dated dated dated [DATE] documented Resident #189 was severely cognitively impaired, understood and understands. Additionally, Resident #189 had a wander/elopement alarm. The comprehensive care plan dated 2/9/2023 documented Resident #189 required supervision with ambulation with a rolling walker on and off the unit. Resident #189 was at risk for elopement and had a wander guard (device that alarms if the resident leaves a designated area) in place and may not leave the floor unaccompanied. The Kardex dated 2/9/2023 documented staff were to check the whereabouts of Resident #189 on rounds, after meals and at change of shift. Review of the active Physician Orders dated 9/9/2024 revealed to check Resident #189's wander guard on right ankle every shift for safety. Review of the facility investigation dated 9/24/2023 at 2:00 PM, documented Registered Nurse/Nursing Supervisor #9 was notified by Licensed Practical Nurse #14 at 1:30 PM that Resident #189 may have gone out on pass without signing out. Registered Nurse/Nursing Supervisor #9 was then informed 10 minutes later that Resident #189 had eloped by following another resident's family out of the building. Security was alerted and the grounds of the facility were immediately searched. The Director of Nursing and 911 was called. The search continued off facility grounds by staff members. Resident #189 was brought back to the facility at 2:30 PM by a family friend who saw Resident #189 walking down a sidewalk. Resident #189 was assessed for any injuries, no injuries documented. Resident #189 stated I just wanted to go see my family member. I didn't know I couldn't leave the building. Resident #189 was placed on 15-minute checks for 48 hours, then 30-minute checks for 24 hours, 1-hour checks for 24 hours, and 4-hour checks for 24 hours without any elopement attempts. A new protocol was established for out on pass monitoring after review and a larger picture of Resident #189 was posted at the security desk. Additionally, the investigation file revealed two in-servicing sheets titled 4th Floor Resident dated 9/24/2023 and Resident Out on Pass Process dated 11/23/2023 with signatures identifying 51 staff members were educated that residents on the 4th floor must be at all times accompanied by a staff member off the floor. Review of the Employee Roster detail report provided by the facility revealed a list of 445 employees and their titles. Review on 9/9/2024 at 9:36 AM of facility surveillance video footage dated 9/24/2023 revealed at 1:25 PM Resident #189 was observed walking with their walker through the lobby. Resident #189 was to the left of a visitor. Two children were to the right of the visitor. The door opened as the visitors approached and Resident #189 walked up and around the left side of the visitor at a fast pace. Resident #189 exited the building, walking alongside the visitor and the children. At 1:27 PM, when Resident #189 and visitors reached the middle of the parking lot, Certified Nursing Aide #16 was observed exiting the building and started following Resident #189 and the visitors. At 1:28 PM the visitors and Resident #189 were observed walking across the street, then Resident #189 was observed walking down the side street adjacent to the facility, alone, then goes off camera view. Certified Nursing Aide #16 proceeded to go in the direction of Resident #189. At 1:31 PM Certified Nursing Aide #16 was seen reentering the parking lot. At 1:33 PM Certified Nursing Aide #16 re-enters the facility. During an interview on 9/5/2024 at 1:21 PM, the Director of Nursing stated there was a facility wide education done on the elopement policy, and it should be in the investigation file. During an interview on 9/5/2024 at 1:32 PM, Licensed Practical Nurse #14 stated on 9/24/2023 Security Officer #2 informed them Resident #189 went out with family and did not sign out. When the visitors came back to the facility 10 minutes later without Resident #189, Security Officer #2 alerted Licensed Practical Nurse #14, who then updated Registered Nurse Supervisor #9 of Resident #189's elopement. Staff then began searching for Resident #189. Resident #189 was brought back to the facility about an hour later. Licensed Practical Nurse #14 stated the resident was found on [NAME] and [NAME] (according to map [NAME] approximately a 40-minute walk from the facility). Licensed Practical Nurse #14 stated they were not sure how Resident #189 was able to get down to the lobby because the elevator should not have moved when the wander guard alarms. During an interview on 9/5/2023 at 4:00 PM, Security Officer #2 stated a blue line will pop up and flash on the wander guard system when a resident with a wander guard goes near an exit or elevator. The Security Officer must clear it with the floor and then clears it in the system before the exit can open, or elevator can move. Security Officer #2 stated it was a busy day with a lot of visitors coming and going. Security Officer #2 stated during the incident on 9/24/2023 with Resident #189, there were multiple alerts going off at the same time, and it is possible that they cleared the alert for Resident #189 on the elevator mistakenly. That is how Resident #189 was able to get on the elevator and make it to the lobby. Security Officer #2 stated when Resident #189 arrived in the lobby, the door had already started opening when the wander guard alarm sounded, and Resident #189 was able to exit with the visitors they were walking with. Security Officer #2 stated they realized Resident #189 had not signed out on pass, called up to the unit and confirmed they had not. Security Officer #2 had Certified Nurse Aide #16, who was in the lobby at the time of elopement with a different resident, go out and attempt to flag down the visitors and Resident #189. Certified Nurse Aide #16 was unsuccessful and returned to the facility. Security Officer #2 stated they went out to the parking lot and could not visualize Resident #189 or the visitors, so they returned to the facility. About 10 minutes later the visitors returned and stated they had not been with Resident #189. This is when the elopement procedures began. During a telephone interview on 9/8/2024 at 9:52 AM, Certified Nurse Aide #16 stated they were in the lobby helping one of their residents get ready to leave when another resident (Resident #189) was seen exiting the facility with people. Certified Nurse Aide #16 stated they weren't sure if that resident (Resident #189) was allowed to leave so they attempted to catch up to the visitors and ask. Certified Nurse Aide #16 stated they were unable to catch up to them and went back into the facility. Certified Nurse Aide #16 stated they did not continue perusing Resident #189 and the visitors because they were unfamiliar with Resident #189. Certified Nurse Aide #16 thought they just forgot to sign out. Certified Nurse Aide #16 stated upon return to the facility, Security Officer #2 stated Resident #189 went out with family and it was no big deal. During an interview on 9/9/2024 at 3:34 PM, the Director of Nursing stated Certified Nursing Aide #16 should have continued to trail Resident #189 and kept eyes on them or ask for assistance out in the community if there was someone nearby. 10 NYCRR 415.12(h)(2)

Based on interview and record review conducted during an extended survey completed on 9/16/24, the facility did not ensure a quality assurance and performance improvement (QAPI) program did not ensure the committee developed and implemented appropriate plans of action to correct quality deficiencies and regularly reviewed, analyzed and acted on available data to make improvements. Specifically, the facility quality assurance and improvement program did not identify, develop, and implement an appropriate plan to prevent and protect all residents from sexual abuse when repeated patterns of sexually inappropriate behaviors occurred. Additionally, when there was a change in the facilities processes for addressing hospital transfer/discharge notifications and bed hold policy notices; the facility quality assurance and performance improvement program did not identify they were not being completed as required. Refer to: F 600 - Free from Abuse and Neglect F 610 - Investigate/Prevent/Correct Alleged Violation F 623 - Notice Requirements Before Transfer/Discharge F 625 - Notice of Bed Hold Policy Before/Upon Transfer The findings are: Review of the policy and procedure titled Long-Term Care, Quality, Quality Assurance Performance Improvement (QAPI) revised 9/23/21 documented, the Quality Assurance Performance Improvement Plan provides guidance for our overall quality improvement program. Quality assurance performance improvement principles will drive decision making within Long Term Care. Decisions will be made to promote excellence in quality of care, quality of life, resident choice, person directed care and resident transitions. Focus areas will include all systems that affect resident and family satisfaction, quality of care and services provided, and all areas that affect the quality of life for persons living and working in our organization. The Administrator and/or [NAME] President of Long-Term Care has the responsibility and is accountable to the Board of Directors for ensuring that Quality Assurance Performance Improvement is properly implemented. Review of the facility's Long-Term Care Corporate Quality Management revised 12/2010 documented, the Long-Term Care Corporate Quality Management Committee is responsible for the oversight of the coordination, integration, and supervision of all aspects of the Long-Term Care services and functions. The committee meets on a quarterly basis and reviews the following by not limited to: Incidents reported to the New York State Department of Health/ and sentinel events. The scope of the Long-Term Care Corporate Quality Management committee is organization wide, and its components include Administrative Officers, Medical Directors, and the facility's departments. The mission of the Quality Management Program is to promote the delivery of resident care in keeping with the highest standards on outcomes and services valued by our customers, medical staff, employees, and payers/ its institutional relationships as the community which it services. The purpose of the program is to provide for overall vision, supervision, education, coordination and integration of the quality assessment and improvement functions. a. Review of an investigation and witness statements dated 9/29/2023 documented that Resident #226 was found by Licensed Practical Nurse #16 in Resident #208's room standing next to #208's bed with their arms at their side when answering a call light. Resident #208's breasts were exposed, and Resident #226 was staring at Resident #208. The 24-Hour Nursing Reports dated 11/10/2023, 11/11/2023, and 11/12/2023 documented that Resident #226 was found in Resident's #50 and #33's room. Review of Resident #226 nursing progress notes revealed the following: 11/9/2023 at 10:57 PM, Registered Nurse Nursing Supervisor #1 documented resident was observed by staff standing in the common area with their genitals out of their pants. Resident #50 and another resident (#33) were in the common area. Resident #226 denied that they had their genitalia. 11/10/2023 at 8:22 PM, Licensed Practical Nurse #5 documented resident was found by staff in Resident #50's room. 11/11/2023 at 9:22 PM Licensed Practical Nurse #6 documented resident was found in Resident 50's room again and this was the third instance. 12/11/2023 Licensed Practical Nurse #18 documented resident was in Resident 50's room. The Nursing Supervisor and the Nurse Practitioner were notified. During an interview on 9/12/24 at 10:07 AM, the Director of Nursing stated they review all incidents that were reported to the New York State Department of Health at the Quality Assurance Meetings for discussion and review of the specifics of the incident and interventions added. The Director of Nursing stated the September Quality Assurance Meeting was held prior to the 9/29/23 reported sexual abuse allegation involving Resident #226 and #208. Therefore, it would have been reviewed during the October 2023 meeting. The October meeting was canceled. Therefore, the sexual abuse allegation should have been discussed at the November Quality Assurance meeting with the committee, however it had not been added it to the November agenda. The December 2023 Quality Assurance Committee meeting was canceled. The 9/29/23 reported sexual abuse allegation involving Resident #226 and #208 was not discussed at a Quality Assurance meeting and it should have been to ensure the entire Quality Assurance Performance Improvement Committee was aware. The Committee should have reviewed the abuse allegation, what interventions were put into place and determined if the plan was appropriate or if the plan required additional interventions. They stated they reviewed the 12/29/23 reported sexual abuse Resident #226 was involved in during the January 2024 Quality Assurance Committee meeting and determined that 1:1 supervision was necessary to continue to ensure resident safety. During an interview on 9/12/24 at 11:19 AM, the [NAME] President of Long-Term Care (former Administrator) stated the reported sexual abuse allegation of 9/29/23 was not discussed at the Quality Assurance Committee meeting with all members and should have been. At the time it was believed to be an isolated incident. They stated they did meet as an informal team, the Director of Nursing, Assistant Director, and themselves and Resident #226 was moved to the dementia unit. They stated if they would have known Resident #226 was in other resident's rooms in November 2023, they would have had additional interventions such as 1:1 supervision to protect other residents. They stated sexual abuse doesn't necessary mean to touch someone, it includes exposing their private areas to someone or in a public area. During an interview on 9/13/24 at 1:01 PM, in the presence of the Director of Nursing, the current Administrator (previous Assistant Administrator), the [NAME] President of Long-Term Care (former Administrator) stated the Quality Assurance Committee was supposed to review all incidents reported to the Department of Health. They stated the purpose was to review the issue, the interventions, discuss the incident and determine if additional interventions were needed to promote quality of care and safety to residents and to improve outcomes. b. Review of Resident's #91's progress notes dated 8/1/24 - 9/11/24 revealed resident was transferred to the hospital on 8/30/24 and returned from the hospital on 9/6/24. Review of the Resident's #91's entire medical record dated 8/1/24 - 9/11/24 There was no documented evidence the Notice of Transfer or Discharge form was completed which included the bed hold policy notification was provided to the resident or resident's representative. Resident #222 progress notes dated 4/1/24 - 9/9/24 documented the following: -4/14/24 transferred to the hospital and readmitted on [DATE]. -5/16/24 transferred to the hospital and readmitted on [DATE]. -5/23/24 transferred to the hospital and readmitted on [DATE]. -8/13/24 transferred to the hospital and readmitted on [DATE]. Review of the resident's medical record dated 4/1/24 - 9/9/24 revealed there was no documented evidence the Notice of Transfer or Discharge form was completed which included the bed hold policy notification and provided to the resident or resident's representative. Review of progress notes dated 2/26/24 - 4/1/24 revealed resident was transferred to the hospital on 3/20/24 for an emergency visit and returned from the hospital on 3/20/24. Review of the resident's electronic medical record 3/20/24 - 9/9/24 revealed there was no documented evidence the Notice of Transfer or Discharge form was completed which included the bed hold policy notification and provided to the resident or resident's representative. During an interview on 9/13/24 at 1:01 PM, in the presence of the Director of Nursing, the current Administrator (previous Assistant Administrator), the [NAME] President of Long-Term Care (former Administrator) stated they have not identified that the Transfer Notification and Bed Hold Notification for residents sent to the hospital was not being done according to the regulations until identified during survey and should have. They stated they don't know why or when the notifications were stopped for hospitalized residents and believes this to be a system failure because it appeared to be widespread for all hospitalized residents. 10NYCRR 415.27(c)(3)(ii)(iv)(v)(4)

Based on interview and record review conducted during a Complaint investigation (#NY00330798 and #NY00325133) during an extended standard survey on 9/16/24, the facility did not ensure that all alleged violations of abuse were thoroughly investigated for four (Resident #33, Resident #50, Resident #208, Resident #226) of ten residents reviewed. Specifically, facility investigations lacked interviews with potential witnesses and other potential victims (Resident #50, Resident #208, and Resident #226). Also, there was lack of an investigation when Resident #226 exposed their genitals in front of Resident #33 and Resident #50 in a common area. The findings are: The policy and procedure titled Identification and Reporting of Abuse, Neglect, Exploitations, of Mistreatment of a Skilled Nursing Facility Resident revised on 9/12/24, it documented that the facility begins an investigation immediately upon discovery of an incident, gather statements from the resident who is the suspected victim of abuse, gather statements from the resident's roommates, gather statements from staff including staff who work with the resident over the prior day, weeks, or months, and other witnesses who may have firsthand knowledge of the events. Resident #226 had diagnoses of stroke (loss of blood flow to part of the brain or bleeding in the brain) and type 2 diabetes mellitus. The Minimum Data Set (a resident assessment tool) dated 9/242023 documented Resident #226 was cognitively intact. The comprehensive care plan dated 7/21/2023 documented staff should check Resident #226's whereabouts on rounds, change of shift, and after meals due to wandering behaviors. Resident #208 had diagnoses of Alzheimer's disease and depression. The Minimum Data Set, dated dated dated [DATE] documented Resident #208 was severely cognitively impaired. The comprehensive care plan dated 4/5/2024 documented Resident #208 had impaired cognitive function, was non-verbal and dependent on staff for meeting emotional, intellectual, physical, social needs. Review of the care plan revealed there were no revisions documented since August of 2022. Review of an investigation dated 9/29/23 at 4:00 PM, completed by Registered Nurse Nursing Supervisor #1, and witness statements dated 9/29/2023 documented that Resident #226 was found by Licensed Practical Nurse #16 in Resident #208's room standing next to #208's bed with their arms at their side when answering a call light. Resident #208's breasts were exposed, and Resident #226 was staring at Resident #208. Resident #226 had denied touching Resident #208. When asked what they were doing, Resident #226 responded nothing, nothing and walked out of the room. It was documented that Resident #208 was asked what happened but did not respond. Resident #81 (roommate) stated that someone had come into the room, but the curtain was pulled so they could not see what had happened and did not hear any noises from Resident #208's side of the room. There were no additional potential witness statements from residents and staff members obtained. There were no interviews conducted with potential other victims. During a telephone interview on 9/9/24 at 10:18 AM, Registered Nurse Nursing Supervisor #1 stated they did not recall who the Assistant Director of Nursing was at the time but would have done what they told them them to do. During an interview on 9/9/24 at 10:55 AM, current Registered Nurse Unit Manager #4 stated that staff should get witness statements from all the staff that were working the day of the incident. During an interview on 9/11/24 at 8:07 AM, the Director of Nursing stated that they would expect written and signed witness statements from all staff who were working on that shift when an incident occurred. During an interview on 9/11/24 at 10:11 AM, the current Administrator stated that there should be witness statements from staff that worked the shifts when incidents occurred. During an interview on 9/12/24 at 8:55 AM, Medical Doctor #1 stated that an investigation should be started with witness statements from other residents, staff who worked that day, and anyone else who may have been on the unit at that time. Medical Doctor #1 stated the incident on 9/29/23 was highly suspicious and could have been abuse. 2. Resident #50 had diagnoses of dementia, arthritis, and seizure disorder. The Minimum Data Set, dated dated dated [DATE] documented Resident #50 was severely cognitively impaired. The comprehensive care plan dated 9/10/2019 and in place in 11/2023 documented Resident #50 was cognitively impaired, preferred to be in bed after dinner, and staff were to check at least every 2-3 hours for incontinence. Resident #33 had diagnoses of dementia and anxiety disorder. The Minimum Data Set, dated dated dated [DATE] documented Resident #33 was severely cognitively impaired. The comprehensive care plan dated 3/15/2017 and in place 11/2023 documented that Resident #33 had dementia. The 24-Hour Nursing Reports dated 11/10/2023, 11/11/2023, and 11/12/2023 documented that Resident #226 was found in Resident's #50 and #33's room. Review of Resident #226 nursing progress notes revealed the following: 11/9/2023 at 10:57 PM, Registered Nurse Nursing Supervisor #1 documented resident was observed by staff standing in the common area with their genitals out of their pants. Resident #50 and another resident (#33) were in the common area. Resident #226 denied that they had their genitalia. 11/10/2023 at 8:22 PM, Licensed Practical Nurse #5 documented resident was found by staff in Resident #50's room. 11/11/2023 at 9:22 PM Licensed Practical Nurse #6 documented resident was found in Resident 50's room again and this was the third instance. 12/11/2023 at Licensed Practical Nurse #18 documented resident was in Resident 50's room. The Nursing Supervisor and the Nurse Practitioner were notified. Review of the 24-Hour Nursing Reports for December 2023 revealed no there was documentation regarding #226 being in Resident #50's room. During an interview on 9/10/2024 at 9:26 AM, Licensed Practical Nurse #18 stated the aides had reported that Resident #226 was found in Resident #50's room on 12/11/2023. Licensed Practical Nurse #18 stated they documented it in progress notes and had reported it to the nursing supervisor and a nurse practitioner. Licensed Practical Nurse #18 stated they did not recall which supervisor or which the nurse. They stated they were asked by Assistant Director of Nursing #1 to write a witness statement and to initiate an investigation. During an interview on 9/10/24 at 10:04 AM, Assistant Director of Nursing #2 stated there were no other investigations for any incidents between Resident #226 and Resident #50 and #33. During an interview on 9/10/2024 at 12:07 PM, Nurse Practitioner #1 stated they were never notified of any allegations of abuse between Resident #226 and Resident #50. During an interview on 9/10/2024 at 12:31 PM, Nurse Practitioner #2 stated they were never notified about Resident #226 exposing themselves or any type of sexual abuse between residents. During an interview on 9/10/24 at 5:57 PM with Registered Nurse Nursing Supervisor #5 stated that they don't recall being notified about Resident #226 genitals being exposed in the common area. They stated they would expect staff to report this to them right away. Registered Nurse Nursing Supervisor #5 stated they would have notified the Director of Nursing, family, and the physician right away and initiated an investigation. They stated they would have gotten witness statements from all the staff that were working on that shift. During an interview on 9/11/2024 at 2:43 PM, the [NAME] President of Long-Term Care (former Administrator) stated they were not aware Resident #226 was entering other resident rooms. The [NAME] President of Long-Term Care stated this situation should have risen to the administrative level for further review. During an interview on 9/12/2024 at 10:07 AM, the Director of Nursing stated they should have been notified by staff of Resident #226's behavior so that additional interventions could have been put into place to prevent sexual abuse. I believe we were not as prudent as we should have been to maintain the safety of all our residents. During an interview on 9/11/24 at 8:07 AM, the Director of Nursing stated that they would expect written and signed witness statements from all staff who were working on that shift when an incident occurred. During an interview on 9/11/24 at 10:11 AM, the current Administrator stated that there should be witness statements from staff that worked the shifts when incidents occurred. They stated they would expect the nursing supervisors to put things into place to prevent any more incidents. During an interview on 9/12/24 at 8:55 AM, Medical Doctor #1 stated they were not aware of any incidents between Resident #226, Resident #50, and Resident #33 that occurred in November 2023. They would expect any instances of abuse to be reported immediately to the nurses and proceed up the chain of command. They stated that an investigation should be started with witness statements from other residents, staff who worked that day, and anyone else who may have been on the unit at that time. 10 NYCRR 415.4(b)(3)

Based on interview and record review conducted during an extended standard survey completed from 9/3/2024 to 9/16/2024, the facility was not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility must operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. The facility must have a governing body, or designated persons functioning as a governing body, that is legally responsible for establishing and implementing policies regarding the management and operation of the facility; and the governing body is responsible and accountable for the Quality Assurance and Performance Improvement program. Specifically, the administration did not ensure policies and procedures were consistently implemented, and the administration was not aware of the extent of the deficient practices cited. The findings are: REFER TO: F 600 - Free from Abuse and Neglect F 610 - Investigation / Prevent / Correct Alleged Violation Review of the facility's undated Resident Handbook documented; in accordance with Federal and State regulation, each resident has the right to be free from verbal, sexual, physical, and mental abuse, or neglect. Any allegation regarding abuse, mistreatment, or neglect is immediately investigated. Review of facility's Abuse Policy and Procedure revised 12/2/22 documented; Resident abuse, neglect, exploitation, involuntary seclusion, or misappropriation of property will not be tolerated. This policy will be administered by the Long-Term Care Administrator and the Director of Nursing. A summary of the investigation shall be forwarded to the Administrator / designee for review and final decision regarding the allegation. a. Resident #226 had diagnoses of stroke (loss of blood flow to part of the brain or bleeding in the brain) and type 2 diabetes mellitus. The Minimum Data Set (a resident assessment tool) dated 9/242023 documented Resident #226 was cognitively intact. Resident #208 had diagnoses of Alzheimer's disease and depression. The Minimum Data Set, dated dated dated [DATE] documented Resident #208 was severely cognitively impaired. Review of an investigation and witness statements dated 9/29/2023 documented that Resident #226 was found by Licensed Practical Nurse #16 in Resident #208's room standing next to #208's bed with their arms at their side when answering a call light. Resident #208's breasts were exposed, and Resident #226 was staring at Resident #208. During an interview on 9/9/2024 at 3:06 PM, Social Worker #1 stated Resident #226 was moved to the dementia unit four days after the 9/29/2023 incident with Resident #208 because there was not an appropriate long term care room available. During an interview on 9/11/2024 at 8:07 AM, the Director of Nursing stated Resident #226 was moved to the dementia unit because there was not another room available. The Director of Nursing stated the nurses should have documented Resident #226's whereabouts but there was not a formal 15-minute check started or 1:1 supervision. The facility daily census reports dated 9/29/23 through 10/3/23 revealed available beds within the facility: Rehabilitation Unit there were 3 empty beds available on 9/29/23 and 9/30/23; 5 empty beds available on 10/1/23 and 10/2/23; and 3 empty beds available on 10/3/23. A Long-Term Care Unit had one bed available on 9/29/23 and 9/30/23, 2 beds available on 10/1/23, 10/2/23 and 10/3/23. In addition, the facility had a closed (POD) leaving the following beds empty 480 - 490 9/29/23 through 10/3/23. b. Resident #50 had diagnoses of dementia, arthritis, and seizure disorder. The Minimum Data Set, dated dated dated [DATE] documented Resident #50 was severely cognitively impaired. Resident #33 had diagnoses of dementia and anxiety disorder. The Minimum Data Set, dated dated dated [DATE] documented Resident #33 was severely cognitively impaired. The 24-Hour Nursing Reports dated 11/10/2023, 11/11/2023, and 11/12/2023 documented that Resident #226 was found in Resident's #50 and #33's room. Review of Resident #226 nursing progress notes revealed the following: 11/9/2023 at 10:57 PM, Registered Nurse Nursing Supervisor #1 documented resident was observed by staff standing in the common area with their genitals out of their pants. Resident #50 and another resident (#33) were in the common area. Resident #226 denied that they had their genitalia. 11/10/2023 at 8:22 PM, Licensed Practical Nurse #5 documented resident was found by staff in Resident #50's room. 11/11/2023 at 9:22 PM Licensed Practical Nurse #6 documented resident was found in Resident 50's room again and this was the third instance. 12/11/2023 Licensed Practical Nurse #18 documented resident was in Resident 50's room. The Nursing Supervisor and the Nurse Practitioner were notified. During an interview on 9/11/2024 at 10:11 AM the current Administrator stated, that Resident #226 should have been placed on 1:1 supervision at that time to ensure they did not go into Resident #208's room or anyone else's room. During an interview on 9/10/2024 at 12:07 PM, Nurse Practitioner #1 stated they did not think Resident #226 was appropriate for a dementia unit. During an interview on 9/12/2024 at 10:07 AM, the Director of Nursing stated they should have been notified by staff of Resident #226's behavior so that additional interventions could have been put into place to prevent sexual abuse. The Director of Nursing stated when Resident #226 was moved to the dementia unit there should have been additional education provided to the staff to observe Resident #226's behaviors and report unusual behaviors to them but does not know if education was provided. The staff education may have fallen through the cracks because the Unit Manager was out on leave. Additionally, After reviewing the medical record the Director of Nursing stated, I believe we were not as prudent as we should have been to maintain the safety of all our residents. During an interview on 9/12/2024 at 8:55 AM, Medical Doctor #1 stated the incident on 9/29/23 was highly suspicious and could have been abuse. Resident #226 should have been put on 1:1 supervision on 9/29/2023. Medical Doctor #1 stated they were not aware of any incidents between Resident #226, Resident #50, and Resident #33 that occurred in November 2023. They would have expected staff to report any incidents of possible sexual abuse to themselves and the Director of Nursing. Medical Doctor #1 stated, had Resident #226 been placed on 1:1 supervision on 9/29/2023, then any other incidents of sexual abuse could have been prevented. During an interview on 9/11/24 at 2:43 PM, the [NAME] President of Long Term Care (former Administrator) stated moving Resident #226 to the dementia unit was not an effective plan. The [NAME] President of Long Term Care stated they would have expected to have been notified that Resident #226 was wandering into other resident's rooms as the progress notes documented in November 2023. The [NAME] President of Long-Term Care stated this situation should have risen to the administrative level for further review. If they had been informed they would have initiated 1:1 supervision earlier to prevent and protect all the vulnerable residents on the dementia unit. During interview on 9/13/24 at 11:36 AM, the Director of Nursing stated after the 9/29/23 sexual abuse allegation they discussed the room change with Assistant Director of Nursing #1 and decided to move Resident #226 to the dementia unit. They did not recall if the former Administrator or the Assistant Administrator were involved in the decision making. They stated they did not move the Resident #226 to the Rehabilitation Unit's open bed because the resident was a long-term care resident but could have; and doesn't recall why they did not move them to an open Long-Term Care bed. During an interview on 9/13/24 at 12:23 PM, the current Administrator (former Assistant Administrator) stated they were not directly involved in reviewing the incidents. The former Administrator at the time was responsible for reviewing the incidents and reviewing the interventions. The facility did not identify these were isolated incidents due to lack of investigations. The investigation should have included interviewing of staff, other residents and reviewing the videos on the unit. They stated psychiatry was available and the facility should have provided additional evaluation and resources to Resident #226, #208 and #50. They stated they do not believe they were part of the conversation to move Resident #226 to the dementia unit but expects the facility to be proactive and have appropriate interventions in place to prevent abuse. They stated moving Resident #226 to the dementia unit was not an effective intervention and would have expected the Unit Manager, Assistant Director of Nursing and Director of Nursing to have had additional interventions in place for resident safety. During an interview on 9/13/24 at 1:59 PM, the [NAME] President of Long Term Care (former Administrator) stated they believed the 9/29/23 reported sexual allegation was an isolated incident and that there was no evidence Resident #226 touched Resident #208. They stated they met with the Assistant Administrator and Director of Nursing and discussed Resident #226's behaviors and recalled being informed the resident had not been inappropriate to anyone else. They stated it was the facility's responsibility to maintain optimal psychosocial well- being and safety for all residents. 10 NYCRR 415.26

Based on observation, interview and record review conducted during an Extended survey completed on 9/16/24, the facility did not ensure the resident's representative was notified immediately of a change of condition for one (Resident #267) of two residents reviewed for notification of change. Specifically, Resident #267's representative was not notified of the resident's tracheostomy (opening into the trachea) tube being removed. The finding is: Resident #267 had diagnoses that included traumatic subdural hemorrhage (bleeding in the brain), acute kidney failure, and depression. The Minimum Data Set (a resident assessment tool) dated 8/11/24 documented Resident #267 was moderately cognitively impaired, usually understood and sometimes understands. The comprehensive care plan dated 5/11/24 documented Resident #267 had a tracheostomy related to impaired breathing mechanics. The comprehensive care plan documented the resident had a knowledge deficit related to their medical condition and/or plan of care. Review of Resident #267's Admission Record, with a printout date of 9/9/24, documented Resident #267s family member was their Health Care Proxy (a person who can legally make medical decisions on behalf of another person if they are unable to communicate their wishes). Review of Family Health Care Decision Act Consent Form dated 5/16/24, documented Resident #267 was determined to lack capacity to make medical decisions. This form documented Resident #267s family member was activated as their Health Care Proxy by the Medical Director. A nursing progress note for Resident #267 dated 8/28/24 at 2:55 PM, Registered Nurse #10 documented trach discontinued, tolerate well spo2 (oxygen saturation in the blood) 98% on room air. resident had appointment today for CT (computed tomography) scan and no issues or concerns noted return from appointment. There was no documentation that the resident's Health Care Proxy was updated. Further review of nursing progress notes dated 8/29/24-9/6/24 revealed no documentation that Resident #267's Health Care Proxy was updated on the removal of the tracheostomy tube. During an observation on 9/3/24 at 10:54 AM, Resident #267 was sitting in the common area, there was no tracheostomy tube present. During a telephone interview on 9/3/24 at 11:56 AM, Resident #267's Health Care Proxy stated they had been asking staff about when they would be attempting to remove Resident #267s tracheostomy tube and was upset because facility staff have not contacted them regarding the matter. During an interview on 9/6/24 at 10:25 AM, Registered Nurse #10 stated they believed Resident #267 was their own responsible party, but their family member was their Health Care Proxy. Registered Nurse #10 stated they believed Resident #267s Health Care Proxy was updated on the removal of their tracheostomy. Registered Nurse #10 stated it was the charge nurse's responsibility to update responsible parties on any changes in condition. Registered Nurse #10 stated there were three different Registered Nurses who worked on the unit as charge nurses, and they could not remember who was in charge the day the resident's tracheostomy tube was removed. During an interview on 9/6/24 at 10:27 AM, Registered Nurse #11, who was working as charge nurse on this date, reviewed the progress notes for Resident #267 and stated that based on the progress notes there was not any documentation that Resident #267s Health Care Proxy was updated on the removal of their tracheostomy tube. Registered Nurse #11 stated Resident #267s family member was their Health Care Proxy, and they should have been updated on the removal of the tracheostomy on the day it was removed. During an interview on 9/9/24 at 3:42 PM, the Director of Nursing stated Resident #267 lacked capacity and they expected staff to update their Health Care Proxy on any change in condition, and the removal of a tracheostomy tube was a change in condition. During an interview on 9/10/24 at 1:07 PM, the Social Worker stated Resident #267 had a Health Care Activation Form in their chart that documented Resident #267 lacked capacity and their family member was their Health Care Proxy. The Social Worker stated Resident #267s Health Care Proxy should be updated on any change in condition, and the removal of a tracheostomy tube was a change in condition. During an interview on 9/11/24 at 12:39 PM, the Director of Nursing and Administrator both stated there was not a policy for notification of change in the facility. 10 NYCRR 415.3 (f)(2)(b)

Based on observation, interview, and record review conducted during a complaint investigation (#NY00324941) during an Extended survey completed on 9/16/24, the facility did not ensure that each resident who was unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for one (Residents #20) of two residents reviewed. Specifically, Resident #20 had greasy, disheveled hair, with matting and knots to the back of their head. The finding is: Resident #20 had diagnoses that included multiple sclerosis (disease central nervous system), age-related physical debility, and epilepsy (seizure disorder). The Minimum Data Set (a resident assessment tool) dated 7/7/24 documented the resident was understood, understands, and had severe cognitive impairment. The Minimum Data Set documented Resident #20 did not exhibit rejection of care behaviors and they required substantial/maximal assistance for personal hygiene. Review of the facility Orientation Checklist for Long Term Care Certified Nursing Assistant revealed technical skills included they implemented a plan of care to include personal care, including hair care. The comprehensive care plan dated 4/19/22 documented Resident #20 had an activity of daily living self-care performance deficit related to weakness. Interventions revised 8/2023 documented the resident required extensive assist of one person for personal hygiene, bathing and showering. The Kardex (resident care guide) dated 9/11/24 documented Resident #20 required extensive assist of one person for personal hygiene, bathing and showering. The skin inspection record dated 8/1/24-8/29/24 documented Resident #20 received a bed bath or shower. There was no documented evidence that Resident #20 refused their hair to be washed. There were no skin inspection records for 9/1/24-9/9/24 that verified a shower or bed bath was given as scheduled. The last documented shower was given on 8/22/24. The nursing progress notes dated 7/31/24-9/10/24 revealed no documented refusals of care for Resident #20. Additionally, nursing progress notes dated 9/1/23-10/28/23 revealed no documented refusals of care. During observations on 9/3/24 at 10:14 AM, 9/4/24 at 3:12 PM, 9/5/24 at 8:43 AM and 10:45 AM, 9/6/24 at 7:52 AM, 9/9/24 at 8:21 AM, 9/10/24 at 10:04 AM, and 9/12/24 at 10:37 AM, Resident #20's hair was greasy in appearance. During the observations on 9/5/24, 9/6/24, 9/10/24 and 9/12/24, Resident #20's hair was uncombed, and disheveled. During an interview on 9/6/24 at 10:50 AM, Certified Nursing Assistant #15 stated they always tried to brush Resident # 20's hair, but their hair is in knots, nurse usually cuts the knots out. They stated the brushes at the facility don't work on Resident #20's hair. During an observation and interview on 9/10/24 at 10:04 AM, Resident #20 was in bed with hair disheveled, uncombed, and greasy. Resident #20 stated they could not recall the last time their hair was washed. Resident #20 stated it was important to them to have their hair brushed and washed, as it made them feel better. During a follow up interview on 9/10/24 at 10:10 AM, Certified Nursing Assistant #15 stated resident's hair should be combed every day, so the resident looked presentable. They stated Resident #20 was unable to brush their own hair, they're dependent on staff to complete. Certified Nursing Assistant #15 stated Resident #20's hair was knotted up very badly and it was uncomfortable for Resident #20 to have their hair combed. During an interview on 9/10/24 at 10:24 AM, Licensed Practical Nurse #15 stated resident's hair should be combed during morning care and is usually washed during showers by the Certified Nursing Assistants. They stated if a shower was refused the Certified Nursing Assistant should make the nurse aware and indicate the refusal on the skin inspection record. Licensed Practical Nurse #15 stated residents' hair should be washed and combed for hygiene purposes and dignity. During an observation and interview on 9/10/24 at 10:34 AM, Registered Nurse #4, Unit Manager, stated residents' hair should be combed daily, just like us we comb our hair every day. They stated grooming was part of a resident's activities of daily living for dignity, and self-worth and should be completed by the certified nursing assistant. Registered Nurse #4, Unit Manager stated Resident #20's hair was thick, matted, and difficult to comb. They stated Resident #20's hair should be washed on their shower days, twice a week by the certified nursing assistants. Registered Nurse #4 observed Resident #20's hair, and stated their hair looked greasy and uncombed. As Registered Nurse #4, attempted to untangle the matted hair, Resident #20 expressed discomfort. During a telephone interview on 9/10/24 at 11:50 AM, Certified Nursing Assistant #14 stated they did not give Resident #20 a shower or wash their hair on 9/9/24 as scheduled. They stated there was so much going on and they forgot to tell the nurse. They stated they combed Resident #20's hair into a ponytail yesterday and didn't think Resident 20's hair was really greasy, but their hair was matted in the back. During an interview on 9/11/24 at 12:39 PM, the Administrator stated they did not have a facility policy for activities of daily living or provision of personal care including hair care. During an interview on 9/12/24 at 9:45 AM, the Director of Nursing stated they expected resident's hair to be, ideally, combed daily with activities of daily living care. They stated hair style was resident dependent, but that it was not acceptable for residents' hair to be knotted, it should be combed though. They stated if a resident refused care, it should be documented. 10 NYCRR 415.12(a)(3)

Based on observation, interview, and record review conducted during an extended standard survey completed on 9/16/24, the facility did not ensure residents were assessed for risk of entrapment from bed rails prior to installation, review the risks and benefits of bed rails with the resident or resident representative, and obtained informed consent prior to the installation of bed rails for one (Resident # 20) of one resident reviewed for bed rails. Specifically, Resident #20 was not assessed for risk of entrapment from bed rails, there was no documented evidence the risks and benefits of bed rails were reviewed and that consents were obtained prior to bed rail use. Additionally, there was lack of maintaining the bed rails in proper working order. The finding is: The policy and procedure titled Transfer/Bed Mobility Bar revised 10/25/22 documented the goal is always to maintain the highest practical functional status for our residents. The use of a transfer/bed mobility bar facilitates this commitment and promotes functional mobility for our residents with optimal bed safety achieved. The policy and procedure titled Side Rail Policy revised 10/27/22 documented side rails may be utilized as an enabler to improve or maintain a resident's functionally independent status in moving to and from a lying position, turning side-to-side, re-positioning in bed, and transferring in/out of bed. When side rails are used, continuous evaluation of their appropriateness is expected to be part of an ongoing assessment. This evaluation is to be done quarterly, annually and with significant change in the resident's condition. Resident's and families should be actively involved in deciding whether to use side rails. The interdisciplinary care team is still responsible to determine whether their use is contraindicated to the health care and safety of the resident. The User-Service Manual, copyright 2013 for bed series utilized in facility documented, Warning: Possible Injury or Death. Do not use any assist device until you verify it is locked in place. Failure to lock assist devices may result in injury; An optimal bed system assessment should be conducted on each resident by a qualified clinician or medical provider to ensure maximum safety of the resident. The assessment should be conducted within the context of, and in compliance with, the state and federal guidelines related to the use of restraints and bed system entrapment guidance. Entrapment zones involve the relationship of components often directly assembled by the healthcare facility rather than the manufacturer. Therefore, compliance is the responsibility of the facility. Resident #20 had diagnoses that included multiple sclerosis (disease central nervous system), age-related physical debility, epilepsy (seizure disorder), and depression. The Minimum Data Set (a resident assessment tool) dated 7/7/24 documented resident was understood, understands, and had severe cognitive impairment. Resident #20 required partial/moderate assistant with rolling left to right. No bed rail use indicated on the assessment. The Kardex (guide used by staff to provide care) dated 9/11/24 documented staff were to to anticipate and meet safety needs; bed mobility extensive assist of one staff member for rolling side to side with bed assist bars. The comprehensive care plan initiated 4/19/22 documented Resident #20 had limited physical mobility related to multiple sclerosis. Intervention revised 8/14/23 documented bed mobility as extensive assist of one for rolling side to side with bed assist bars. Additionally, revision dated 1/23/24 documented Resident #20 was at risk for falls related to confusion, deconditioning, incontinence, and immobility. Interventions initiated 1/23/24 included to anticipate and meet resident's needs. During observations on 9/3/24 at 10:19 AM and 3:32 PM, 9/4/24 at 3:12 PM, and 9/5/24 at 8:43 AM, 10:45 AM, and 3:26 AM Resident #20 was in bed with bed assist bar to right side of bed unlatched, unsecured from bed frame. Review of Plant Operations Bed Inventory was last completed 5/15/23-5/18/23 documented entrapment, compliance mattress/assist rail fit. During a continuous observation on 9/6/24 from 9:54 AM to 10:40 AM, Resident #20 was observed to utilize the bed assist bars during care when prompted by staff and encouraged by Certified Nurse Aide #15. During an interview on 9/5/24 at 3:46 PM, Certified Nurse Aide #13 stated all bed assist bars should be locked into place for safety. If they were not locked into place the resident may not be safe and could fall out of the bed. Certified Nursing Assistant #13 stated if there was an issue with a bed assist bar, they would let the nurse know and put a maintenance order in through the computer. During an interview on 9/5/24 at 3:55 PM, Certified Nursing Assistant #12 stated all residents had bed assist bars on their beds. They stated the bed assist bars can be unlatched and pulled away from the bed to boost a resident in bed or when transferring a resident out of or into the bed. They stated any staff member that moves the bed assist rail was responsible to make sure they are locked back into place after moving. Additionally, they stated that if the bed assist rail weren't locked into place the resident wouldn't be able to hold on to them, they could fall or slid out of the bed. During an observation and interview on 9/5/24 at 4:16 PM, Licensed Practical Nurse #2 stated that if the bed assist bars were left unlatched it would be a safety issue. Licensed Practical Nurse #2 checked the bed assist bars on Resident #20's bed and stated the bed assist rail to the right side of the bed was unlatched. Licensed Practical Nurse #2 attempted to latch the bed assist bar into place and was unable to do so. They stated the bed assist bar was supposed to lock. During an interview on 9/5/24 at 4:22 PM, the Registered Nurse #4, Unit Manager, stated there were no side rail assessment done for the bed assist bars, as they were on every bed and therapy makes the recommendations for use. Registered Nurse #4 stated handrails, side rails help residents with turning, positioning, sitting up and as a barrier to protect residents from falling out of bed. They stated the nursing staff were responsible for making sure the bed assist bars were secured during care. Additionally, they stated safety, maintenance concerns with the bed assist bars should be reported to them or environmental services. During an interview on 9/9/24 at 9:27 AM, Physical Therapist #2 stated bed assist rails shouldn't move if a resident reaches for it, they should be locked into place. They stated if a bed assist bar was unlatched it would be safety concern. The resident could have trouble using the bed assist rail or could fall from the bed. Additionally, they stated physical therapy makes recommendations for use of the bed assist bar for mobility purposes. During an interview on 9/9/24 at 9:57 AM, Therapy Manager stated bed assist bar assessments were completed with physical therapy evaluations, whether the resident can use the bed assist bars or not. They stated bed assist bars for each resident are care planned accordingly. They stated if there was a risk for use identified with the presence of bed assist bars it was discussed with the interdisciplinary team. The interdisciplinary teams determined if bed assist bars should be removed or padded if a resident has seizures, hypertonic (muscle-state of abnormally high tension) or have flailing arms that could cause injury or risk for entrapment with use of the bed assist bars. During an interview on 9/10/24 at 9:00 AM, Director of Environmental Services stated that all beds had bed assist bars, except for on the pediatric unit or if specified to remove per a resident's care plan. They stated they were not aware of any assessments for side rail use and that entrapment was highly unlikely. Director of Environmental Services stated there were no routine audits to check proper installment of the bed assist bars. They stated the only time there was an audit was when the beds were being placed into a room. During an interview on 9/10/24 at 9:33 AM, the Director of Nursing stated they did not not currently have any beds with side rails, they have bed assist bars. They stated all beds came equipped with the bed assist bars and there were no nursing evaluations for the bed assist bars. They stated there was no consent required with the use of bed assist rails because they weren't considered a restraint. Additionally, they expected anyone providing care to a resident to make sure the bed assist bars were latched, appropriately, in place for safety. During an interview on 9/10/24 at 9:43 AM, the current Administrator stated they did not know the definition of a bed rail specifically. They stated the facility utilized bed assist bars and that no consent for use was obtained. They stated the therapy department conducts quarterly and as needed assessments on the appropriateness of the bed assist bars. To their knowledge no education regarding entrapment with use of the bed assist rails was provided to the residents or families. They stated they had not been made aware of any risk for entrapment and did not know if there was a potential risk for entrapment with the use of the bed assist bars. 10 NYCRR 415.12 (h)(1)

Based on interview and record review conducted during a Complaint investigation (#NY00336618) during an Extended survey completed on 9/16/24, the facility did not ensure that residents are free of significant medication errors for one (Resident #250) of three residents reviewed. Specifically, on 3/20/24 Registered Nurse #3 erroneously administered Resident #247's morning medications to Resident #250 which resulted in a significant medication error. The finding is: The policy and procedure titled Medication Ordering, Interpretation and Administration Guidelines revised 10/3/22 documented prior to all medication administration, scanning both the patient's wristband and the medication barcode are required. The facility's Medication Administration Competency Assessment Tool revised 5/11/23 documented medications were administered using the right resident, right medication, right dose, resident route, right time, right reason/indication for medication, right documentation, and right response. Resident #250 had diagnoses including chronic respiratory failure, tracheostomy status (an opening created in the trachea (windpipe) that provides an alternative airway for breathing), and gastrostomy status (an opening into the stomach from the abdominal wall, for the placement of a feeding tube). The Minimum Data Set (a resident assessment tool) dated 10/24/23 documented Resident #250 was rarely/never understood, and rarely/never understands. The comprehensive care plan initiated 10/18/23 documented Resident #250 had global developmental delays secondary to bronchopulmonary dysplasia (a chronic lung disease which affects premature infants) originating in the prenatal period, resident was not able to make needs known, and staff would anticipate the resident's needs. Review of facility Medication Error Form documented on 3/20/24 a medication error was made by Registered Nurse #3 involving Resident #250. Registered Nurse #3 gave the medications Keppra (an anti-seizure drug), Onfi (used to treat seizures), Omeprazole (used to treat too much acid in the stomach) and a multivitamin to the wrong resident, then called Doctor #1 and pulled out most of the medications via the mic-key (a low-profile tube that allow children to receive nutrition, fluids, and medicine directly into the stomach) right after. Review of facility Long Term Care Transfer Form dated 3/20/24 at 9:30 AM documented Resident #250 was given the wrong medications including Keppra 5 milliliters, Onfi 4 milliliters, Omeprazole 9.5 milliliters and multivitamin 0.5 milliliters. Registered Nurse #3 pulled out most of the medications right after giving them. Review hospital emergency department note dated 3/20/24 at 5:10 PM documented Resident #250 presented with accidental ingestion of medication, earlier this morning at around 9 AM they were given by mistake other resident's medications which are as follows, Onfi 10 milligrams, Keppra 500 milligrams, omeprazole 19 milligrams and multivitamin. Facility managed to aspirate a lot of the medication but not all of, and they discussed the case with poison control who recommended transferring the resident to the emergency department for observation and further investigation. Resident #250 was observed for 6 hours as per poison control recommendations, no change in vitals or baseline clinical status, and resident was sent back safely to the facility with close observation. During an interview on 9/10/24 at 2:21 PM, Registered Nurse #3 stated it was their mistake and they realized they gave medication to Resident #250 that was intended for Resident #247 immediately after they exited Resident #250's room, therefore they immediately returned to Resident #250 and extracted gastric contents including the medications from Resident #250's stomach by the gastric tube. They stated they had the nurse who was working with them call Doctor #1 (the on-call doctor) immediately and they advised them to continue to monitor Resident #250. They stated Doctor #1 called back within 5 minutes and provided an order to send Resident #250 to the emergency room for evaluation. Registered Nurse #3 stated they were concerned for Resident #250 because of the medications that were given and they should have followed the 5 rights (right resident, right route, right medication, right dosage, right time) when administering medications. During an interview on 9/6/24 at 10:36 AM, Medical Director #2 stated Doctor #1 was on call on the date the medication error occurred and called New York State Poison Control and was informed of the risks of sedative/ hypnotic toxicity (drugs that cause central nervous system depression) and advised to monitor Resident #250's carbon dioxide levels. Medical Director #2 stated the facility was unable to monitor a resident's carbon dioxide levels therefore Resident #250 was sent to the emergency room for observation. Medical Director #2 stated Resident #250 did not have a seizure disorder diagnosis and received the medications Onfi (a prescription medicine used along with other medicines to treat seizures associated with Lennox-Gastaut syndrome (a complex, rare, and severe type of epilepsy) in people 2 years or age of older) which is the most concerning because of the central nervous system depression and they were only 10 months old at the time of the medication error. They also received Keppra 500 milligrams which was more than a loading dose (an initial higher dose given at the beginning of treatment) for this resident's age at the time of the medication error. Medical Director #2 stated this was a significant medication error. During an interview on 9/10/24 at 1:37 PM, Registered Nurse Unit Manager Assistant Director of Nursing #3 stated Registered Nurse #3 provided medications to Resident #250 that were intended for another resident and because of the medications provided they would consider this a significant medication error. During an interview on 9/10/24 at 1:48 PM, the Director of Nursing stated Resident #250 received medications that were not prescribed to them and considered this a significant medication error. During an interview on 9/10/24 at 2:12 PM, the facility's Pharmacy Consultant #1 stated they would consider this as a significant medication error because of the potential for sedation related to the medications provided and Resident #250's age. 10 NYCRR 415.12(m)(2)

Based on record review and interview conducted during an extended standard survey completed on 9/16/24, the facility did not ensure that the resident or resident representative was notified in writing, of the transfer and the reason for hospitalization for three (Resident #91, #222 and #250) of three residents reviewed. Specifically, Resident #91 was sent to the hospital on 8/30/24 and Resident #222 had multiple hospitalization s (4/14/24, 5/16/24, 5/23/24 and 8/13/24) with no written notification to the resident or their representative of the Notice of Transfer or Discharge. Resident #250 was transferred to the hospital on 3/20/24 with no written notification to the resident or their representative of the Notice of Transfer or Discharge and facility did not send a copy of the Transfer or Discharge notice to the Office of the State Long Term Care Ombudsman. The findings are: The facility policy titled Transfer, Resident Discharge revised 8/2023 documented, it was the policy of this facility that each resident has the right to remain in the facility and not be transferred or discharged unless a transfer or discharge is necessary for the resident's welfare and resident's needs, including urgent medical needs, that cannot be met in the facility. The transfer/discharge notice will be issued with a discharge date at least thirty days before the resident is transferred or discharged in a language and manner that the resident can understand. If the transfer/discharge is necessary due to an emergency, the notice will be issued as soon as practicable when an immediate transfer or discharge is required by the resident's urgent medical condition. The Social Worker will review and explain the notice to the resident and their representative and discuss the resident's right to appeal the discharge. At a minimum, the notice will include: the reason for transfer/discharge, the effective date of the transfer/discharge, location to which the resident will be transferred. The Social Worker or designee will complete the form, Notice of Resident Transfer or Discharge. The facility form titled Notice of Transfer or discharge date d 12/12/18 revealed fillable areas for resident's name, resident representative, date of notice, location to which resident is to be transferred or discharged and reasons for proposed transfer or discharge under 10 NYCRR 415.3(h) including but not limited to, an immediate transfer or discharge is required by the resident's urgent medical needs. 1. Resident #91 had diagnoses including displaced intertrochanteric fracture of left femur (break of long bone in the thigh), diabetes mellitus, and chronic kidney disease. The Minimum Data Set (a resident assessment tool) dated 7/22/24 revealed the resident was cognitively intact. Review of progress notes dated 8/1/24 - 9/11/24 revealed Resident #91 was transferred to the hospital on 8/30/24 and returned from the hospital on 9/6/24. Review of the resident's entire medical record dated 8/1/24 - 9/11/24 revealed there was no evidence that Notice of Transfer or Discharge form was completed and provided to the resident or resident's representative. 2. Resident #222 had diagnoses including chronic respiratory failure with hypoxia (low oxygen level), epilepsy (seizure disorder), and spastic quadriplegic cerebral palsy (stiff, jerky movements of all extremities due to damage to the brain). The Minimum Data Set, dated dated dated [DATE], 5/16/24, and 8/13/24 revealed the resident was severely cognitively impaired. Resident #222 progress notes dated 4/1/24 - 9/9/24 documented the following: -4/14/24 transferred to the hospital and readmitted on [DATE]. -5/16/24 transferred to the hospital and readmitted on [DATE]. -5/23/24 transferred to the hospital and readmitted on [DATE]. -8/13/24 transferred to the hospital and readmitted on [DATE]. Review of the Resident #222's entire medical record dated 4/1/24 - 9/9/24 revealed there was no documented evidence the Notice of Transfer or Discharge form was completed and provided to the resident's representative. 3. Resident #250 had diagnosis including chronic respiratory failure, tracheostomy status (an opening created in the trachea (windpipe) that provides an alternative airway for breathing), and gastrostomy status (an opening into the stomach from the abdominal wall, for the placement of a feeding tube). The Minimum Data Set, dated dated dated [DATE] documented Resident #250 was rarely/never understood, and rarely/never understands others. Review of progress notes dated 2/26/24 - 4/1/24 revealed resident was transferred to the hospital on 3/20/24 for an emergency visit and returned from the hospital on 3/20/24. Review of the resident's electronic medical record 3/20/24 - 9/9/24 There was no documented evidence the Notice of Transfer or Discharge form was completed and provided to the resident or resident's representative and a copy provided to the Office of the State Long-Term Care Ombudsman. During an interview on 9/10/24 at 9:13 AM, Social Worker #2 stated they do not complete a Notice of Transfer or Discharge form and provide to the resident or their representatives. They stated they had not completed and provided the form for Residents #222 and #250. They stated they believe the nursing department completes the information and provides it to the resident's representative when a resident is transferred to a hospital. During an interview on 9/10/24 at 9:24 AM, the Long Term Care Health Information Manager #1 stated they had not notified the Office of the State Long-Term Care Ombudsman of Resident #250's transfer to the hospital because they were not discharged to the hospital and was listed on the discharge list. They stated they generate a discharge list from the facility's computerized system and send a list of resident's names that were discharged to the hospital monthly via e-mail to the Office of the State Long-Term Care Ombudsman. They stated they do not receive a form titled Notice of Transfer or Discharge for any residents sent to a hospital / acute care setting from nursing or Social Work department to send to family or their representatives or the Office of the State Long-Term Care Ombudsman. During an interview on 9/10/24 at 10:10 AM, Executive Secretary #1 stated they used to be responsible to complete the Notice of Transfer or Discharge form and the process was to complete and mail the forms to the resident or representatives for transfers and discharges and then send a copy to the Office of the State Long-Term Care Ombudsman. They stated the task was transferred to the Long-Term Care Health Information Manager over a year ago and does not know who provided the training and what their process has been since they were no longer responsible. During an interview on 9/10/24 at 10:27 AM, Long Term Care Health Information Manager #1 stated they were educated by Social Worker #1 that the facility Social Workers would be completing and providing the Notice of Transfer or Discharge forms for only residents who are discharge to home or another facility, but not residents transferred or discharged to a hospital setting. During an interview on 9/10/24 at 10:47 AM, Social Worker #2 stated they had not completed the Notice of Transfer or Discharge forms for residents sent to the hospital and stated the [NAME] President of Long Term Care (former Administrator) confirmed this was a Nursing Department's job to complete the form, and send it to Long Term Health Information Manager #1. The Long Term Health Information Manager was responsible to send the form to the resident or resident's representative and the Office of the State Long-Term Care Ombudsman. During an interview on 9/10/24 at 10:56 AM, Social Worker #1 stated they provided education to Social Worker #2 and Long Term Care Health Information Manager #1 that the Notice of Transfer or Discharge form was to be completed only for residents who were going home or community and was not completed for any residents transferred or discharged to a hospital setting. They stated they had not completed the Notice of Transfer or Discharge from and provided it to Resident #91's or their family. They stated they do not know who was responsible to complete the Notices of Transfer or Discharge form for those residents hospitalized . During an interview on 9/10/24 at 11:03 AM, The [NAME] President of Long Term Care (former Administrator) stated discussion were had with Social Worker #1, #2 and Long Term Care Health Information Manager #1 and they had identified the Notice of Transfer or Discharge form and notification process to residents or representatives in writing was not being completed for any resident's transfer to an acute or hospital setting. They stated they do not know how long the facility had not been completing this process as required. During an interview on 9/10/24 at 12:11 PM, the Ombudsman stated they have been receiving Notices of Transfer or Discharge for residents except had not received notification of Resident #250's transfer. They stated even though the resident was in the emergency room for hours and not admitted they should have been notified. 10 NYCRR 415.3(i)(1)(iii)(a-c)

Based on record review and interview conducted during an extended standard survey completed on 9/16/24, the facility did not ensure that the resident or resident representative was notified in writing of the bed hold policy for three (Resident #91, #222 and #250) of three residents reviewed for hospitalization . Specifically, Resident #91 was sent to the hospital on 8/30/24, Resident #222 had multiple hospitalization s (4/14/24, 5/16/24, 5/23/24 and 8/13/24) and Resident #250 was transferred to the hospital on 3/20/24 with no written notification to the resident or their representative of the facility's bed hold policy. The findings are: Review of facility Resident Handbook undated documented; Bed Reservation Policy as follows: Residents hospitalized paying with private funds - Residents privately paying for basic services with private funds may reserve their room at the facility by continuing to pay the basic daily service rate while they are in the hospital. The resident / representative will be contacted with the current daily rate. Notification of bed reservation cancellation must be given by resident or resident representative. Residents hospitalized receiving Medicare, Other Insurance (HMO) assistance - Bed reservations are not covered by Medicare or other private insurance carriers. If a resident would like to reserve their bed they can opt to pay using private funds. Residents hospitalized receiving Medicaid assistance - New York State Department of Health regulations are amended to provide a bed reservation for nursing home patients [AGE] years of age or older and are hospitalized on ly if the resident is receiving hospice in the facility. The bed reservation is limited to an aggregate of 14 days in any 12-month period. Review of facility form titled Notice of Transfer or discharge date d 12/12/18 revealed fillable areas of the facility's Bed Hold Policy with a fillable area of the facility rate of money per day for the length of the hospital stay or up to the maximum days allowable by current Medicaid guidelines. 1. Resident #91 had diagnoses including displaced intertrochanteric fracture of left femur (break of long bone in the thigh), diabetes mellitus, and chronic kidney disease. The Minimum Data Set (a resident assessment tool) dated 7/22/24 revealed the resident was cognitively intact. Review of progress notes dated 8/1/24 - 9/11/24 revealed resident was transferred to the hospital on 8/30/24 and returned from the hospital on 9/6/24. There was no documented evidence the Notice of Transfer or Discharge form was completed which included the bed hold policy notification was provided to the resident or resident's representative. Review of the resident's entire medical record dated 8/1/24 - 9/11/24 There was no documented evidence the Notice of Transfer or Discharge form was completed which included the bed hold policy notification was provided to the resident or resident's representative. 2. Resident #222 had diagnoses including chronic respiratory failure with hypoxia (low oxygen level), epilepsy (seizure disorder), and spastic quadriplegic cerebral palsy (stiff, jerky movements of all extremities due to damage to the brain). The Minimum Data Set, dated dated dated [DATE], 5/16/24, and 8/13/24 revealed the resident was severely cognitively impaired. Resident #222 progress notes dated 4/1/24 - 9/9/24 documented the following: -4/14/24 transferred to the hospital and readmitted on [DATE]. -5/16/24 transferred to the hospital and readmitted on [DATE]. -5/23/24 transferred to the hospital and readmitted on [DATE]. -8/13/24 transferred to the hospital and readmitted on [DATE]. Review of the resident's medical record dated 4/1/24 - 9/9/24 revealed there was no documented evidence the Notice of Transfer or Discharge form was completed which included the bed hold policy notification and provided to the resident or resident's representative. 3. Resident #250 had diagnosis including chronic respiratory failure, tracheostomy status (an opening created in the trachea (windpipe) that provides an alternative airway for breathing), and gastrostomy status (an opening into the stomach from the abdominal wall, for the placement of a feeding tube). The Minimum Data Set, dated dated dated [DATE] documented Resident #250 was rarely/never understood, and rarely/never understands others. Review of progress notes dated 2/26/24 - 4/1/24 revealed resident was transferred to the hospital on 3/20/24 for an emergency visit and returned from the hospital on 3/20/24. Review of the resident's electronic medical record 3/20/24 - 9/9/24 revealed there was no documented evidence the Notice of Transfer or Discharge form was completed which included the bed hold policy notification and provided to the resident or resident's representative. During an interview on 9/10/24 at 9:13 AM, Social Worker #2 stated they do not complete a Notice of Transfer or Discharge form and stated the facility doesn't allow residents to hold beds. During an interview on 9/10/24 at 10:27 AM, the Long-Term Care Health Information Manager #1 stated they were educated by Social Worker #1 the facility Social Workers would be completing and providing the Notice of Transfer or Discharge forms for only residents who are discharge to home or another facility, but not residents transferred or discharged to a hospital setting. During an interview on 9/10/24 at 10:56 AM, Social Worker #1 stated they provided education to Social Worker #2 and Long-Term Care Health Information Manager #1 that the Notice of Transfer or Discharge form was to be completed only for residents who are going home or community and is not completed for any residents transferred or discharged to a hospital setting. They stated they do not know who was responsible to complete the Notice of Transfer or Discharge form for residents hospitalized . During an interview on 9/10/24 at 11:03 AM, the [NAME] President of Long-Term Care (former Administrator) stated after discussions with Social Worker #1, #2 and Long-Term Care Health Information Manager #1 they had identified the Notice of Transfer or Discharge form and bed hold policy notification process to residents or representatives in writing was not being completed for any resident's transfer to an acute or hospital setting. They stated they do not know how long the facility had not been completing this process as required. 10 NYCRR 415.3(i)(3)(i)(a)

Based on interview and record review conducted during an Abbreviated survey (Complaint #NY00342510) completed on 5/22/24, the facility did not ensure that all alleged violations including abuse, neglect, exploitation, or mistreatment were reported immediately, but not later than two hours after the allegation is made. If the events that caused the allegation do not involve abuse or result in seriously bodily injury not later than 24 hours to the facility's Administrator and to other officials (including to the State Survey Agency) for one (Resident #1) of three residents reviewed. Specifically, facility staff did not report an allegation of resident neglect to the Director of Nursing or the Administrator which resulted not reporting to the State Survey Agency as required. The finding is: The policy and procedure titled Identification and Reporting of Abuse, Neglect, Exploitation, or Mistreatment of a Skilled Nursing Facility Resident, as per Public Health Law Section 2803-d dated 8/30/99 documented any nursing home employee who becomes aware of abuse, mistreatment, neglect shall immediately report their concerns to the Nursing Home Administrator or designee and to other officials in accordance with State law. Resident #1 had diagnoses which included congestive heart failure, orthostatic hypotension (low blood pressure), and history myocardial infarction (heart attach). The Minimum Data Set (a resident assessment tool) dated 5/5/24 documented the resident was cognitively intact. The comprehensive care plan dated 2/9/24 documented Resident #1's medical conditions included congestive heart failure. Interventions included vital signs, weights, medications, treatments, labs, and diagnostic tests per doctor/nurse practitioner orders. Review of the investigation file revealed a form titled An investigation of an Incident dated 5/13/24. A statement signed by Certified Nurse Aide #1 on 5/17/24 documented, On Monday (5/13/24) aide notified nurse twice before they told them that the resident was in distress, when they told the nurse the resident could not breathe the nurse on duty said; 'take them this dinner and I can't leave dining room during meals'. They told the nurse 'No, you need to go see her' nurse gave them back talk so they took the food and went to resident's room and seen that the resident was changing colors. They yelled 8 times for help and grabbed the cart to take their vitals and their oxygen sats were 38% (percent) and they screamed more, nurse eventually came, they left the room and did not return. During a telephone interview on 5/21/24 at 12:24 PM, Certified Nurse Aide #3 stated that Certified Nurse Aide #1 asked them to go get Licensed Practical Nurse #1 for Resident #1. When I spoke to Licensed Practical Nurse #1, they stated they were unable to leave the dining room because residents were eating. They went back to Resident #1's room to let Certified Nurse Aide #1 know what Licensed Practical Nurse #1 had said. At that time Certified Nurse Aide #3 stated Certified Nurse Aide #1 had the pulse oximeter (electronic device that measures the saturation of oxygen carried in your red blood cells) on Resident #1 and it was low. Certified Nurse Aide #3 stated they went back to the dining room to notify Licensed Practical Nurse #1 that the resident was in respiratory distress. Licensed Practical Nurse #1 then responded to Resident #1's room. During a telephone interview on 5/21/24 at 12:46 PM, Certified Nurse Aide #2 stated they asked Certified Nurse Aide #1 to get Licensed Practical Nurse #1 from the dining room because Resident #1 was requesting them by name and was having trouble breathing. Certified Nurse Aide #1 returned to Resident #1's and told them Licensed Practical Nurse #1 stated they couldn't leave the dining room. Certified Nurse Aide #2 stated they believe Licensed Practical Nurse #1 should have responded quicker and believed Licensed Practical Nurse #1 was neglectful. Certified Nurse Aide #2 stated they informed Nursing Supervisor Registered Nurse #1 that Licensed Practical Nurse #1 did not respond immediately but had not reported negligence. Certified Nurse Aide #2 stated they expected Certified Nurse Aide #1 to have reported the allegation of neglect to the Nursing Supervisor. During a telephone interview on 5/21/24 at 1:29 PM, Certified Nurse Aide #1 stated they believed Licensed Practical Nurse #1 had not responded fast enough to Resident #1's medical needs. On 5/21/24 at 3:40 PM, Certified Nurse Aide #1 stated they had not reported the allegation of neglect until 5/16/24 and had reported it to Licensed Practical Nurse Unit Manager #2. During a telephone interview on 5/21/24 at 2:31 PM, Licensed Practical Nurse #1 stated Certified Nurse Aide #1 informed them Resident #1 was having some breathing difficulty and asked if the resident was short of breath or couldn't breathe. Certified Nurse Aide #1 didn't look anxious or act like it was an emergent situation. A few minutes later Certified Nurse Aide #3 approached them in the dining room and stated Resident #1 was having trouble breathing. Licensed Practical Nurse #1 stated they transported a resident out of the dining room and responded to Resident #1's room. At that time, they observed Resident #1 to be in respiratory distress. During an interview on 5/21/24 at 4:04 PM, Licensed Practical Nurse Unit Manager #2 stated that Certified Nurse Aide #1 reported to them on 5/16/24 they believed that Licensed Practical Nurse #1 was neglectful on 5/13/24 because they had not responded fast enough to Resident #1's requests for medical assistance. Licensed Practical Nurse Unit Manager #2 stated they had not immediately reported the allegation of neglect to the Interim Director of Nursing (Registered Nurse #2). They had requested the camera footage from the Security Manager and wanted to verify the actions of Licensed Practical Nurse #1 before the reported the allegation. Licensed Practical Nurse Unit Manager #2 stated the reported the allegation the next day (5/17/24). Licensed Practical Nurse Unit Manager #2 stated, looking back they should have informed the Interim Director of Nursing immediately. During an interview on 5/22/24 at 2:10 PM, the Interim Director of Nursing (Registered Nurse #2) stated there was a delay in reporting allegation of neglect. Certified Nurse Aide #1 should have reported the allegation on immediately 5/13/24. During an interview on 5/22/24 at 3:22 PM, the Assistant Administrator stated they would have expected Certified Nurse Aide #1 to have reported the allegation of neglect immediately on 5/13/24 to the Nursing Supervisor. The allegation should have been reported accordingly to the New York State Department of Health. 10 NYCRR 415.4(b)(2)

Based on observation, interview and record review conducted during a Standard survey (Complaints NY 560 and NY 847) completed 8/23/22 through 8/30/22, the facility did not ensure that all alleged violations including abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of resident property are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for three of four residents reviewed. Specifically, the facility did not report an injury of unknown origin (Resident #137) and allegations of verbal abuse and neglect (Residents #46 and #106) within the two-hour time frame. The findings are: The policy and procedure (P&P) titled Identification and reporting of Abuse, Neglect, Exploitation, Mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The P&P documented investigations of injuries of unknown origin must be immediately investigated to rule out abuse. The state survey agency must be notified within two hours after forming the suspicion of injury of unknown origin. 1. Resident #137 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS- a resident assessment tool) dated 6/22/22 documented Resident #137 was rarely understood, rarely understands and was severely cognitively impaired. The MDS documented the resident required total assist with all activities of daily living (ADL's) and was non ambulatory. The comprehensive care plan (CCP) documented Resident #137 had a communication problem, developmental delays and musculoskeletal imbalances secondary to brain injury. The Progress Note dated 5/3/22 at 6:36 PM documented the resident was noted to have swelling to their left thigh, MD (medical doctor) notified, new order to give Motrin and the MD will see in the AM. Area had the same temperature as the rest of the body, no redness or warmth to the area and positive pedal (foot) pulses present. The Progress Note dated 5/4/22 at 9:23 PM documented Resident #137 was kept home from school and seen by the MD; x-ray was ordered that demonstrated a fractured femur. Mother notified and the resident was being sent to the hospital to be evaluated by an orthopedic specialist. The Health Electronic Response Data System (HERDS- software that logs nursing home (NH) complaints sent by the facility) provided by the facility document the resident's fractured femur was reported to the New York State Department of Health (NYSDOH) on 5/6/22 at 5:52 PM. During an interview on 8/29/22 at 2:54 PM, the Assistant Director of Nursing (ADON) #1 stated they reported the injury of unknown origin to the Director of Nurses (DON) and to the Administrator when the fracture was identified on x-ray. Injuries of unknown origin should be called to the state agency within two hours. The ADON also stated they reported the incident to the state agency (5/6/22) but could not recall why it was reported so late. During an interview on 8/29/22 at 2:59 PM, the DON stated Resident #137 had an injury of unknown origin, and they were unsure when the incident was called to the state agency. The DON further stated the fracture should have been called when identified. During an interview on 8/30/22 at 12:29 PM, the Administrator stated, we would follow our P&P. Injury of unknown origin would have to be called if pathology could not be ruled out. 2. Resident #46 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented Resident #46 had moderate cognitive impairment, was understood, and understands. Resident #106 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented Resident #106 was cognitively intact, was understood and understands. An Investigation Summary Form, signed by ADON #3, dated 1/19/22, documented a Certified Nurse Aide (CNA) #7, was named by two different residents (#46,106), on 1/18/22 at 11:00 AM, alleging inappropriate verbal remarks and/or vulgar language that occurred on the overnight shift. Review of HERDS incident form provided by the facility documented ADON #3 reported the alleged abuse to NYSDOH on 1/19/22 at 2:07 PM. Further review of the NH Incident Form documented there was reasonable cause to believe that abuse, neglect, or mistreatment occurred. During an interview on 8/29/22 at 3:40 PM, Licensed Practical Nurse (LPN) #4 stated that two residents (#46, 106) reported concerns regarding CNA #7 on 1/18/22 during their medication pass . LPN #4 stated they were aware of the two-hour reporting time frame for allegations of abuse. LPN #4 stated they thought, maybe, ignorance of the CNA, but not abuse. Additionally, LPN #4 stated they reported the residents' allegations to Registered Nurse (RN) #6 Unit Manager (UM), immediately, and it would be the RN #6 UM responsibility to report it from there. During interview on 8/29/22 at 3:58 PM, RN #6 UM stated LPN #4 reported the allegation to them on 1/18/22. It was an allegation of verbal abuse. I was, fairly new, at that time, and wasn't sure about the reporting requirements, but I reported it to ADON #3, after speaking with the residents, and ADON #3 instructed to have Social Worker (SW) follow up with the residents. I know the reporting requirements now. During interview on 8/30/22, ADON #3 stated two residents reported concerns, from the previous night shift to LPN #4 regarding CNA #7 and allegations of being rude. I was concerned about potential verbal abuse. The allegation was reported by the residents on 1/18/22, I wasn't sure of the specifics. We started investigating then called it in. We are required to report two hours from the time we are notified. During interview on 8/30/22 at 10:48 AM, Social Worker (SW) #1 stated RN #6 UM notified them regarding the allegation on 1/18/22. It sounded like verbal abuse to me. I talked to the residents, but the RN #6 UM would be responsible to call it in, I think. During interview on 8/30/22, the DON stated they were not working at the facility at that time. ADON #1 and #3 were interim. The allegation was reported by staff, up the chain of command, but it wasn't presented as abuse. The expectation is that abuse allegations are called into the DOH within two hours. During interview on 8/30/22 at 3:09 PM, the Administrator stated we would follow our policy. If there is a suspicion of abuse, it should be reported to the Supervisor/management, immediately, so it can be reported to the DOH as required. 415.4 (b) 2

Based on observation, interview and record review conducted during the Standard survey started on 8/23/22 and completed on 8/30/22, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (Resident #29) of six residents reviewed for quality of care during activities of daily living. Specifically, Resident #29 was observed to have a bilateral axillary (underarm) rash on 8/26/22 and a treatment was not ordered until 8/29/22. Additionally, a nurse applied a medicated powder to Resident #29's bilateral axillary rash without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The finding is: The facility policy and procedure (P&P) titled Physician Orders-Long Term Care effective 7/21/14 documented telephone and verbal orders shall be accepted only by a licensed nurse, pharmacist or such other licensed practitioner as permitted by regulation or law. All verbal and/or telephone orders shall be transcribed in a medical record entry which shall include the date, title, name, title/status and signature of the person transcribing the order and the name of the prescribing practitioner and shall be authenticated by the prescribing practitioner as soon possible. 1. Resident #29 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - a resident assessment tool) dated 5/29/22 documented Resident #29 had severe cognitive impairment, rarely/never understands, and was sometimes understood. The Comprehensive Care Plan (CCP) revised on 9/28/21, documented Resident #29 had potential impairment to skin integrity related to decreased mobility and incontinence. During an observation on 8/26/22 at 8:18 AM, Certified Nursing Assistant (CNA) #3 and Licensed Practical Nurse (LPN) #2 Unit Manager (UM) provided AM care to Resident #29. Resident #29 yelled out in pain stating it hurts as CNA #3 washed Resident's #29 bilateral axilla. The wash cloth was observed to have pink tinged drainage on it. Resident #29's bilateral axilla were noted to be red and excoriated. LPN #2 UM stated that the resident had an order to apply an antifungal powder to their bilateral axillas. LPN #2 UM exited the room and then returned within a few minutes with a medicine cup of white powder and applied it to the resident's bilateral axilla. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The order start date was 9/28/20 and was discontinued on 8/28/22. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation that the antifungal powder was applied to the resident's red, excoriated bilateral axilla on 8/26/22, 8/27/22 nor 8/28/22. Review of the Order Summary Report revealed that a verbal order was received on 8/29/22 for [MEDICATION(S)] powder to be applied to Resident #29's abdominal fold/armpits topically every day and evening shift for fungal rash. There was no order for antifungal powder on 8/26/22, 8/27/22 and 8/28/22. During an interview with LPN #1 on 8/29/22 at 12:08 PM, they stated that Resident #29 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #1 stated they did not observe Resident #29's bilateral axilla and did not apply any [MEDICATION(S)] powder or cream to the resident all week. LPN #1 further stated there was not an order to do so. During an interview with LPN #2 UM on 8/29/22 at 12:58 PM, they stated that during the care observation on 8/26/22, they noted the resident had dry, excoriated skin to their bilateral axilla and abdominal folds. LPN #2 UM stated they applied [MEDICATION(S)] powder to Resident #29's bilateral axilla during the care observation and that there was an order to apply [MEDICATION(S)] powder to the Resident #29's abdominal folds but not to their bilateral axilla. LPN #2 UM stated they received a new treatment order today and they did not receive an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 8/30/22 at 1:48 PM, the Director of Nursing (DON) stated the Assistant Director of Nursing (ADON) #2 was responsible for weekly skin monitoring. The DON stated that ADON #2 does not track fungal rashes unless it was a non-healing rash. The DON stated that once a skin issue was noted, then a treatment needs to be ordered as soon as possible. The DON stated that prior to applying a medicated skin treatment, the nurse should check the order. The DON stated that LPN #2 UM should have read the orders prior to applying the antifungal powder and contacted the provider to obtain a new treatment order when the fungal rash was noted to Resident #29 on 8/26/22. During an interview on 8/30/22 at 2:03 PM, the ADON #2 stated that they expected when a new rash was noted that the medical provider be notified to obtain a new treatment order. The ADON stated the treatment should be initiated the first day a rash was noted. 415.12

Based on observation, record review, and interview conducted during the Standard survey started 8/23/22 and completed on 8/30/22, the facility did not ensure that a resident with limited range of motion (ROM) received appropriate treatment and equipment to prevent further decrease in range of motion for two (Resident #100 and #138) of four residents reviewed for range of motion (ROM) services. Specifically, Resident #100 was not provided ROM according to therapy recommendations and plan of care and Resident #138 was not provided a palm posey (assistive device that positions the fingers away from the palm) to their right and left hand as planned by Occupational Therapy (OT). The findings are: Review of the facility policy and procedure (P&P) titled Physical/Occupational Therapy-SNF (skilled nursing facility)-Range of Motion (preventative routine) dated 7/23/19, documented ROM programs are implemented to prevent and manage contractures (loss of joint mobility), maintain joint mobility, and for stretching of upper extremities and lower extremities muscles for functional benefits. ROM programs are completed by ROM Certified Nursing Assistants (CNAs) per therapists' recommendations. Review of the facility P&P titled Upper Extremity Splint dated 7/23/19 documented splints are used to prevent and manage contractures, stabilize bones/joints and allow continuous stretching to the muscles for functional benefits. 1. Resident #100 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS- a resident assessment tool) dated 6/29/22 documented the resident was moderately cognitively impaired and had a lower extremity impairment in ROM on both sides. During an interview on 8/24/22 at 8:41 AM, Resident #100 stated they believe they received ROM once a week. Review of the comprehensive Care Plan (CCP) revision dated 8/27/20, revealed Resident #100 had limited ROM related to limited mobility. The goal was to maintain current ROM with a planned intervention for a ROM program as recommended by therapy. Review of Resident #100's undated Bedside Kardex Report (guide used by staff to provide care), identified as current by the Director of Nursing (DON), revealed ROM program as recommended by Therapy. Review of the PT (Physical Therapy) - Therapist Progress and Discharge Summary dated 6/29/22 revealed the resident was discharged from skilled PT services and was placed on a ROM program with recommendations to provide AAROM (active assisted range of motion) to B (bilateral) LE (lower extremities) 3 times per week to slow the progression of contractures. Review of the OT - Therapist Progress and Discharge Summary dated 6/30/22 revealed the resident was discharged from skilled OT services and was placed on a ROM program with recommendations to provide AAROM 3 times per week to maintain ROM and decrease the risk of contractures to bilateral upper extremities (BUE). Review of the Documentation Survey Report dated June 1, 2022 through August 25, 2022 for AAROM BLE 3 times per week and AAROM BUE 3 times per week revealed the following: For June 2022, ROM was initialed as completed once for the entire month. Remaining dates were either left blank or documented as NA (Non-applicable). For July 2022, ROM was initialed as completed once for the entire month. Remaining dates were either left blank or documented as NA. For August 2022, ROM was initialed as completed twice between August 1 - 25th 2022. There was no documentation that Resident #100 refused any ROM exercises. During an observation and interview on 8/25/22 at 10:18 AM, CNA #5 provided AM care and stated they do not perform ROM to the resident because it was a task the ROM aide from the therapy department was responsible to do. During an interview on 8/26/22 at 10:14 AM, the ROM Aide stated the therapy department had assigned ROM aides to each unit but the assigned ROM aide for Resident #100's unit had been out on disability for a year and the ROM aide that was temporarily covering that unit was not working that week. The ROM aide stated ROM should be documented in the electronic medical record (EMR) upon completion of doing the ROM. The ROM aide stated the Therapy Department Director was responsible to assign staff to ensure ROM was provided to the residents. During an interview on 8/26/22 at 11:02 AM, the Therapy Department Director stated the ROM aides were responsible to provide ROM to the resident and document in the EMR; blanks and / or NA documented in the EMR indicated the ROM aide was not able to complete the ROM task as scheduled. The Therapy Department Director stated they were not aware ROM was not being completed for Resident #100 according to the therapy recommendations and plan of care and that they should have known. The Therapy Department Director stated they were responsible to schedule staff and ensure ROM was being completed according to the resident's recommendations. During an interview on 8/30/22 at 10:40 AM, the DON stated they would have expected the resident to have received ROM as recommended by the therapy department. 2. Resident #138 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS- a resident assessment tool) dated 7/17/22 documented the resident was severely cognitively impaired and had impairments in ROM on both sides of their lower and upper extremities. Review of the comprehensive Care Plan (CCP) dated 6/16/21 revealed Resident #138 had a self-care performance deficit related to chronic respiratory failure and [CONDITION(S)]. The goal was resident's needs would be anticipated and met by staff with a planned intervention for bilateral posey palm guards at all times except during hygiene or ROM. Review of an undated Bedside Kardex Report (guide used by staff to provide care), identified as current by Registered Nurse (RN) Unit Manager (UM) #2, revealed for Dressing / Splint Care - bilateral posey palm guards at all times except during hygiene or ROM. Review of the OT Progress Note dated 4/29/22 revealed Resident #138 continues to wear bilateral palm posey at all times except for hygiene and ROM. Intermittent observations of Resident #138 from 8/23/22 through 8/26/22 revealed the following: - on 8/23/22 at 10:04 AM, the resident was in bed and the resident's right hand digits (fingers) were curled in towards their palm. There was no palm posey in place. The left hand was under the covers and unable to be visualized. The resident was not receiving hygiene or ROM at this time. - on 8/25/22 at 9:45 AM, the resident was in bed and resident's right hand digits were curled in towards their palm. There was no palm posey in place. The left hand was under the covers and unable to be visualized. Observed two palm posies located on the dresser at the foot end of the bed. The resident was not receiving hygiene or ROM at this time. - on 8/25/22 at 10:15 AM, the resident was in bed, no palm posey in either hand; both palm posies were located on the dresser at the foot end of the bed. The resident was not receiving hygiene or ROM at this time. - on 8/26/22 at 8:44 AM, the resident was in bed, no palm posey in either hand and the posies were located on the dresser at the foot end of the bed. The resident was not receiving hygiene or ROM at this time. The Physical Therapist (PT) was observed to enter the room, viewed the resident's hands and applied a palm posey to each hand. During an interview on 8/26/22 at 8:44 AM, the PT stated they were ensuring the resident had their palm posies on and stated they found the palm posies on the dresser top, therefore applied the palm posies as recommended. The PT stated the nursing staff were responsible to apply the palm posies to the resident's hands at all times except during hygiene and ROM. The PT stated the palm posies were used to prevent further contractures of the resident's hands. During an interview on 8/26/22 at 8:54 AM, CNA #6 stated they were familiar with the resident and provided care to the resident yesterday. CNA #6 stated they didn't know the resident had bilateral hand palm posies and would have known this information if it was on the plan of care. Upon review of the resident's Kardex, CNA #6 stated the plan of care indicated the resident should have a palm posey applied to each hand except during hygiene and ROM. CNA #6 stated she should have applied the palm posies yesterday and they should have been on today During an interview on 8/26/22 at 8:58 AM, RN #1 stated the CNAs were to apply a palm posey to each of the resident's hands and they were to be worn at all times except during hygiene and ROM. During an interview on 8/26/22 at 9:18 AM, RN #2 UM stated the resident was to have palm posies applied by the CNAs, and the staff nurses were responsible to ensure the CNAs were following the plan of care, and ultimately the nursing staff were responsible to ensure the plan of care was followed. During an interview on 8/26/22 at 9:34 AM, the Therapy Department Director stated the nursing staff were responsible to follow the therapy recommendations and apply the palm posies as recommended to prevent further contractures of the resident's hands. During an interview on 8/30/22 at 10:40 AM, the DON stated the recommendation for a bilateral palm posey to be applied to either hand was on the resident's Kardex and they expect the CNAs, nurses and the UM to ensure the care plan was followed to prevent further contractures. 415.12(e)(2)

Based on observation, interview, and record review conducted during the Standard survey started 8/23/22 and completed on 8/30/22, the facility did not ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for one (Resident #56) of four residents reviewed for respiratory care. Specifically, there was not an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The finding is: The facility policy and procedure (P&P) titled Oxygen Therapy, O2 revised 11/10 documented a written physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . All oxygen therapy orders must include parameters, flow rate or percent FIO2 (fraction of inspired oxygen). Oxygen therapy is defined as the administration of oxygen at concentrations greater than that in ambient air with the intent of treating or preventing the symptoms and manifestations of [CONDITION(S)] (low oxygen level). Oxygen is listed as a medication by the U.S. Pharmacopoeia; it requires a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Resident #56 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - resident assessment tool) dated 6/4/22 documented that resident was in a persistent vegetative state. Review of Resident #56's Order Summary Report dated 12/10/21 through 8/31/22 revealed no evidence of an oxygen or humidification orders prior to 8/29/22. The comprehensive Care Plan (CCP) dated 2/18/22 revealed the resident used oxygen therapy related to impaired beathing mechanics, a history of respiratory failure and a history of COVID-19 with an intervention of O2 via [CONDITION(S)] ([CONDITION(S)]-opening into the trachea) collar at 6 liters (L) humidified. Review of Medication Administration Records (MAR) dated 7/1/22 through 8/28/22 revealed no evidence of an oxygen or humidification order. Review of Treatment Administration Records (TAR) dated 7/1/22 through 8/28/22 revealed no evidence of an oxygen or humidification order. Review of a hospital discharge (d/c) summary dated 12/10/21 documented the resident needed oxygen at 6 L per minute (L/min) via [CONDITION(S)] mask. Review of a physician's progress note dated 7/20/22 at 1:00 PM, revealed the resident had oxgyen via a [CONDITION(S)] collar at 7 L/min. Intermittent observations of Resident #56 from 8/24/22 through 8/29/22 revealed the following: - on 8/24/22 at 8:08 AM, the resident was in bed, wearing a [CONDITION(S)] collar which was connected to bedside oxygen at 5 L / min with humidification. - on 8/25/22 at 9:03 AM, the resident was in bed wearing a [CONDITION(S)] collar which was connected to bedside oxygen at 5 L / min with humidification. - on 8/26/22 at 10:40 AM, the resident was in bed wearing a [CONDITION(S)] collar which was connected to bedside oxygen at 5 L / min with humidification. - on 8/29/22 at 9:01 AM, the resident was in bed wearing a [CONDITION(S)] collar which was connected to bedside oxygen at 5 L / min with humidification. During an interview on 8/29/22 at 12:46 PM, Registered Nurse (RN) #3 stated the resident is receiving 5 L/min of oxygen with humidification and there should be a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Upon review of the orders and TAR, RN #3 stated they did not see an order for [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 8/29/22 at 12:48 PM, Licensed Practical Nurse (LPN) #3 stated they are unable to see an oxygen and humidification order and there should be an order to ensure the appropriate amount was provided. During an interview on 8/29/22 at 1:02 PM, RN #2 Unit Manager (UM) observed Resident #56 with humidifed oxygen at 5 L / min, then stated an oxygen and humidification order was not necessary. Upon review of the hospital d/c summary which documented oxygen was supposed to be at 6 L / min, and review of the MD progress note that documented oxygen at 7 L / min, the RN #2 UM stated the doctor didn't write an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The RN #2 UM stated they should have ensured there was an oxygen order. During an interview on 8/29/22 at 1:57 PM, the Medical Doctor (MD), who wrote the 7/20/22 physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 8/30/22 at 2:13 PM, the Assistant Director of Nursing (ADON) #2 stated they were acting as the UM at the time of the resident's admission on 12/10/21 and they should have ensured the oxygen liter flow and humidification orders were written and on the TAR, to ensure the nurses had orders to follow. During an interview on 8/30/22 at 10:59 AM, the Director of Nursing (DON) stated the resident should have had a specific oxygen and humidification order to ensure the staff were providing the actual liter flow and humidification required according to the hospital discharge summary unless an MD had made adjustments. The DON stated the oxygen liter flow and humidification should be noted on the TAR and the nurses should document every shift that it was provided. 415.12(k)(6)

Based on interview and record review conducted during the Standard survey started on 8/23/22 and completed on 8/30/22, the facility did not ensure that the pharmacist reported irregularities to the attending physician, the facility's Medical Director and Director of Nursing (DON), and that these reports were acted upon for one (Resident #159) of five residents reviewed for Drug Regimen Reviews. Specifically, the Consultant Pharmacist's did not identify the continued use of a PRN (as needed) [MEDICATION(S)] ([CONDITION(S)] antianxiety medication) in use for six months, and the physician did not act upon the recommendations in a timely manner. Additionally, there was lack of identifying and reporting that the medication was not administered per the physician's order. The finding is: The facility policy and procedure (P&P) titled Guidelines for the Use of Psychoactive Medications revised 11/9/15, documented a psychoactive medication is defined as any medication whose primary function is to treat disorders of thought process, mood, behavior, or sleep. Pharmacy responsibility included to initiate [CONDITION(S)] Drug Review and collaborate with the physician regarding regulatory compliance. An undated facility P&P titled Procedure for the Medication Regimen Review (MRR) documented the Consultant Pharmacist will review all residents' medical records within 7 days of admission, monthly, or within 7 days of notification of a significant change, to optimize medication use. Medication irregularities will be communicated to the Medical Provider, Medical Director, and the DON who will address the MRR recommendations. Medication irregularities include: -Central Nervous System (CNS) Agent PRN medication with duration longer than 14 days. If a medical provider believes a PRN CNS Agent medication is needed for more than 14 days, a new order must be written with rationale for continuation. An undated facility P&P titled Medication Monitoring documented the MRR included preventing, identifying, reporting, and resolving medication related problems, medication errors, or other irregularities, and collaborating with other members of the interdisciplinary team (IDT). MRR activities includes ensuring the duration of therapy is indicated and is appropriate for the resident. In performing MRR, the Consultant Pharmacist incorporates federally mandated standards of care. Resident specific MRR recommendations and findings are documented and acted upon by the facility and/or medical provider. Antianxiety/Sedative PRN medications should have a duration of 14 days. Antianxiety/Sedative PRN medications with a duration longer than 14 days must have a new order written by the medical provider. PRN orders for [CONDITION(S)] drugs are limited to 14 days. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should indicate the duration for the PRN order. 1. Resident #159 was admitted to the facility with diagnoses including dementia, anxiety and delusional (belief that is contradicted by reality) disorder. The Minimum Data Set (MDS- a resident assessment tool) dated 7/24/22 documented the resident had severe cognitive impairment and antianxiety medication was received on six of the past seven days. Review of the Order Summary Report dated 8/30/22 documented active physician orders as of 8/20/22 included: -[MEDICATION(S)] ([MEDICATION(S)]) Solution 2 mg (milligram)/ml (milliliter) inject 1mg intramuscularly (IM) every (q) 8 hours (hrs) PRN aggression with a start date of 12/7/21. There was no documented duration/end date. -[MEDICATION(S)] ([MEDICATION(S)]) Tablet 1 mg give 1mg by mouth (po) q 8 hrs PRN for aggression if you're not able to give po, give IM, with a start date of 12/7/21. The was no documented duration and/or end date. Review of the Medication Administration Record (MAR) revealed the following: -12/1/21 through 12/31/21 PRN [MEDICATION(S)] was administered 23 times. -1/1/22 through 1/31/22 PRN [MEDICATION(S)] was administered 23 times. -2/1/22 through 2/28/22 PRN [MEDICATION(S)] was administered 16 times. -3/1/22 through 3/31/22 PRN [MEDICATION(S)] was administered 25 times. -4/1/22 through 4/30/22 PRN [MEDICATION(S)] was administered 21 times. -5/1/22 through 5/31/22 PRN [MEDICATION(S)] was administered 15 times. -6/1/22 through 6/30/22 PRN [MEDICATION(S)] was administered 21 times. -7/1/22 through 7/31/22 PRN [MEDICATION(S)] was administered 30 times. -8/1/22 through 8/31/22 PRN [MEDICATION(S)] was administered 19 times. Further review of the MAR dated 7/1/22-7/31/22 revealed: - on 7/3/22 at 8:31 PM, [MEDICATION(S)] 1mg PO was signed off as administered and on 7/3/22 at 9:24 PM, [MEDICATION(S)] 1mg IM was signed off as administered. Review of Progress Notes written by Licensed Practical Nurse (LPN) #7, documented the following: - on 7/3/22 at 10:03 PM, the resident was in their room screaming out. PRN [MEDICATION(S)] 1mg administered with no effect. PRN IM [MEDICATION(S)] administered with no effect. The resident remained in their room yelling out. Vital signs were stable and had no complaint of pain. There was no documented evidence that a one- time physician order was obtained for the additional [MEDICATION(S)] dose or that the resident refused either doses (PO or IM) of [MEDICATION(S)] 1mg that were documented as administered. An email sent by the Consultant Pharmacist #3 dated 8/30/22 at 3:59 PM, contained a [MEDICATION(S)] ([MEDICATION(S)]) report for Resident #159 that documented [MEDICATION(S)] was removed from the facility's Pyxis (automated electronic medication system) as follows: -[MEDICATION(S)] 1mg PO was removed on 7/3/22 at 8:28 PM. -[MEDICATION(S)] 1mg IM was removed on 7/3/22 at 8:33 PM. Review of the facility monthly MRR reports dated 8/2021 through 5/2022, signed by the Consultant Pharmacist #1, documented no irregularities reported for Resident #159 during this timeframe. The MRR dated 6/2022 documented to see report. Review of the Monthly Summary Consultant Pharmacist MRR signed by the Consultant Pharmacist #1, dated 6/4/22 and signed by the DON on 6/9/22 documented irregularities as follows: Resident #159 had PRN order for [MEDICATION(S)] ([MEDICATION(S)]) initiated on 12/3/21. Please document: 1) the rationale for using this medication for more than 14 days in the resident's medical record and 2) What the duration will the PRN med be used for. Review of Consultant Pharmacist MRR Recommendation dated 6/4/22, signed by the physician on 8/26/22, documented the physician disagreed with the recommendation and documented the patient continued to require the medication for increased behaviors. There was no duration indicated for the use of the PRN [MEDICATION(S)]. Review of Resident #159's MRR reports dated 7/2022 through 8/2022, signed by the Consultant Pharmacist #1, documented no irregularities were reported. There was no documented evidence [MEDICATION(S)] 1mg PO or [MEDICATION(S)] 1mg IM was identified as not being administered per the physician's order on 7/3/22. During an interview on 8/30/22 at 9:36 AM, Registered Nurse (RN) #5 Unit Manager (UM) stated usually MRR recommendations from the Consultant Pharmacist were given to the doctor, reviewed, and orders were implemented, if applicable, then filed in the resident specific paper chart. Resident #159's recommendation from 6/2022 was missing from the resident's paper chart, so the MD reviewed the recommendation from 6/4/22 on 8/26/22. RN #5 UM stated [MEDICATION(S)] 1mg PO and [MEDICATION(S)] 1mg IM were two separate orders. Unless there was a one- time physician order, the medication can only be given every 8hrs, as ordered. An attempt to contact LPN #7 (the nurse who administered the 7/3/22 [MEDICATION(S)] doses) on 8/30/22 at 11:18 AM was unsuccessful. During a telephone interview on 8/30/22 at 11:22 AM, the Consultant Pharmacist #1 stated [MEDICATION(S)] 1mg PO and [MEDICATION(S)] 1mg IM were two separate orders. If staff were unable to give the PO dose, they could use the IM [MEDICATION(S)]. The medication can only be given q8hrs unless a one-time order from a medical provider was obtained. The Consultant Pharmacist #1 stated they were aware of the regulation for PRN psychoactive medication requiring a duration for use when used beyond 14 days and that was reviewed quarterly, if not monthly, with the IDT, including the DON and medical providers. The Consultant Pharmacist #1 stated they had made the recommendation to indicate duration of use on the previous PRN order in February of 2021 and that was why it was not re-addressed until June 2022 after the resident was restarted on the PRN medication in December 2021. The Consultant Pharmacist #1 stated the MRR recommendations needed to get addressed and reviewed by the doctor and would expect them to be addressed within 30-60 days, but sooner would be ideal. The Consultant Pharmacist #1 reviewed resident #159's EMR, including the July 2022 MAR and stated they reviewed the resident's record each month with the MRR but missed that the physician's order was not followed when [MEDICATION(S)] PO and IM doses were administered too close together on 7/3/22. During an interview on 8/30/22 at 11:53 AM, the Hospital Consultant Pharmacist #2 stated the hospital pharmacy stocks narcotics in the facility Pyxsis machine. They stated Resident #159's [MEDICATION(S)] 1mg PO and [MEDICATION(S)] 1mg IM were two separate orders. They would expect nursing to get a one-time order from a medical provider if an additional dose was required outside of the current physician order of every 8hrs and document the order in the medical record. During an interview on 8/30/22 at 12:12 PM, the DON stated they received MRR recommendations from the Consultant Pharmacist then distributed them to the specific units/Unit Managers. The DON stated they had medical providers in the facility all the time and would have expected to see Consultant Pharmacist MRR addressed within 7 days of receiving them. The DON stated they didn't know what happened to (Resident #159's) 6/4/22 Consultant Pharmacist recommendation, that was why the MD addressed it on 8/26/22. During an interview on 8/30/22 at 1:14 PM, the MD stated they were aware if PRN psychotropics were used more than 14 days they needed to be reordered or have duration for use indicated. The MD stated they did not agree with the 6/4/22 recommendation due to documentation of the resident's continued aggression, agitation, and behavioral concerns. The MD stated the medication could be scheduled but staff never knew when the resident was going to require the medication. If the medication was required for continued use it should be renewed every 14 days. The MD stated the orders for PO and IM [MEDICATION(S)] were two separate orders and if staff were unable to administer the PO dose, they should give the medication IM. The MD stated they would have expected a call for a one time order for an additional dose outside of the every 8 hour dose. 415.18(c)(2)

Based on observation, interview and record review conducted during a Complaint investigation (Complaint #NY 849) during a Partial Extended survey completed on [DATE], the facility failed to ensure the adequate care and treatment of [REDACTED].#1, 2, 3, 4) of seven residents reviewed for respiratory care. Specifically, a 16-month old infant (Resident #1), with physician's orders [REDACTED]. The resident had a history of [REDACTED]. When the nurse returned to Resident #1's room, the resident was found unresponsive, cardiopulmonary resuscitation (CPR) was initiated and the resident was transferred to the hospital where he was pronounced dead after unsuccessful attempts to resuscitate the infant. In addition, Residents #2, 3 and 4 were also in their facility rooms alone, on pulse oximetry monitors and receiving enteral tube feedings (a method to provide nutrition when unable to take food through the mouth) when the facility failed to provide adequate supervision of the resident pulse oximetry levels. This was a pattern of IMMEDIATE JEOPARDY WITH ACTUAL HARM and SUBSTANDARD QUALITY OF CARE TO RESIDENT HEALTH AND SAFETY. The Immediate Jeopardy was removed prior to the exit on [DATE]. The finding is: 1. Resident #1 was a 16 month-old infant with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated [DATE] revealed the resident had severely impaired cognitive skills, and rarely or never understood. Review of the physician's orders [REDACTED]. Review of Interim physician's orders [REDACTED]. Review of the Pediatric Comprehensive Admission History and Physical completed by the Nurse Practitioner (NP) on [DATE] revealed the resident had multiple emergency department visits for respiratory distress and pneumonia. The NP documented that the resident had no known medication, food or seasonal allergies [REDACTED]. The NP documented that the anterior and posterior lungs were clear to auscultation (listening) during this assessment. Review of the Care Planning Report, dated [DATE] revealed the resident was a "Full Code" (an emergency situation that requires immediate attention), had cognitive deficits of developmental delays and all needs will be anticipated by staff. The section for Discharge Planning listed the intervention as "Home with community services as needed." Further review of the Care Planning Report, dated [DATE], revealed a section for Medical Issues that included BPD ([MEDICATION NAME] [DIAGNOSES REDACTED] - a [MEDICAL CONDITION] in infants and children), [MEDICAL CONDITION], status [REDACTED]. The interventions included "monitor for s/sx (signs/ symptoms) of respiratory distress/ [MEDICAL CONDITION] (a reduction of oxygen supply to the body tissues), address any medical issues upon onset. Also included was a Safety Section which stated "Potential for injury related to Trach([MEDICAL CONDITION]) and Global developmental delay. The interventions included "notify nurse of any alarms, distress or desaturations as needed." Review of the medical record revealed a Nursing Progress Note dated [DATE] at 5:34 PM, Registered Nurse (RN) #3 documented she checked on the resident to see if the resident's GT feed was completed. The RN documented the resident was in a high chair for his GT feed with the Humivent on the [MEDICAL CONDITION] and pulse oximetry was "on". RN #3 documented that "she found (the) resident, his Humivent was off and pulse oximetry was not picking up." Further review of the Nursing Progress Note, dated [DATE], 5:35 PM, revealed the nurse immediately placed the resident in bed and started CPR (cardiopulmonary resuscitation) "as resident was unresponsive and not appeared breathing." RN #3 documented she called for help, the respiratory therapist immediately arrived to assist in CPR and a code (an emergency situation that requires immediate attention) was called. The RN documented that at 5:40 PM the paramedics arrived, continued CPR and transported the resident to the hospital emergency department. Review of the Respiratory Therapy Progress Note revealed that on [DATE] at 8:50 PM, the Registered Respiratory Therapist (RRT) #1 documented that the resident's manual CPT (chest physical therapy - treatment to loose mucous) and suctioning was completed at 3:,[DATE]:00 PM. RRT #1 documented that the "patient tolerated (it) well." According to RRT #1 progress note documentation, the resident was "left in the crib with rails up, on pulse oximetry with [MEDICAL CONDITION](HME- heat moisture exchanger) on." RRT #1 documented, "No respiratory distress. Pt (patient) was smiling and quite active in crib." Further review of RRT #1 Progress Note documentation revealed, "I was called in pt's room around 1730 (5:30 PM), pt was in crib unresponsive and nurse was bagging (medical device used to provide assisted ventilation) pt." RRT #1 documented that the nurse and RRT #1 could not obtain the resident's heart rate, a code was called, and CPR was initiated. During an interview with RN #3 on [DATE] at 3:10 PM, RN #3 stated that she left Resident #1 in a high chair in his room with the pulse oximeter sensor secured to his toe and the Humivent secured at the resident's [MEDICAL CONDITION] site on [DATE], at approximately 4:15 PM. RN #3 stated that it is routine to leave the pediatric resident alone in their room during routine GT feeds. RN #3 stated she re-approached the resident's room on [DATE] at approximately 5:30 PM to check on the completion of the GT feed. RN #3 stated she heard the pulse oximetry audible alarm and the lights on the monitor screen were red and indicated "0". RN #3 stated that normally the lights are green. During an interview on [DATE] at 1:30 PM, RRT #1 stated that he remembered that Resident #1 had an elevated heart rate alarm shortly after the 4:00 PM respiratory treatment and CPT on [DATE]. The RRT #1 stated that an elevated heart rate alarm is not unusual after CPT. RRT #1 stated he returned to Resident #1's room when he received the Patient Safety Net pager notification of an elevated heart rate, calmed the resident and left Resident #1 in the crib in the resident's room. RRT #1 further stated that he recalled being with another resident on the Pediatric Long Term Care Unit, who was ventilator dependent and having oxygen desaturation, when he heard his name being called multiple times with increasing urgency on [DATE] at approximately 5:30 PM. RRT #1 stated that the resident he was caring for was off the ventilator and being suctioned. RRT #1 stated that he stabilized the resident, placed the resident back on the ventilator and responded to staff calling his name within approximately one minute of last being called. RRT #1 stated that he could not recall whether his Patient Safety Net pager alarmed for Resident #1 while caring for the ventilator dependent resident. RRT #1 stated, "I was caring for a critical resident and knew could not leave him at that time." RRT #1 stated once he responded to the co-worker's call outs, he found RN #3 bagging (providing oxygen to the lungs) Resident #1 and CPR was initiated. RRT #1 stated that he was aware that the Pediatric Long Term Care Unit has several Patient Safety Net pagers. RRT #1 stated that all RRTs assigned to the Pediatric Long Term Care Unit will carry a Patient Safety Net pager, and the Unit Manager also carries a pager. RRT #1 stated that he was not sure if nurses are to carry the Patient Safety Net pager as well. 2. Resident #2 is a seven-year old with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. 3. Resident #3 is an eight-year old with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. 4. Resident #4 is a [AGE] year old with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. During an interview with RN #3 on [DATE] at 3:10 PM, RN #3 stated that the pulse oximetry alarm will sound when the resident's pulse oximetry level drops below a pre-set level and a Patient Safety Net pager will sound. RN #3 stated that she was not carrying a Patient Safety Net pager on [DATE] because she did not receive a pager at report from the nurse going off shift and no pager was found on the medication cart, where they are sometimes left. RN #3 stated that the pagers are frequently broken. RN #3 stated that the Respiratory Therapist (RT) had the pager that day. RN #3 revealed that she thought the RT was with another resident when she found the resident non-responsive. During an interview with the Pediatric Long Term Care Unit RN/ Unit Manager (UM) #2 on [DATE] at 9:00 AM, RN/UM #2 stated that RRT and each nurse on the Pediatric Long Term Care Unit should carry the Patient Safety Net pager. RN/UM #2 stated that all residents on the Pediatric Long Term Care Unit are placed on Patient Safety Net pulse oximetry monitor when left alone in their rooms even without physician's orders [REDACTED]. RN/UM #2 continued to state that the pager will display a room number, the resident's blood oxygen level and a heart rate when a problem is detected by the pulse oximetry equipment. RN/UM #2 stated she was not aware that RN #3, assigned to the resident on [DATE] from 7:00 AM through 7:00 PM, did not carry a Patient Safety Net pager during that shift. RN/ UM #2 stated she was not aware that there was only one functioning Patient Safety Net pager on the Pediatric Long Term Care Unit on [DATE]. During an interview with the RN #3 on [DATE] at 10:10 AM, RN #3 stated that nursing staff were not required to carry a Patient Safety Net pager for the pulse oximetry alarm and she did not see an available pager for her use on [DATE]. RN #3 continued by saying that she did not believe that it was mandatory for the nurses to carry the Patient Safety Net pager. RN #3 also stated that she could not hear the pulse oximetry audible alarm from a closed room or if on the "other side" of the Pediatric Long Term Care Unit. At a later interview on [DATE] at 3:00 PM, RN #3 stated that there were two Patient Safety Net pagers on the Pediatric Long Term Care Unit on [DATE]. RN #3 stated that the RRT and another RN, working on the Pediatric Long Term Care Unit were carrying the Patient Safety Net pagers. When asked why she was not carrying a pager, RN #3 stated "there were only two pagers working today." During an interview on [DATE] at 2:20 PM with the Licensed Practical Nurse (LPN) #1 who was working on the Pediatric Long Term Care Unit as float staff on [DATE] from 7:00 AM to 7:00 PM, LPN #1 stated that he works on the Pediatric Long Term Care Unit about once a month and does not carry a pager while working on the unit. LPN #1 stated he was passing medication and completing "tube feedings" on the "back" section of the Pediatric Long Term Care Unit on [DATE] when the code was called. LPN #1 continued by stating he received a seven day orientation to the Pediatric Long Term Care Unit before he began working on unit. LPN #1 stated he did not remember being oriented to the Patient Safety Net pager system and was not familiar with the pager system. LPN #1 stated he did not think that the resident's pulse oximeter was attached to a pager but was not sure. During an interview with the Registered Nurse/ Director of Nursing (DON) on [DATE] at 3:30 PM, the DON stated that all residents are placed on the pulse oximetry monitor whenever they are in their room. Interview with the RN #3 on [DATE] at approximately 1:00 PM, RN #3 stated that Resident #2 was in his room on [DATE], between 4:00 and 5:00 PM and was attached to the Pulse Oximeter. Interview with LPN #1 on [DATE] at approximately 1:15 PM, LPN #1 stated that Resident's #3 was in his room for a tube feeding on [DATE] between 4:00 PM and 5:00 PM and Resident's #4 was in his room on [DATE] between 4:00 PM and 5:00 PM. LPN #1 stated that both residents were attached to the Pulse Oximeter. During an interview with the Pediatric Unit Medical Director on [DATE] at 1:30 PM, the Physician stated the his understanding of the Patient Safety Net systems was that all staff were to carry pagers. The Pediatric Medical Director stated that two nurses and one RT or two RT's and one nurse, depending on the pediatric unit staffing, would carry a pager. The Pediatric Medical Director further stated that the person closest to the resident's room should respond to a pager going off and the pager alarm will sound until someone responds and manually resets the alarm from the resident's room. During an interview with the Administrator on [DATE] at 1:55 PM, the Administrator stated that all RN's and RRTs on the Pediatric Long Term Care Unit should carry a Patient Safety Net pager. The Administrator stated that the Unit Manager should be aware of what equipment is functioning on the nursing unit, including the Patient Safety Net equipment. The Administrator stated she was not aware that only one Patient Safety Net pager was in use on [DATE]. 5. During an interview on [DATE] at approximately 5:00 PM, the Administrator stated that actions were taken to remove the Immediate Jeopardy situation in the facility. a. Review of a letter to the New York State Department of Health, signed by the Administrator, dated [DATE], revealed an Immediate Jeopardy Abatement Plan was submitted included the following: A RN or RT will be stationed at the Patient Safety Net monitor, located at the Pediatric Long Term Care Unit nurse's station, to identify any issues and will hear/ respond to the localized alarm as the back-up measure until additional pagers arrive. In-servicing of all pediatric Professional Nurses and RT, prior to their work shift beginning [DATE], continuing until all staff have been in-serviced. No pediatric trained Professional Nurse or RT will be permitted to work on the Pediatric Long Term Care Unit until they have completed the in-service. Additional pagers were acquired and will be available for use on the Pediatric Long Term Care Unit (three pagers on [DATE] and one additional pager on [DATE]). The development of a policy on "Resident Safety Net Monitoring System for Pulse Oximetry which all pediatric trained Professional Nurses and RT will be in-serviced on. Addition of a Respiratory Manager to oversee and educate the respiratory therapy staff, complete RT competencies and review of RT policies and procedures. Development of interdisciplinary staff meetings on the Pediatric Long Term Care Unit to assist in the identification of any equipment and supply issues needed (quality assurance). b. Observations and interviews on [DATE] revealed the following: Observation of the Pediatric Unit nursing station on [DATE] between 6:00 to 7:00 pm revealed RRT #1 was stationed at the pulse oximetry screen for monitoring of pulse oximetry alarms. Observations on the Pediatric Long Term Care Unit, on [DATE] at approximately 6:30 PM, revealed Residents #2, 3, 4, 8, 9, and 10 were in their respective rooms and attached to the pulse oximetry monitors. Interview with the RN/ Supervisor #1, RN/Unit Manager #2, RNs #4 and #5, RRT #1, #2 and #3 revealed that staff were in-serviced on the use, availability and information available on the Patient Safety Net pager and the procedures to follow if the pager malfunctions. 414.12(k)(6)

Based on observation, interview and record review during a Complaint investigation (Complaint # NY 849) during a Partial Extended survey completed on [DATE], the facility failed to ensure that the residents' environment remained as free of accident hazards as possible; and each resident receives adequate supervision and assistive devices to prevent accidents. The facility failed to provide adequate supervision for residents dependent on the facility's Patient Safety Net monitoring system while alone in their room for four (Resident #1, 2, 3, 4) of seven residents reviewed for accidents. Specifically, a 16-month old infant (Resident #1), with physician's orders [REDACTED]. The resident had a history of [REDACTED]. When the nurse returned to Resident #1's room, the resident was found unresponsive, cardiopulmonary resuscitation (CPR) was initiated and the resident was transferred to the hospital where he was pronounced dead after unsuccessful attempts to resuscitate the infant. In addition, Residents #2, 3 and 4 were also in their facility rooms alone, on pulse oximetry monitors and receiving enteral tube feedings (a method to provide nutrition when unable to take food through the mouth) when the facility failed to provide adequate supervision. This was a pattern of IMMEDIATE JEOPARDY WITH ACTUAL HARM and SUBSTANDARD QUALITY OF CARE TO RESIDENT HEALTH AND SAFETY. The Immediate Jeopardy was removed prior to the exit on [DATE]. The findings are: 1. Resident #1 was a 16 month-old infant with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated [DATE] revealed the resident had severely impaired cognitive skills, and rarely or never understood. Review of the physician's orders [REDACTED]. Further review of the physician's orders [REDACTED]. Review of Interim physician's orders [REDACTED]. Review of the Pediatric Comprehensive Admission History and Physical completed by the Nurse Practitioner (NP) on [DATE] revealed the resident had multiple emergency department visits for respiratory distress and pneumonia. The NP documented that the resident had no known medication, food or seasonal allergies [REDACTED]. The NP documented that the anterior and posterior lungs were clear to auscultation (listening) during this assessment. Review of the medical record revealed the Physician documented weekly rounds on ,[DATE], ,[DATE], and [DATE] and documented "no reported issues" on ,[DATE] and "no new issues" on [DATE]. Review of the Care Planning Report, dated [DATE] revealed the resident was a "Full code" (an emergency situation that requires immediate attention), had cognitive deficits of developmental delays and all needs will be anticipated by staff. The section for Discharge Planning listed the intervention as "Home with community services as needed." Further review of the Care Planning Report, dated [DATE], revealed a section for Medical Issues that included BPD ([DIAGNOSES REDACTED] - a chronic lung disease in infants and children), tracheostomy, status [REDACTED]. The interventions included "monitor for s/sx (signs/ symptoms) of respiratory distress/ hypoxia (a reduction of oxygen supply to the body tissues), address any medical issues upon onset. Also included was a Safety Section which stated "Potential for injury related to Trach (tracheostomy) and Global developmental delay. The interventions included "notify nurse of any alarms, distress or desaturations as needed." Review of the medical record revealed a Nursing Progress Note dated [DATE] at 5:34 PM, Registered Nurse (RN) #3 documented she checked on the resident to see if the resident's GT feed was completed. The RN #3 documented the resident was in a high chair for his GT feed with the Humivent on the tracheostomy and pulse oximetry was "on". RN #3 documented that "she found (the) resident, his Humivent was off and pulse oximetry was not picking up." Further review of the Nursing Progress Note, dated [DATE], 5:35 PM, revealed the nurse immediately placed the resident in bed and started CPR (cardiopulmonary resuscitation) "as resident was unresponsive and not appeared breathing." RN #3 documented she called for help, the respiratory therapist immediately arrived to assist in CPR and a code was called. The RN documented that at 5:40 PM the paramedics arrived, continued CPR and transported the resident to the hospital emergency department. Review of the Respiratory Therapy Progress Note revealed that on [DATE] at 8:50 PM, the Registered Respiratory Therapist (RRT) #1 documented that the resident's manual CPT (chest physical therapy - treatment to loose mucous) and suctioning was completed at 3:,[DATE]:00 PM. RRT #1 documented that the "patient tolerated (it) well." According to RRT #1's progress note documentation, the resident was "left in the crib with rails up, on pulse oximetry with humidity trach (HME-heat moisture exchanger) on." RRT #1 documented, "No respiratory distress. Pt (patient) was smiling and quite active in crib". Further review of RRT #1's progress note revealed, "I was called in pt's room around 1730 (5:30 PM), pt was in crib unresponsive and nurse was bagging (medical device used to provide assisted ventilation) pt." RRT #1 documented that the nurse and RRT #1 could not obtain the resident's heart rate, a code was called, and CPR was initiated. During an interview with RN #3 on [DATE] at 3:10 PM, RN #3 stated she that she starts all "tube feeds" first between 4:00 to 4:15 PM and then "passes medication once the feeds are started." RN #3 stated that she would begin with Resident #1 due to his room location. RN #3 stated that she removed Resident #1 from his crib and placed the 16-month old in an infant high chair, securing the infant with the chair's chest harness. RN #3 stated she routinely completed the resident's GT feeds in the high chair because he was active and had disconnected his feeding tube once when she had completed the GT feed while the infant remained in bed. RN #3 stated that she left Resident #1 with the pulse oximeter sensor secured to his toe and the Humivent secured at the resident's tracheostomy site when she left the resident alone in his room on [DATE] at approximately 4:15 PM. RN #3 stated that it is routine to leave the pediatric resident alone in their room during routine tube feeds. RN #3 stated she had completed all other feeds and medication administration ordered for that time period when she approached the resident's room at approximately 5:30 PM to check on the completion of the GT feed. RN #3 stated she heard the pulse oximetry audible alarm and the lights on the monitor screen were red and indicated "0." RN #3 stated that normally the lights are green. During an interview with RRT #1 on [DATE] at 1:30 PM , the RRT #1 stated that he remembered that Resident #1 had an elevated heart rate alarm shortly after the 4:00 PM respiratory treatment and CPT on [DATE]. RRT #1 stated that an elevated heart rate alarm is not unusual after CPT. RRT #1 stated he returned to Resident #1's room when he received the Patient Safety Net pager notification of an elevated heart rate, calmed the resident and left Resident #1 in the crib in the resident's room. RRT #1 further stated that he recalled being with another resident on the Pediatric Long Term Care Unit, who was ventilator dependent and having oxygen desaturation, when he heard his name being called multiple times with increasing urgency on [DATE] at approximately 5:30 PM. RRT #1 stated that the resident, he was caring for, was off the ventilator and being suctioned. RRT #1 stated that he stabilized the resident, placed the resident back on the ventilator and responded to staff calling his name within approximately one minute of last being called. RRT #1 stated that he could not recall whether his Patient Safety Net pager alarmed for Resident #1 while caring for the ventilator dependent resident. RRT #1 stated, "I was caring for a critical resident and knew I could not leave him at that time." RRT #1 stated once he responded to the co-worker's call outs, he found RN #3 bagging (providing oxygen to the lungs) Resident #1 and CPR was initiated. RRT #1 stated that he was aware that the Pediatric Long Term Care Unit has several Patient Safety Net pagers. RRT #1 stated that all RRTs assigned to the Pediatric Long Term Care Unit will carry a Patient Safety Net pager, and the Unit Manager also carries a pager. RRT #1 stated that he was not sure if nurses are to carry the Patient Safety Net pager as well. 2. Resident #2 is a seven year old with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. 3. Resident #3 is an eight year old with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Further review revealed an order to infuse Peptamen Jr with Prebio (liquid nutrition) via the jejunostomy tube at 100 cc per hour until a total volume of 1000 cc per 24 hours has infused and to start the infusion at 3:00 PM. 4. Resident #4 is a [AGE] year old with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. During an interview with the RN #3 on [DATE] at 3:10 PM, RN #3 stated that the pulse oximetry alarm will sound when the resident's pulse oximetry level drops below a pre-set level and a Patient Safety Net pager will sound. RN #3 stated that she was not carrying a Patient Safety Net pager on [DATE] because she did not receive a pager at report from the nurse going off shift and no pager was found on the medication cart, where they are sometimes left. RN #3 stated that the pagers are frequently broken. RN #3 stated that RRT #1 had the pager that day. RN #3 revealed that she thought RRT #1 was with another resident when she found the resident non-responsive. During an interview with the Pediatric Long Term Care Unit RN/ Unit Manager (UM) #2 on [DATE] at 9:00 AM, RN/UM #2 stated that RRT #1 and each nurse on the Pediatric Long Term Care Unit should carry the Patient Safety Net pager. RN/UM #2 stated that all residents on the Pediatric Long Term Care Unit are placed on Patient Safety Net pulse oximetry monitor when left alone in their rooms even without Physician orders [REDACTED]. When a resident is out of their room, they receive constant supervision by unit staff and do not require the Patient Safety Net system. The RN/UM #2 continued to state that the pager will display a room number, the resident's blood oxygen level and a heart rate when a problem is detected by the pulse oximetry equipment. RN/UM #2 stated that the Pediatric Long Term Care Unit can get a replacement pager from the facility's corporate Biomed Department, within one half hour, if a pager is broken. RN/UM #2 stated she was not aware that RN #3 assigned to the resident on [DATE] from 7:00 AM through 7:00 PM did not carry a Patient Safety Net pager during that shift. RN/UM #2 stated she was not aware that there was only one functioning Patient Safety Net pager on the Pediatric Long Term Care Unit on [DATE]. During an interview with RN #3 on [DATE] at 10:10 AM, RN #3 stated that nursing staff were not required to carry a Patient Safety Net pager for the pulse oximetry alarm and she did not see an available pager for her use on [DATE]. RN #3 continued by saying that she did not believe that it was mandatory for the nurses to carry the Patient Safety Net pager. RN #3 also stated that she could not hear the pulse oximetry audible alarm from a closed room or if on the "other side" of the Pediatric Long Term Care Unit. In an interview on [DATE] at 3:00 PM, RN #3 stated that there were two Patient Safety Net pagers on the unit on [DATE]. RN #3 stated that the RRT and another RN, working on the Pediatric Long Term Care Unit were carrying the Patient Safety Net pagers. When asked why she was not carrying a pager, RN #3 stated "there were only two pagers working today." During an interview on [DATE] at 2:20 PM with the Licensed Practical Nurse (LPN) #1 who was working on the Pediatric Long Term Care Unit as float staff on [DATE] from 7:00 AM through 7:00 PM, the LPN #1 stated that he works on the Pediatric Long Term Care Unit about once a month and does not carry a pager while working on the unit. LPN #1 stated he was passing medication and completing "tube feedings" on the "back" section of the Pediatric Long Term Care Unit on [DATE] when the code was called. LPN #1 continued by stating he received a seven day orientation to the Pediatric Long Term Care Unit before he began working on unit. LPN #1 stated he did not remember being oriented to the Patient Safety Net pager system and was not familiar with the pager system. LPN #1 stated he did not think that the resident's pulse oximeter was attached to a pager but was not sure. During an interview with the Registered Nurse/ Director of Nursing (DON) on [DATE] at 3:30 PM, the DON stated that all residents on [DATE] would have been placed on the pulse oximetry monitor whenever they are in their room. When a resident is out of their room, the Patient Safety Net pager system does not alarm but the portable ventilator or portable pulse oximetry equipment alarm will sound. The DON stated that all children on the Pediatric Long Term Care Unit must be with staff when out of their room. Interview with RN #3 on [DATE] at approximately 1:00 PM, RN #3 stated she always completes Resident's #2 tube feeding while in his room. She stated that Resident #2 was in his room on [DATE], between 4:00 and 5:00 PM and was attached to the Pulse Oximeter. Interview with LPN #1 on [DATE] at approximately 1:15 PM, LPN #1 stated that Resident's #3 was in his room for a tube feeding on [DATE] between 4:00 PM and 5:00 PM and Resident's #4 was in his room on [DATE] between 4:00 PM and 5:00 PM. LPN #1 stated that both residents were attached to the Pulse Oximeter. During an interview with the Pediatric Unit Medical Director on [DATE] at 1:30 PM, the Physician stated that his understanding of the Patient Safety Net system was that all staff were to carry pagers. The Pediatric Medical Director stated that two nurses and one RT or two RT's and one nurse, depending on the pediatric unit staffing, would carry a pager. The Pediatric Medical Director further stated that the person closest to the resident's room should respond to a pager going off and the pager alarm will sound until someone responds and manually resets the alarm from the resident's room. During an interview with the Administrator on [DATE] at 1:55 PM, the Administrator stated that all RN's and RRTs on the Pediatric Long Term Care Unit should carry a Patient Safety Net pager. The Administrator stated that the RN assigned to a resident is the first individual responsible to respond to a pager alarm and the RRT should respond to the pager alarm if they are available. The Administrator stated that the Unit Manager should be aware of what equipment is functioning on the nursing unit, including the Patient Safety Net equipment. The Administrator stated she was not aware that only one Patient Safety Net pager was in use on [DATE]. 5. During an interview on [DATE] at approximately 5:00 PM, the Administrator stated that actions were taken to remove the Immediate Jeopardy situation in the facility. a. Review of a letter to the New York State Department of Health, signed by the Administrator, dated [DATE], revealed an Immediate Jeopardy Abatement Plan was submitted included the following: A RN or RT will be stationed at the Patient Safety Net monitor, located at the Pediatric Long Term Care Unit nurse's station, to identify any issues and will hear/ respond to the localized alarm as the back-up measure until additional pagers arrive. In-servicing of all pediatric Professional Nurses and RT, prior to their work shift beginning [DATE], continuing until all staff have been in-serviced on the use, availability and information available on the Patient Safety Net pager and the procedures to follow if the pager malfunctions. No pediatric trained Professional Nurse or RT will be permitted to work on the Pediatric Long Term Care Unit until they have completed the in-service. Additional pagers were acquired and will be available for use on the Pediatric Long Term Care Unit (three pagers on [DATE] and one additional pager on [DATE]). The development of a policy on "Resident Safety Net Monitoring System for Pulse Oximetry which all pediatric trained Professional Nurses and RT will be in-serviced on. Addition of a Respiratory Manager to oversee and educate the respiratory therapy staff, complete RT competencies and review of RT policies and procedures. Development of interdisciplinary staff meetings on the Pediatric Long Term Care Unit to assist in the identification of any equipment and supply issues needed (quality assurance). b. Observations and interviews on [DATE] revealed the following: Observation of the Pediatric Long Term Care Unit nurse's station on [DATE] between 6:00 - 7:00 pm revealed RRT #1 was stationed at the pulse oximetry screen for monitoring of pulse oximetry alarms. Observations on the Pediatric Long Term Care Unit, on [DATE] at approximately 6:30 PM, revealed Residents # 2, 3, 4, 8, 9, and 10 were in their respective rooms and attached to the pulse oximetry monitors. Interview with the RN/ Supervisor #1, RN/Unit Manager #2, RNs #4 and #5, RRT #1, #2 and #3 revealed that staff were in-serviced on the use, availability and information available on the Patient Safety Net pager and the procedures to follow if the pager malfunctions. 415.12(h)(1)

Based on interview and record review conducted during a Complaint investigation (Complaint #NY 849) during a Partial Extended survey completed on [DATE], the facility failed to ensure that all alleged violations of mistreatment, neglect, or abuse are thoroughly investigated, and failed to ensure that all alleged violations involving resident neglect or abuse are reported immediately to other officials in accordance with State law through established procedures (including to the State survey and certification agency). One (Resident #1) of seven residents reviewed for accidents and incidents had issues involving the lack of an investigation and reporting, according to State law. Specifically, Resident #1, a 16-month old resident, was found in his room, not breathing and without a pulse. Cardiopulmonary resuscitation (CPR) was initiated and the resident was transferred to a local hospital. Once in the emergency department, the resident was found to be without any cardiac activity and Resident #1 was pronounced dead in the emergency department. The facility failed to investigate and report the incident to the New York State (NYS) Department of Health (DOH) according to State law. The lack of an investigation and reporting to the New York State Department of Health resulted in a pattern of IMMEDIATE JEOPARDY WITH NO HARM and SUBSTANDARD QUALITY OF CARE TO RESIDENT HEALTH AND SAFETY. The Immediate Jeopardy was removed prior to the exit on [DATE]. REFER TO: F323 - Free of Accident Hazards/Supervision/Devices - S/S=K F328 - Treatment/Care for Special Needs - S/S=K The findings are: 1. Resident #1 was a 16 month-old infant with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated [DATE] revealed the resident had severely impaired cognitive skills, and rarely or never understood. Review of the Physician's Orders, signed [DATE], revealed orders for [MEDICAL CONDITION] care every shift and as needed, suctioning the resident's [MEDICAL CONDITION] and mouth every shift and as needed, and for the resident to have continuous pulse oximetry (an electronic device that measures the level of oxygen in the blood) readings and resuscitation orders (CPR). Review of Interim Physician's Orders revealed an order, signed [DATE], for Oxygen 21 percent (%) as needed for desaturation less than 93% and a "Trach Humivent" (a device that provides moisturized air to the [MEDICAL CONDITION]). Review of a Nursing Progress Note revealed that on [DATE], at 5:34 PM, the Registered Nurse (RN) #1 documented she checked on the resident to see if the resident's gastrostomy tube (GT- tube inserted through the abdomen that delivers nutrition directly to the stomach) feed was completed. The RN documented that the resident was in a high chair for his GT feed with the Humivent on the [MEDICAL CONDITION] and pulse oximetry was "on". The RN documented that "she found (the) resident, his Humivent was off and pulse oximetry was not picking up." Further review of the Nursing Progress Note, dated [DATE] at 5:35 PM, revealed the RN immediately placed the resident in bed and started CPR "as resident was unresponsive and appeared not breathing." Review of a Nursing Progress Note dated [DATE] revealed RN #3 documented, she called for help, the Registered Respiratory Therapist (RRT) #1 immediately arrived to assist in CPR and a code (an emergency situation that requires immediate attention) was called. The RN documented that at 5:40 PM the paramedics arrived, continued CPR and transported the resident to the hospital emergency department. Review of the Respiratory Therapy Progress Note revealed that on [DATE] at 8:50 PM, RRT #1 documented that the resident's manual CPT (chest physical therapy - treatment to loosen mucous) and suctioning was completed at 3:,[DATE]:00 PM. The "patient tolerated (it) well" and the resident was "left in the crib with rails up, on pulse oximetry with [MEDICAL CONDITION](HME- heat moisture exchanger) on." The RRT #1 documented, "No respiratory distress. Pt (patient) was smiling and quite active in crib." Further review of RRT #1 Progress Note revealed, "I was called in pt's room around 1730 (5:30 PM), pt was in crib unresponsive and nurse was bagging (medical device used to provide assisted ventilation) pt." The RRT #1 documented that the nurse and RRT #1 could not obtain the resident's heart rate, a code was called, and CPR was initiated. During an interview with the Assistant Administrator on [DATE] at 8:30 AM, the incident investigation and any corresponding documentation was requested. The Assistant Administrator stated the facility did not complete an incident investigation and stated "when you review the record you will see why." During an interview with RN #3 on [DATE] at 3:10 PM, RN #3 stated she had the pulse oximeter monitor secured on the resident's toe and the Humivent secured at the resident's [MEDICAL CONDITION] site when she left the resident alone in his room on [DATE] at approximately 4:15 PM. RN #3 stated that as she approached the resident's room at approximately 5:30 PM, she heard the pulse oximetry monitor's audible alarm and the lights on the monitor display were red and indicated "0." RN #3 stated that normally the lights are green. RN #3 further stated, during this interview, that the pulse oximetry alarm will sound when the resident's pulse oximetry level drops below a pre-set level and a pager alarm will sound. RN #3 stated that she was not carrying a Patient Safety Net pager on [DATE] because she did not receive a pager at report from the nurse going off shift and no pager was found on the medication cart, where the pagers are sometimes left. RN #3 stated that the pagers are frequently broken. RN #3 stated that RRT #1 had the pager that day. RN #3 revealed that she thought RRT #1 was with another resident when she found the resident non-responsive. During an interview with the RN/Unit Manager (UM) #2 on [DATE] at 9:00 AM, RN/UM #2 stated that RRTs and each nurse on the Pediatric Long Term Care Unit should carry the Patient Safety Net pager. The RN/UM #2 stated that all residents on the Pediatric Long Term Care Unit are placed on the Patient Safety Net pulse oximetry monitor when left alone in their rooms, even without a Physician order, for continuous pulse oximetry levels. RN/UM #2 continued to state that the pager will display a room number, the resident's blood oxygen level and a heart rate when a problem is detected by the pulse oximetry equipment. RN/UM #2 stated that Pediatric Long Term Care Unit staff can get a replacement pager from the facility's corporate Biomed Department, within one half hour, if a pager is broken. RN/UM #2 stated she was not aware that RN #3, assigned to the resident on [DATE] from 7:00 AM through 7:00 PM, did not carry a Patient Safety Net pager during that shift. RN/UM #2 stated she was not aware that there was only one functioning Patient Safety Net pager on the Pediatric Long Term Care Unit on [DATE]. During an interview with the Vice President of Long Term Care (LTC) on [DATE] at approximately 9:10 AM, the Vice President of LTC stated that he began working with the skilled nursing facility after the [DATE] cardiopulmonary arrest and death of Resident #1. The Vice President of LTC stated he became aware of this incident at the start of his employment last week and is aware that an incident investigation of the cardiopulmonary arrest and death of Resident #1 did not occur. The Vice President of LTC stated that an investigation should have been completed. During an interview with RN #3 on [DATE] at 10:10 AM, RN #3 stated that nursing staff were not required to carry a Patient Safety Net pager for the pulse oximetry alarm and she did not see an available pager for her use on [DATE]. RN #3 continued by saying that she did not believe that it was mandatory for the nurses to carry a Patient Safety Net pager. During an interview with the Administrator on [DATE] at 1:55 PM, the Administrator stated that all RNs and RRTs on the Pediatric Long Term Care Unit should carry a Patient Safety Net pager. The Administrator stated that the RN assigned to a resident is the first individual responsible to respond to a pager alarm and the RRT should respond to the pager alarm if they are available. The Administrator stated that the RN/UM should be aware of what equipment is functioning on the nursing unit, including the Patient Safety Net equipment. The Administrator stated she was not aware that only one Patient Safety Net pager was in use on [DATE]. Review of the facility policy, entitled [MEDICAL CONDITION] Care Adult/Pediatric, effective [DATE], revealed in Section C- Procedure: item #5. Complications and Reportable Incidents listed directions to notify the responsible Physician for a respiratory rate less than 8. The policy did not provide instruction as to when a facility accident/ incident report must be completed. Review of the NYS DOH Division of Residential Services "Nursing Home Incident Reporting Manual" revised [DATE] revealed the section entitled, "Malfunction or misuse of equipment" stated "If misuse of equipment or faulty equipment results in resident accidents, this is reportable under quality of care." 2. During an interview with the Administrator on [DATE] at approximately 5:00 PM, the Administrator stated that actions were taken to remove the Immediate Jeopardy situation in the facility. a. Review of a letter to the NYS DOH, signed by the Administrator, dated [DATE], revealed an Immediate Jeopardy Abatement Plan was submitted included the following: A RN or RT will be stationed at the Patient Safety Net monitor, located at the Pediatric Long Term Care Unit nurse's station, to identify any issues and will hear/ respond to the localized alarm as the back-up measure until additional pagers arrive. In-servicing of all pediatric Professional Nurses and RT, prior to their work shift beginning [DATE], continuing until all staff have been in-serviced on the use, availability and information available on the Patient Safety Net pager and the procedures to follow if the pager malfunctions. No pediatric trained Professional Nurse or RT will be permitted to work on the Pediatric Long Term Care Unit until they have completed the in-service. Additional pagers were acquired and will be available for use on the Pediatric Long Term Care Unit (3 pagers on [DATE] and one additional pager on [DATE]). The development of a policy on "Resident Safety Net Monitoring System for Pulse Oximetry which all pediatric trained Professional Nurses and RT will be in-serviced on the use, availability and information available on the Patient Safety Net pager and the procedures to follow if the pager malfunctions. Addition of a Respiratory Manager to oversee and educate the RT staff, complete RT competencies and review of RT policies and procedures. Development of interdisciplinary staff meetings on the Pediatric Long Term Care Unit to assist in the identification of any equipment and supply issues needed (quality assurance). b. Observations and interviews on [DATE] revealed the following: Observation of the Pediatric Long Term Care Unit nurse's station on [DATE] between 6:00 through 7:00 pm revealed RRT #1 was stationed at the pulse oximetry screen for monitoring of pulse oximetry alarms. Observations on the Pediatric Long Term Care Unit, on [DATE] at approximately 6:30 PM, revealed Residents #2, 3, 4, 8, 9, and 10 were in their respective rooms and attached to the pulse oximetry monitors. Interview with the RN/ Supervisor #1, RN/UM #2, RNs #4 and #5, RRT #1, #2 and #3 revealed that staff were in-serviced on the use, availability and information available on the Patient Safety Net pager and the procedures to follow if the pager malfunctions. 415.4 (b)(2)(3)(4)

Based on observation, interview and record review conducted during a complaint investigation (Complaint #NY 849) during a Partial Extended survey completed on [DATE], it was determined that the governing body did not develop and implement policies and procedures regarding the management and operation of the facility to ensure that the facility was managed in a manner that protected the health and safety of its residents. Specifically, a 16-month old infant (Resident #1), with physician's orders [REDACTED]. The resident had a history of [REDACTED]. When the nurse returned to Resident #1's room, the resident was found unresponsive, cardiopulmonary resuscitation (CPR) was initiated and the resident was transferred to the hospital where he was pronounced dead after unsuccessful attempts to resuscitate the infant. In addition, Residents #2, 3 and 4 were also in their facility rooms alone, on pulse oximetry monitors and receiving enteral tube feedings (a method to provide nutrition when unable to take food through the mouth) when the facility failed to provide adequate supervision. The lack of oversight by the governing body resulted in a deficiency which was determined to constitute Substandard Quality of Care. This was a pattern of IMMEDIATE JEOPARDY WITH ACTUAL HARM and SUBSTANDARD QUALITY OF CARE TO RESIDENT HEALTH AND SAFETY. The Immediate Jeopardy was removed prior to the exit on [DATE]. REFER TO: F225 - Investigate/Report Allegations/Individuals - S/S = K F323 - Free of Accident Hazards/Supervision/Devices - S/S=K F328 - Treatment/Care for Special Needs - S/S=K The findings are: 1. Resident #1 was a 16 month-old infant with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated [DATE] revealed the resident had severely impaired cognitive skills, and rarely or never understood. Review of the physician's orders [REDACTED]. Review of Interim physician's orders [REDACTED]. Review of the Care Planning Report, dated [DATE] revealed the resident was a "Full code" (an emergency situation that requires immediate attention), had cognitive deficits of developmental delays and all needs will be anticipated by staff. The section for Discharge Planning listed the intervention as "Home with community services as needed." Further review of the Care Planning Report, dated [DATE], revealed a section for Medical Issues that included BPD ([MEDICATION NAME] [DIAGNOSES REDACTED] - a [MEDICAL CONDITION] in infants and children), [MEDICAL CONDITION], status [REDACTED]. The interventions included "monitor for s/sx (signs/ symptoms) of respiratory distress/ [MEDICAL CONDITION] (a reduction of oxygen supply to the body tissues), address any medical issues upon onset. Also included was a Safety Section which stated "Potential for injury related [MEDICAL CONDITION] and Global developmental delay. The interventions included "notify nurse of any alarms, distress or desaturations as needed." Review of the medical record revealed a Nursing Progress Note dated [DATE] at 5:34 PM, Registered Nurse (RN) #3 documented she checked on the resident to see if the resident's GT feed was completed. The RN #3 documented the resident was in a high chair for his GT feed with the Humivent on the [MEDICAL CONDITION] and pulse oximetry was "on". RN #3 documented that "she found (the) resident, his Humivent was off and pulse oximetry was not picking up." Further review of the Nursing Progress Note, dated [DATE], 5:35 PM, revealed the nurse immediately placed the resident in bed and started CPR (cardiopulmonary resuscitation) "as resident was unresponsive and not appeared breathing." RN #3 documented she called for help, the respiratory therapist immediately arrived to assist in CPR and a code was called. The RN documented that at 5:40 PM the paramedics arrived, continued CPR and transported the resident to the hospital emergency department. Review of the Respiratory Therapy Progress Note revealed that on [DATE] at 8:50 PM, the Registered Respiratory Therapist (RRT) #1 documented that the resident's manual CPT (chest physical therapy - treatment to loose mucous) and suctioning was completed at 3:,[DATE]:00 PM. RRT #1 documented that the "patient tolerated (it) well." According to RRT #1's progress note documentation, the resident was "left in the crib with rails up, on pulse oximetry with [MEDICAL CONDITION](HME-heat moisture exchanger) on." RRT #1 documented, "No respiratory distress. Pt (patient) was smiling and quite active in crib". Further review of RRT #1's progress note revealed, "I was called in pt's room around 1730 (5:30 PM), pt was in crib unresponsive and nurse was bagging (medical device used to provide assisted ventilation) pt." RRT #1 documented that the nurse and RRT #1 could not obtain the resident's heart rate, a code was called, and CPR was initiated. During an interview with the Assistant Administrator on [DATE] at 8:30 AM, the incident investigation and any corresponding documentation was requested. The Assistant Administrator stated the facility did not complete an incident investigation and stated "when you review the record you will see why." During an interview with RN #3 on [DATE] at 3:10 PM, RN #3 stated she that she starts all "tube feeds" first between 4:00 to 4:15 PM and then "passes medication once the feeds are started." RN #3 stated that she would begin with Resident #1 due to his room location. RN #3 stated that she removed Resident #1 from his crib and placed the 16-month old in an infant high chair, securing the infant with the chair's chest harness. RN #3 stated she routinely completed the resident's GT feeds in the high chair because he was active and had disconnected his feeding tube once when she had completed the GT feed while the infant remained in bed. RN #3 stated that she left Resident #1 with the pulse oximeter sensor secured to his toe and the Humivent secured at the resident's [MEDICAL CONDITION] site when she left the resident alone in his room on [DATE] at approximately 4:15 PM. RN #3 stated that it is routine to leave the pediatric resident alone in their room during routine tube feeds. RN #3 stated she had completed all other feeds and medication administration ordered for that time period when she approached the resident's room at approximately 5:30 PM to check on the completion of the GT feed. RN #3 stated she heard the pulse oximetry audible alarm and the lights on the monitor screen were red and indicated "0." RN #3 stated that normally the lights are green. During an interview with RRT #1 on [DATE] at 1:30 PM , the RRT #1 stated that he remembered that Resident #1 had an elevated heart rate alarm shortly after the 4:00 PM respiratory treatment and CPT on [DATE]. RRT #1 stated that an elevated heart rate alarm is not unusual after CPT. RRT #1 stated he returned to Resident #1's room when he received the Patient Safety Net pager notification of an elevated heart rate, calmed the resident and left Resident #1 in the crib in the resident's room. RRT #1 further stated that he recalled being with another resident on the Pediatric Long Term Care Unit, who was ventilator dependent and having oxygen desaturation, when he heard his name being called multiple times with increasing urgency on [DATE] at approximately 5:30 PM. RRT #1 stated that the resident, he was caring for, was off the ventilator and being suctioned. RRT #1 stated that he stabilized the resident, placed the resident back on the ventilator and responded to staff calling his name within approximately one minute of last being called. RRT #1 stated that he could not recall whether his Patient Safety Net pager alarmed for Resident #1 while caring for the ventilator dependent resident. RRT #1 stated, "I was caring for a critical resident and knew I could not leave him at that time." RRT #1 stated once he responded to the co-worker's call outs, he found RN #3 bagging (providing oxygen to the lungs) Resident #1 and CPR was initiated. RRT #1 stated that he was aware that the Pediatric Long Term Care Unit has several Patient Safety Net pagers. RRT #1 stated that all RRTs assigned to the Pediatric Long Term Care Unit will carry a Patient Safety Net pager, and the Unit Manager also carries a pager. RRT #1 stated that he was not sure if nurses are to carry the Patient Safety Net pager as well. 2. Resident #2 is a seven year old with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. 3. Resident #3 is an eight year old with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. 4. Resident #4 is a [AGE] year old with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. During an interview with the RN #3 on [DATE] at 3:10 PM, RN #3 stated that the pulse oximetry alarm will sound when the resident's pulse oximetry level drops below a pre-set level and a Patient Safety Net pager will sound. RN #3 stated that she was not carrying a Patient Safety Net pager on [DATE] because she did not receive a pager at report from the nurse going off shift and no pager was found on the medication cart, where they are sometimes left. RN #3 stated that the pagers are frequently broken. RN #3 stated that RRT #1 had the pager that day. RN #3 revealed that she thought RRT #1 was with another resident when she found the resident non-responsive. During an interview with the Pediatric Long Term Care Unit RN/ Unit Manager (UM) #2 on [DATE] at 9:00 AM, RN/UM #2 stated that RRT #1 and each nurse on the Pediatric Long Term Care Unit should carry the Patient Safety Net pager. RN/UM #2 stated that all residents on the Pediatric Long Term Care Unit are placed on Patient Safety Net pulse oximetry monitor when left alone in their rooms even without Physician orders [REDACTED]. When a resident is out of their room, they receive constant supervision by unit staff and do not require the Patient Safety Net system. The RN/UM #2 continued to state that the pager will display a room number, the resident's blood oxygen level and a heart rate when a problem is detected by the pulse oximetry equipment. RN/UM #2 stated that the Pediatric Long Term Care Unit can get a replacement pager from the facility's corporate Biomed Department, within one half hour, if a pager is broken. RN/UM #2 stated she was not aware that RN #3 assigned to the resident on [DATE] from 7:00 AM through 7:00 PM did not carry a Patient Safety Net pager during that shift. RN/UM #2 stated she was not aware that there was only one functioning Patient Safety Net pager on the Pediatric Long Term Care Unit on [DATE]. During an interview with RN #3 on [DATE] at 10:10 AM, RN #3 stated that nursing staff were not required to carry a Patient Safety Net pager for the pulse oximetry alarm and she did not see an available pager for her use on [DATE]. RN #3 continued by saying that she did not believe that it was mandatory for the nurses to carry the Patient Safety Net pager. RN #3 also stated that she could not hear the pulse oximetry audible alarm from a closed room or if on the "other side" of the Pediatric Long Term Care Unit. In an interview on [DATE] at 3:00 PM, RN #3 stated that there were two Patient Safety Net pagers on the unit on [DATE]. RN #3 stated that the RRT and another RN, working on the Pediatric Long Term Care Unit were carrying the Patient Safety Net pagers. When asked why she was not carrying a pager, RN #3 stated "there were only two pagers working today." During an interview on [DATE] at 2:20 PM with the Licensed Practical Nurse (LPN) #1 who was working on the Pediatric Long Term Care Unit as float staff on [DATE] from 7:00 AM through 7:00 PM, the LPN #1 stated that he works on the Pediatric Long Term Care Unit about once a month and does not carry a pager while working on the unit. LPN #1 stated he was passing medication and completing "tube feedings" on the "back" section of the Pediatric Long Term Care Unit on [DATE] when the code was called. During an interview with the Vice President of Long Term Care (LTC) on [DATE] at approximately 9:10 AM, the Vice President of LTC stated that he began working with the skilled nursing facility after the [DATE] cardiopulmonary arrest and death of Resident #1. The Vice President of LTC stated he became aware of this incident at the start of his employment last week and is aware that an incident investigation of the cardiopulmonary arrest and death of Resident #1 did not occur. The Vice President of LTC stated that an investigation should have been completed. During an interview with the Administrator on [DATE] at 1:55 PM, the Administrator stated that all RN's and RRTs on the Pediatric Long Term Care Unit should carry a Patient Safety Net pager. The Administrator stated that the RN assigned to a resident is the first individual responsible to respond to a pager alarm and the RRT should respond to the pager alarm if they are available. The Administrator stated that the Unit Manager should be aware of what equipment is functioning on the nursing unit, including the Patient Safety Net equipment. The Administrator stated she was not aware that only one Patient Safety Net pager was in use on [DATE]. 5. During an interview on [DATE] at approximately 5:00 PM, the Administrator stated that actions were taken to remove the Immediate Jeopardy situation in the facility. a. Review of a letter to the New York State Department of Health, signed by the Administrator, dated [DATE], revealed an Immediate Jeopardy Abatement Plan was submitted included the following: A RN or RT will be stationed at the Patient Safety Net monitor, located at the Pediatric Long Term Care Unit nurse's station, to identify any issues and will hear/ respond to the localized alarm as the back-up measure until additional pagers arrive. In-servicing of all pediatric Professional Nurses and RTs, prior to their work shift beginning [DATE], continuing until all staff have been in-serviced on the use, availability and information available on the Patient Safety Net pager and the procedures to follow if the pager malfunctions. No pediatric trained Professional Nurse or RT will be permitted to work on the Pediatric Long Term Care Unit until they have completed the in-service. Additional pagers were acquired and will be available for use on the Pediatric Long Term Care Unit (three pagers on [DATE] and one additional pager on [DATE]). The development of a policy on "Resident Safety Net Monitoring System for Pulse Oximetry which all pediatric trained Professional Nurses and RT will be in-serviced on. Addition of a Respiratory Manager to oversee and educate the respiratory therapy staff, complete RT competencies and review of RT policies and procedures. Development of interdisciplinary staff meetings on the Pediatric Long Term Care Unit to assist in the identification of any equipment and supply issues needed (quality assurance). b. Observations and interviews on [DATE] revealed the following: Observation of the Pediatric Long Term Care Unit nurse's station on [DATE] between 6:00 - 7:00 pm revealed RRT #1 was stationed at the pulse oximetry screen for monitoring of pulse oximetry alarms. Observations on the Pediatric Long Term Care Unit, on [DATE] at approximately 6:30 PM, revealed Residents # 2, 3, 4, 8, 9, and 10 were in their respective rooms and attached to the pulse oximetry monitors. Interview with the RN/ Supervisor #1, RN/Unit Manager #2, RNs #4 and #5, RRT #1, #2 and #3 revealed that staff were in-serviced on the use, availability and information available on the Patient Safety Net pager and the procedures to follow if the pager malfunctions. Interview with the Administrator and the Vice President of LTC on [DATE] at approximately 5:00 PM, revealed the facility had no written policy and procedure to address the availability and information available on the Patient Safety Net pager and the procedures to follow if the pager malfunctions. This deficiency and the potential serious impact it represents to the quality of care of facility residents, demonstrates a failure on the part of the governing body to ensure effective management and operation of the facility. 415.26(b)(2)(3)