Every finding on record at Lilac Manor Rehabilitation and Nursing Center

Based on observations, interviews, and record review conducted during the Recertification Survey, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good personal hygiene and grooming for three of seven residents reviewed (Residents #40, #53, and #120). Specifically, Residents #40 and #53 required staff assistance with hand hygiene and nail care and were repeatedly observed with dark debris under their fingernails, including while eating meals, without staff providing needed hand hygiene. Resident #120 was repeatedly observed with a significant amount of facial hair, required staff assistance with grooming, stated they wanted to be shaved, and staff did not offer or provide shaving assistance.The findings include: The facility policy titled Activities of Daily Living-Personal Hygiene and Incontinence Care, effective August 2025, included the purpose was to ensure residents received consistent, respectful, and individualized assistance with personal hygiene and activities of daily living while maintaining dignity, privacy, safety, and independence. Fingernails and toenails were to be kept clean and trimmed based on resident preference. Staff were to assist residents with hair care, shaving, and other grooming needs identified in the care plan. Staff were to document activities of daily living care and refusals according to facility policy and the resident's care plan. Changes in the resident's ability to perform activities of daily living or changes in condition were to be reported to nursing and addressed through the care planning process.1. Resident #40 had diagnoses including left-sided hemiplegia and hemiparesis (weakness and paralysis affecting one side of the body) following a stroke, depression (a common mood disorder), and heart failure (a condition in which the heart cannot pump enough blood to meet the body's needs). The Minimum Data Set (a resident assessment tool) dated 05/02/2026 included Resident #40 was cognitively intact, was dependent on staff for bathing and showering, required supervision with personal hygiene, and did not reject care during the assessment period.Review of Resident #40's current Comprehensive Care Plan last revised 11/26/2025 revealed the resident had an activity of daily living self-care deficit related to limited mobility, left upper extremity contractures (tightening of muscles or joints that limits movement), and a stroke. Staff were to assist the resident with bathing, showering, and personal hygiene. The care plan did not include behaviors related to refusal of care. During an observation and interview on 08/10/2026 at 10:23 AM, Resident #40 was lying in bed. The fingernails on the resident's right hand were long and had dark debris underneath. Resident #40 stated they felt rejected and overlooked because they believed other residents received care while their care needs were not always met. Resident #40 stated they preferred female caregivers but would accept care from male caregivers when needed.During an observation and interview on 08/10/2026 at 12:59 PM, Resident #40 was sitting in bed and eating a grilled cheese sandwich with the right hand. Dark debris remained underneath the resident's fingernails. Resident #40 stated no one had offered to help wash their hands or provided a wet cloth so they could try to clean their hand.During an interview on 08/10/2026 at 3:44 PM, Registered Nurse Manager #1 stated Resident #40 had a behavior of putting their hand inside their brief. Registered Nurse Manager #1 stated staff were expected to provide the resident with hand hygiene before meals.During an interview on 08/11/2026 at 11:56 AM, Licensed Practical Nurse #2 stated Resident #40 was easy going and only refused care when they did not like how a staff member handled them. Licensed Practical Nurse #2 stated there were times when only one Certified Nurse Assistant was working on the unit and it was possible Resident #40 did not receive timely care.During an observation and interview on 08/11/2026 at 12:13 PM, Resident #40 was lying in bed. The fingernails on the resident's right hand remained long with dark debris underneath, and two fingernails were broken and jagged.During an observation and interview on 08/13/2026 at 8:58 AM, Resident #40 was in bed eating breakfast. The fingernails on the resident's right hand remained long, two fingernails were broken and jagged, and dark debris remained underneath the fingernails. Resident #40 stated no one had offered hand hygiene before the meal. Resident #40 stated some days care was delayed or did not occur unless a particular staff member was working.2. Resident #53 had diagnoses which included left-sided hemiplegia and hemiparesis following a stroke, dysphagia (difficulty swallowing), and dysarthria (difficulty speaking due to damage to the nervous system). The Minimum Data Set, dated [DATE] included Resident #53 had moderate cognitive impairment, required partial assistance with bathing and showering, required supervision with personal hygiene, and did not reject care during the assessment period.Review of Resident #53's current Comprehensive Care Plan last revised on 09/08/2025 revealed the resident had an activity of daily living self-care deficit related to limited movement and contractures of the left upper extremity. Staff were to provide maximal assistance with bathing and showering and set-up assistance with personal hygiene. The care plan did not include behaviors related to refusal of care. During an observation and interview on 08/10/2026 at 10:06 AM, Resident #53 was seated in a wheelchair. The fingernails on the resident's right hand were long with dark debris underneath. Resident #53 used the right hand to stretch the fingers of the contracted left hand, which also had long fingernails. Resident #53 stated their certified nursing assistant did not have time to wash them and stated they often waited too long for care.During an observation and interview on 08/10/2026 at 12:32 PM, Resident #53 was in their room eating a peanut butter and jelly sandwich with the right hand. Dark debris was visible underneath the resident's fingernails. Resident #53 stated no one had washed their hands before the meal and they wished someone had because their hands had not been washed since the prior day. Speech and Language Pathologist #1 stated they observed a staff member deliver Resident #53's meal tray without first providing hand hygiene. Speech and Language Pathologist #1 stated Resident #53 could not wash their hands without assistance and stated poor hand hygiene had been observed as a broader problem at the facility.During an interview on 08/10/2026 at 1:06 PM, Certified Nursing Assistant #3 stated hand hygiene was provided before meals at times and both Resident #40 and Resident #53 required staff assistance with hand washing. Certified Nursing Assistant #3 stated Resident #40 put their hand inside their brief and Resident #53 scratched their skin until it bled, so the residents' fingernails should be kept clean and appropriately trimmed. Certified Nursing Assistant #3 stated staff were expected to offer assistance even when residents did not ask for it.During an interview on 08/10/2026 at 4:03 PM, Registered Nurse Manager #1 stated Resident #40 and Resident #53 required assistance with hand hygiene and could not complete it without help. Registered Nurse Manager #1 stated staff were expected to provide hand hygiene before meals.During an interview on 08/13/2026 at 1:09 PM, the Director of Nursing stated staff were expected to provide residents with hand hygiene before all meals, especially residents known to place their hands inside their brief or scratch their skin. The Director of Nursing stated they were disappointed Residents #40 and #53 ate meals with debris underneath their fingernails. The Director of Nursing stated nail care was expected on the resident's shower day and whenever staff saw nail care was needed. The Director of Nursing stated any staff member could assist Resident #53 with hand hygiene and staff received training on personal grooming during orientation.3. Resident #120 had diagnoses including hemiplegia and hemiparesis following a stroke, aphasia (a brain disorder that affects a person's ability to speak, read, write, or understand language), and heart failure. The Minimum Data Set, dated [DATE] included Resident #120 had severe cognitive impairment and did not reject care during the assessment period.Review of Resident #120's current Comprehensive Care Plan last revised 05/13/2026 included the resident had an activity of daily living self-care deficit related to weakness and activity intolerance. Staff were to assist the resident with bathing, showering, and personal hygiene. The care plan did not include behaviors related to refusal of care. Review of Resident #120's progress notes from 07/12/2026 through 08/12/2026 revealed the resident received a shower and skin check on 08/05/2026 after a nurse observed a bug crawling on the resident. The progress note did not document shaving or other grooming assistance was provided or refused.During an observation and interview on 08/06/2026 at 11:08 AM, Resident #120 had a significant amount of facial hair. Resident #120 stated family members shaved them when they visited, but they did not visit often. Resident #120 stated they wanted to be shaved and still needed morning care.During an observation and interview on 08/10/2026 at 9:52 AM, Resident #120 continued to have a significant amount of facial hair. Resident #120 stated they wanted to be shaved but felt they had to wait for family to visit and did not know when family would come. Resident #120 stated they would allow staff to shave them if staff offered. Resident #120 stated staff had not offered shaving assistance.During an observation on 08/11/2026 at 11:11 AM, Resident #120 continued to have a significant amount of facial hair, and nose hair was hanging from the resident's nostrils.During an interview on 08/11/2026 at 11:20 AM, Registered Nurse #4 stated Resident #120 had received a bed bath that morning and the nurse completed a skin assessment. Registered Nurse #4 stated family members visited and shaved Resident #120, but the family had not requested exclusive responsibility for shaving. Registered Nurse #4 stated staff also shaved Resident #120 and the resident generally did not refuse care. Registered Nurse #4 stated if Resident #120 refused care, staff were expected to reapproach the resident.During an interview on 08/11/2026 at 11:30 AM, Certified Nursing Assistant #3 stated they were not familiar with Resident #120 because they had recently been assigned to the unit from another floor. Certified Nursing Assistant #3 stated they noticed Resident #120 needed a shave but had not offered shaving assistance. Certified Nursing Assistant #3 stated staff were expected to offer care even if a resident did not ask. If a resident refused, staff were expected to reapproach the resident and report the refusal to the nurse.During an interview on 08/13/2026 at 1:54 PM, the Director of Nursing stated staff were expected to offer shaving assistance to Resident #120 even if the resident did not ask. The Director of Nursing stated the resident may have preferred family members to provide shaving, but because family visited infrequently, staff should have offered assistance so the resident did not have to wait for grooming care. The Director of Nursing stated personal grooming was expected to be provided on the resident's shower or bed bath day and whenever needed.Title 10 New York Codes, Rules and Regulations 415.12(a)(3)

Based on observations, interviews, and record review, the facility failed to ensure an effective pest control program for three (3) (Second Floor, Third Floor, and Fifth Floor) of six (6) resident use floors. Specifically, mouse droppings and pest harborage (any condition, location, or physical environment that provides shelter, protection, or breeding grounds for pests) areas were observed on the Second, Third, and Fifth floors, and Resident #1 stated they had seen a mouse in their room.The findings include:The facility's Pest Control Policy, dated April 2025, included the facility shall maintain an effective pest control program to ensure the building is kept free of insects and rodents.During an observation on 05/13/2026 at 3:31 PM, there were mouse droppings on the floor on both sides below one (1) heater in the dining room on the Fifth Floor, and holes in the bottom of the wall on the right and left side of the heater. Mouse droppings and a hole were observed in the wall on the right side of a second heater in the Fifth Floor dining room.In an interview on 05/13/2026 at 3:46 PM, Housekeeper #1 stated housekeeping staff cleaned up mouse droppings and had seen a mouse in the basement on 05/11/2026.Resident #1 had medical diagnoses that included dysphagia (difficulty swallowing), diabetes, and immunodeficiency due to drugs (a weakened immune system from drug side effects). The Minimum Data Set (a resident assessment tool) included Resident #1 was cognitively intact. During an observation and interview on 05/13/2026 at 4:19 PM, mouse droppings were seen in Resident #1's room (room [ROOM NUMBER]) by the heater. Resident #1 stated they had seen a mouse in their room the night before. During an observation on 05/14/2026 at 9:12 AM, a hole was observed in the wall of the Second Floor dining room near the upper left corner of the heater and mouse droppings were observed on the floor. During an observation on 05/14/2026 at 9:25 AM, mouse droppings were on the floor between the nightstand and the heater in room [ROOM NUMBER] on the Second Floor.In an interview on 05/14/2026 at 9:43 AM, Certified Nursing Assistant #1 stated they had seen mice in the facility near mouse traps.In an interview and observation on 05/14/2026 at 1:36 PM, the Director of Maintenance stated there was an opening in the wall near the mouse droppings under the heater in resident room [ROOM NUMBER] and the hole needed to be fixed.In an interview on 05/14/2026 at 3:07 PM, the Director of Environmental Services stated they were aware the facility had a mouse problem. The Director of Environmental Services stated the facility was switching pest control vendors because the facility needed a more aggressive approach for the pest problem. In an interview on 05/15/2026 at 1:13 PM, the Administrator stated they were aware of the facility's mouse issue, the facility was changing pest control vendors because the current vendor frequency was monthly, but the facility needed weekly. Title 10 New York State Codes, Rules and Regulations 415.29(j)(5)

Based on observations, interviews, and record review, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior, for two (2) of three (3) resident rooms (Rooms #215 and #524). Specifically, there were multiple ceiling tiles with stains, cracks, and bowing (drooping or curving downward) observed in room [ROOM NUMBER] (Resident #4's room) and multiple ceiling tiles with stains in room [ROOM NUMBER]. The findings include:The facility's Maintenance Service policy dated April 2025 included the Maintenance Department was responsible for maintaining the building in compliance with current federal, state, and local laws, regulations and guidelines; and maintaining the building in good repair.During an observation on 05/13/2026 at 3:16 PM, room [ROOM NUMBER] had six (6) ceiling tiles with brown stains. During an observation and interview on 05/14/2026 at 1:33 PM, the Director of Maintenance stated the ceiling tiles in room [ROOM NUMBER] needed to be replaced. Resident #4 had diagnoses that included hypertension (high blood pressure), depression, and anxiety disorder. The Minimum Data Set (a resident assessment tool) dated 03/07/2026 revealed Resident #4 had moderate cognitive impairment. During an observation on 05/14/2026 at 9:25 AM, Resident #4's room (room [ROOM NUMBER]) had six (6) ceiling tiles with brown stains. Three (3) of six (6) stained tiles had visible bowing and one (1) of six (6) tiles had visible cracks around a ceiling sprinkler. In an interview on 05/14/2026 at 11:57 AM, Resident #4 stated they had complained to Maintenance when they were admitted to the facility because the ceiling tiles looked nasty, and Maintenance said they would look into it. Resident #4 stated the ceiling looked bad. In an interview and observation on 05/14/2026 at 1:36 PM, the Director of Maintenance stated the ceiling tiles were bowing, they did not know how long they had been like that and needed to be replaced. In an interview on 05/15/2026 at 1:13 PM, the Administrator stated they were not aware of ceiling tiles that needed to be replaced, and ceiling tiles had been ordered to have in stock for the facility.Title 10 New York State Codes, Rules and Regulations 415.5(h)(2)

Based on interviews and record review conducted during the Abbreviated Survey (Complaint ID: NY00357848/520132) from 08/18/2025 to 08/20/2025, for one (1) (Resident #1) of five (5) residents reviewed, the facility did not immediately notify the resident representative when there was a need to alter treatment significantly. Specifically, Resident #1 was prescribed Lovenox (a medication used to treat and prevent blood clots) injections. Following several refusals of the medication, it was discontinued by a provider, and the resident representative was not notified. This is evidenced by:Review of an untitled facility policy, last revised June 2013, included the facility shall notify the resident if alert and oriented, his or her Attending Physician, and representative (in case of a confused resident) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). Alert and oriented residents may elect for their representatives to be made aware of the above conditions.Resident #1 had diagnosis including acute embolism (condition where a blood clot travels through the bloodstream and blocks a blood vessel) and thrombosis (blood clot) of right femoral vein, vascular dementia (cognitive decline caused by damage to the blood vessels in the brain), and a history of cerebral infarction (a type of stroke caused by a blockage in a blood vessel to the brain). The Minimum Data Set (a resident assessment tool), dated 09/23/2024, documented the resident had severely impaired cognition and used an anticoagulant (a blood thinner medication used to treat and prevent blood clots).Review of the comprehensive care plan, dated 09/23/2024, included Resident #1 had a deep vein thrombosis. Interventions included, but were not limited to, give medications as ordered and to monitor, document, and report any signs or symptoms of complications.Review of medical orders, dated 09/20/2024, included Lovenox (enoxaparin sodium) Injection Solution prefilled syringes 60 milligrams/0.6 milliliters, inject 1 syringe subcutaneously every 12 hours for deep vein thrombosis for 29 days.Review of the September 2024 Medication Administration Record revealed Resident #1 had refused the Lovenox on 4 of 14 opportunities. In a medical progress note dated 09/27/2024, Nurse Practitioner #1 documented Resident #1 was seen for refusals of the Lovenox injections and nursing staff had advised the resident on the indication (the specific medical condition or purpose for which a drug is prescribed) for the medication. Nurse Practitioner #1 documented the Lovenox was discontinued.In a progress note dated 10/04/2024, a Licensed Practical Nurse documented Resident #1 was diaphoretic, fluids were pushed, and vital signs were obtained. This information was documented in facility provider book (used by nursing staff to communicate resident concerns to the medical provider) for follow up and the 24-hour report (used by nursing staff to communicate resident concerns from shift to shift) for continued monitoring. Review of progress notes from 09/24/2025 to 10/04/2025 did not include documented evidence Resident #1's representative had been notified of the Lovenox refusals or the medication later being discontinued.Review of an Emergency Department Provider Note, dated 10/04/2024, revealed Resident #1 was transported to the hospital for evaluation and admitted with a diagnosis of acute ischemic stroke (a condition that occurs when a sudden blood flow blockage to the brain causes brain cells to die). The provider documented Resident #1's representative reported they were unsure if the resident was getting Lovenox injections at the skilled nursing facility.During a phone interview on 08/18/2025 at 1:00 PM, the Medical Director stated they were not involved with Resident #1's care at that time. They stated the provider should have notified the resident's representative about the discontinuation of the Lovenox.10 NYCRR 415.3(f)(2)(ii)(c)

Based on observations, interviews, and record review conducted during the Recertification Survey and Complaint Investigations (NY00327022, NY00323935, NY00343607) it was determined that for five (1st, 2nd, 3rd, 4th, and 5th floors) of five occupied resident-use floors and one of one basement, the facility did not provide housekeeping or maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, hot water was not maintained above 90 degrees Fahrenheit ( F), floors, walls, and ceilings were dirty and/or in disrepair, bathrooms and shower rooms were dirty and in disrepair, ventilation exhaust units in bathrooms, showers, and soiled utility rooms were not functioning resulting in foul odors, ice machines were dirty, ready stand lifts were dirty, plumbing fixtures were not maintained and/or working properly, there were ceiling plumbing leaks, overhead lights were not functional or functioning properly, light lenses and covers were missing, there were damaged electrical fixtures with exposed wiring, there was a dirty fan, and there was standing water on floors. The findings are: Observations on 5/28/24 at 9:24 AM included a faucet leak in the kitchen two bay sink where the handles were attached and up through the back flow preventer. Observations on 5/28/24 from 9:52 AM to 2:30 PM included the following: 1. There was a black, slimy residue underneath the handwash sink next to the ice machine on the 5th floor near the nurse station. The residue appeared to be coming from a leaking drainpipe under the sink. 2. The lights over the beds in resident rooms [ROOM NUMBERS] were inoperable and the cover was missing from the light fixture in room [ROOM NUMBER]. Additionally, there was a hole in the wall from the doorknob in room [ROOM NUMBER]. 3. There was a strong urine and fecal odor in the 3rd, 4th and 5th floor soiled utility rooms across from the nurse stations. The exhaust ventilation grates in the ceilings of these rooms were observed not drawing air out of the room. Additionally, there was urine, body odor, and a sewage odor throughout the fifth floor and on the elevator. 4. The floor in the shower room near room [ROOM NUMBER] was dirty with hair and dark debris. 5. The bathroom in room [ROOM NUMBER] had a significant fecal odor, the toilet was clogged, and the exhaust ventilation was not functional. 6. There was a Packaged Terminal Air Conditioner (PTAC) unit disassembled on the floor of room [ROOM NUMBER] with the plug missing and exposed wire ends coming from a partially open electrical outlet box. 7. There was a strong urine and fecal odor in room [ROOM NUMBER] (unoccupied) and the bathroom toilet was clogged with yellow and brown material. The exhaust ventilation grate in the bathroom ceiling was observed not drawing air out of the room. 8. The garbage storage room on the 4th floor contained a sink with brown debris in the base and no handles to turn it on. There was also a section of drywall missing in this room that was approximately three feet long by 1.5 feet wide. 9. The sinks in the 3rd and 5th floor garbage storage rooms, near rooms [ROOM NUMBERS], lacked handles and were not functional. 10. The staff bathroom door by the 4th floor dining room was locked with a sign that read: Out of order temporarily. 11. The ice machine dispenser on the counter next to the 4th floor nurse station had a slimy brown, pink, and black residue in the area where the ice ejects. 12. There was a toilet seat in the 4th floor dining room bathroom on the floor next to the toilet. 13. The footrests on ready stand lifts located in the hallway near room [ROOM NUMBER], the 2nd floor therapy room, and in the 2nd floor shower room were dirty with an accumulation of crumbs and other debris. 14. The light lens above the bed in room [ROOM NUMBER] was cracked and damaged, and the exhaust ventilation grate in the ceiling of the bathroom room was observed to not be drawing air out of the room. 15. There was a flower vase in room [ROOM NUMBER] that was filled with a cloudy yellow liquid with dead moldy flowers floating. 16. A Wind Machine brand portable fan located in the hall on an overbed table near the 3rd floor nurse station had a build-up of dust on the cover and fan blades. 17. There was a strong urine and fecal odor in rooms 309, 318, and throughout the corridor from rooms 301 to 308 (3rd floor). 18. The temperature of the water from the shower fixture in the 2nd floor shower room (across from room [ROOM NUMBER]) did not get higher than 74 F, after being run for several minutes. 19. The main fire alarm annunciator panel behind the reception desk in the 1st floor lobby displayed several supervisory trouble signals related to the penthouse exhaust fans for toilets and lounges. 20. The urinal in the 1st floor men's bathroom across from the reception desk would not completely flush. When activated the device would briefly flush and did not push the urine down the drain. 21. One of the three toilets in the basement women's locker room was not functional and one of the two sinks in the room was inoperable. Additionally, one of the two sinks was not functional in the 1st floor women's bathroom near the lobby and the other sink would only dispense cool water. 22. There was approximately four inches of standing water on the floor in the basement boiler room. A sump pump was observed in a pit outside the basement boiler room with an accumulation of water, leaves, and garbage, and the drains in this pit appeared to be clogged. 23. The ceiling lighting in the basement fire pump room, generator room, and boiler room were continuously blinking and flashing brightly. 24. There was standing water on the floor in the basement air handler room with water dripping down from the unit. During an interview on 5/28/24 at 10:22 AM Resident #97 stated that they have not had a shower since early December 2023 and that they receive bed baths with cold water, and were told that the facility does not have hot water. During another interview at 12:41 PM Resident #512 stated that they had not had a shower in a month as staff told them that they were having trouble with the water and that it is cold. Observations on 5/30/24 at 12:08 PM included a floor tile in the 4th floor dining room that was loose, partially broken, and not adhered to the floor. During an interview on 5/31/24 at 4:35 PM Certified Nursing Assistant #1 stated we can usually give resident showers when the water is warm but usually the water is freezing, and that the water has been cold consistently since June of last year. Certified Nursing Assistant #1 also stated that the high side hall on every unit does not have hot water or a full strong stream, and sometimes the water looks green or yellow. Observations on 5/31/24 at 5:11 PM included the hot water temperature in the shower on the 5th floor next to room [ROOM NUMBER] was 73.8 F after running for several minutes, and the water came out at a very low pressure like drips. Observations on 5/31/24 at 10:04 AM included an approximately one foot by four-foot ceiling tile in the 2nd floor corridor outside room [ROOM NUMBER]was brown, stained, and wet from a leak above. During an interview on 5/31/24 at 10:45 AM, the regional maintenance director stated that for maintenance it is just themself, because one of the maintenance staff is out on medical leave and the other one left about two weeks ago. Further record review at 2:52 PM revealed another maintenance technician was hired 5/2/24 and was terminated from employment 5/21/24. Observations on 5/31/24 at 11:12 AM included an electrical connection behind and above the dryers in the first-floor laundry room had green and red wires exposed including the copper wiring ends and wire nuts. During an interview on 5/31/24 at 12:34 PM a resident family member stated that the floors in the room are sticky, dirty, and the facility smells of urine and feces, and that it is not right or humane. During an interview on 5/31/24 at 1:31 PM Resident #97 stated that they denied a bed bath last night because the water was too cold, and they would have taken a shower if the water was warm and if they were offered. Record review of a facility grievance for resident #73 and dated 1/15/24 documented that this resident does not have hot water for when they wash up and that staff wash them with cold water. Observations on 6/2/24 at 5:47 PM included the hot water temperature in the 5th floor shower room near room [ROOM NUMBER] was 75.3 F after running for several minutes, and the water pressure was observed to be just a trickle. Further observations included the toilet in this shower room was filled with paper and stool and the shower room smelled of stool. Review of a nursing progress note dated 6/4/24 at 6:31 AM revealed that Resident #75 had a bed bath and that there had been no hot water on the unit (4th floor). During an interview on 6/4/24 at 10:26 AM Licensed Practical Nurse #1 stated that they knew a couple of times the water went out and that they do not think the water is hot. During an interview on 6/4/24 at 11:23 AM the Regional Director of Maintenance stated that maintenance takes daily water temperatures and records them in a log. Record review of hot water temperature logs revealed multiple temperatures of hot water at points of use in resident rooms were less than 90 F beginning on 5/14/24. During an interview on 6/4/24 at 12:22 PM Certified Nursing Assistant #2 stated that they do not use the showers on the 5th floor because the water is cold and it is very difficult to give residents showers. Certified Nursing Assistant #2 also stated that only the shower on unit two (second floor) had hot water, and they have to get people up and get them downstairs. Certified Nursing Assistant #2 stated that there was a shower list, but they had to go down and check to see if the shower was occupied. On 6/4/24 at 12:41 PM the surveyor thermometer was calibrated using the ice-point method and read 32.1 F. In an interview on 6/5/24 at 2:31 PM The Director of Nursing stated many residents refuse showers as they do not want to go to another floor. The Director of Nursing stated the water pumps are in house and that they are working on someone to get them installed so that the 5th floor can have better water pressure. During an interview on 6/6/24 at 8:51 AM Certified Nursing Assistant #3 stated the water temperatures have been inconsistent for 6 months and the water pressure in the shower room at the end of the hall has been bad for about a month or two. 10NYCRR: 415.29, 415.29(c), 415.29(d), 415.29(g), 415.29(h)(1), 415.29(i)(1,2), 415.29(j)(1) 47641

Based on observations, interviews, and record review conducted during a Recertification Survey and Complaint Investigations (NY00337587, NY00324938, NY00321613, NY00323935, NY00317625, NY00328756) for six of six residents reviewed, the facility could not provide evidence that allegations of resident abuse and injuries of unknown origin were thoroughly investigated. Specifically for Resident #22 there was no evidence that an allegation of staff abuse had been investigated. For Residents #44, #68 and #100 there was no evidence that allegations of resident-to-resident abuse had been investigated. For Residents #87 and #371 there was no evidence that the facility investigated injuries of unknown origin. This is evidenced by but not limited to the following: 1. Resident #371 had diagnoses that included a history of falls, adult failure to thrive, and visual hallucinations. The Minimum Data Set Resident assessment dated [DATE] documented the resident was cognitively intact. Review of the Comprehensive Care Plan dated [DATE], revealed Resident #371 had a self-care performance deficit with activities of daily living and was totally dependent on staff for bed mobility, transfers, and toileting. Review of Resident #371's electronic medical record revealed the following: a. On [DATE] Nurse Practitioner #2 documented that the resident had a swallow evaluation due to bilateral neck swelling and demonstrated pharyngeal dysphagia (difficulty swallowing) likely caused by swelling. b. On [DATE] a Nurse Manager documented that the resident was seen by the Physician who said the neck swelling had gotten bigger and that the resident was still complaining of difficulty swallowing with fluids getting stuck. The resident was sent to the emergency department. c. On [DATE], in a hospital progress note, the hospital Physician documented that they evaluated Resident #371 and determined that resident had a laryngeal (voice box) fracture. The Physician documented that laryngeal fractures were most often caused by trauma, but that the patient (Resident #371) had no clear history to account for this. However, fracture during a fall or from non-accidental trauma could not be excluded. d. On [DATE] a Medical Examiner request included that a subpoena had been sent to the facility informing them that Resident #371 had died on [DATE]. The Medical Examiner requested an incident report from the facility that would explain why the resident was transported to the hospital on [DATE]. During an interview on [DATE] at 11:51 AM, the Director of Nursing stated that if a resident had an injury with unknown origin, a Registered Nurse should assess the resident, determine if the resident could state what happened, notify the medical team, the resident's family, and then they would initiate an investigation. The Director of Nursing said they had spoken with the hospital Social Worker who felt Resident #371's injuries were consistent with someone who had been assaulted. The Director of Nursing said they did not attribute the resident's neck swelling to anything that needed to be investigated but that looking back, the Registered Nurse who discovered the swelling to the resident's neck should have initiated an investigation, but they did not think of it at the time. During an interview on [DATE] at 9:53 AM, Nurse Practitioner #2 stated they evaluated Resident #371 and felt it was urgent to send the resident to the hospital because the resident's neck was large, and they were having trouble swallowing. Nurse Practitioner #2 said when an injury of unknown origin occurs, the facility should complete an Incident/Accident report, investigate, and determine a root cause. Nurse Practitioner #2 said that given the hospital provider's notes that trauma could not be excluded, the facility should have started an investigation. During a phone interview on [DATE] at 2:26 PM, a family member said they saw Resident #371 a few days before they were sent to the hospital and that they had had a red mark on the left side of their throat and the following week their neck was swollen. The family member stated that no one from the facility had called them regarding the resident's neck being red and swollen. 2. Resident #22 had diagnoses that included heart failure, hypertension, and chronic obstructive pulmonary disease. The Minimum Data Set Resident assessment dated [DATE] documented the resident was cognitively, able to make themselves understood and able to understand with clear comprehension. An Incident/Accident Report provided by the facility included that a progress note dated [DATE] and written by a nurse documented that physical aggression took place in Resident #22's room. Resident #22 had reported that two Certified Nursing Assistants were rough when providing care, held their arm down and pushed their fingernails into their back. Resident #22 reported that one of the Certified Nursing Assistants pinched their skin and stuck their middle finger out at the resident on their way out of their room. The Incident/Accident Report included that both Certified Nursing Assistants were told to not go back into Resident #22's room for any reason, that the resident was alert and oriented, did not have any injuries and that the investigation was ongoing. The facility was unable to provide any further documentation that the alleged incident had been investigated. During an interview on [DATE] at 2:31 PM, the Director of Nursing stated that they did recall the alleged incident with Resident #22 on [DATE]. The Director of Nursing stated that Resident #22 can be a storyteller but that a lot of the things they say can have some merit. The Director of Nursing stated one of the Certified Nursing Assistants was terminated due to the alleged incident and that they believe a full investigation was completed but the facility could not locate it. 3. Resident # 68 had diagnoses that included weakness, repeated falls, and dementia. The Minimum Data Set Resident assessment dated [DATE], included the resident was severely impaired cognitively. Resident #100 had diagnoses that included dementia, diabetes, and heart disease. The Minimum Data Set Resident assessment dated [DATE], documented the resident was severely impaired cognitively. Review of Resident #68's current Comprehensive Care Plan revealed the resident could display aggression and had impaired cognitive thought process due to their dementia. Review of Resident #100's Comprehensive Care Plan dated [DATE], revealed the resident was aggressive towards others and had impaired cognitive thought processes related to their dementia. Review of an Incident/Accident Report dated [DATE] revealed that Resident #100 sustained a lump on top of their head with a small cut, after being hit in the head with a reaching device by another resident. The Incident and Accident report did not include witness statements, or any additional notes related to the event. Review of the compliant form reported to the Department of Health by the previous Administrator revealed that a resident-to-resident incident involving Resident #100 and Resident #68 had occurred on [DATE]. Upon request, the facility could not provide any evidence that a thorough investigation of the incident had been completed. Additionally, several subsequent incidences were reported to the Department of Health by the facility, and the facility could not provide evidence that any of these incidences had been investigated. During an interview on [DATE] at 10:05 AM, the Corporate Infection Preventionist stated the incident was identified in either February or [DATE] and that the investigations were missing, likely due to changes in facility leadership. In an emailed correspondence dated [DATE] at 11:04 AM, the Corporate Infection Preventionist stated that they could not locate any facility investigations related to these events. 10 NYCRR 415.4(b)(1) 46526 46880 47641

46526 Based on interviews, and record review conducted during the Recertification Survey and Complaint Investigation (NY00318393), it was determined that for 4 of 10 residents reviewed for medication administration, the facility did not ensure that the residents were free from significant medication errors. Specifically, there was no documented evidence that Resident #37 had received multiple prescribed medications on multiple days, that Resident #42 received the correct dose of narcotic pain medication on several days, that Resident #52 received the correct doses of narcotic pain medication on several days, and that Resident #100 had received the full ordered course of an antibiotic as ordered. This is evidenced by the following: The facility policy Administering Medications, dated April 2019, included that medications are to be administered in accordance with prescribed orders, including any required time frame. The policy noted that the individual administering the medication checks the label three times to verify the right resident, right medication, right dose, right time, and right method (route) of administration before giving the medication. The facility policy, Adverse Consequences and Medication Errors, dated revised April 2014, defined a medication error as the preparation or administration of drugs or biological which is not in accordance with physician's order, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. Examples of a medication error would include but not limited to, an omission (a drug is ordered but not administered) and the wrong dose. 1. Resident #42 had diagnoses that included heart failure, diabetes, and a pressure ulcer. The Minimum Data Set Resident assessment dated [DATE], included that Resident #42 was cognitively intact. The current Physician orders included oxycodone 5 milligrams daily and give 30 minutes before the pressure ulcer dressing change for pain. Review of the Medication Administration Record for 5/14-5/29/24, revealed that oxycodone 5 milligrams had been signed off as administered daily. Review of the Control Substance Record (the list of narcotic medications the nurses remove from the narcotic cabinet per resident) revealed that on 5/16, 5/18, 5/21, 5/22, 5/24, 5/25, 5/26, 5/27, and 5/28 multiple (2 or 3) 5 milligrams oxycodone tablets had been removed for Resident #42 (versus one tablet). In a nursing progress noted dated 5/29/24, Nurse Practitioner #3 documented that more oxycodone may have been administered to Resident #42 than ordered. Review of a Nursing Medication Incident Report dated 5/29/24 signed by the Director of Nursing and a summary dated 5/29/24 signed by the Corporate Infection Preventionist revealed that the Director of Nursing notified the Medical Director and the consulting pharmacist of the error for Resident #42 and Licensed Practical Nurse #5 received immediate reeducation. The Incident Report included a statement from Licensed Practical Nurse #5 that they administered the increased narcotics to Resident #42 as per a previous order (versus the current order). In an interview on 6/6/24 at 9:14 AM, Resident #42 stated they believed they get their pain medication every eight hours but they did not feel it was working and could be stronger. In an interview on 6/6/24 at 11:26 AM Registered Nurse Manager #3 stated nurses should follow the Physician orders when giving medications. 2. Resident #52 had diagnoses that included Ankylosing spondylitis (chronic inflammatory disease of the spine), complex regional pain syndrome of left lower limb, and depression. The Minimum Data Set Resident assessment dated [DATE], included that Resident #52 was cognitively intact. Review of current Physician orders, dated 5/9/24 revealed oxycodone 5 milligrams tablet, give 1.5 tablets (7.5 milligrams) three times daily (scheduled for 6:00 AM, 12:00 PM, and 5:00 PM). The June 2024 Medication Administration Record documented that nursing staff signed off that 7.5 milligrams of oxycodone was administered three times a day to Resident #52 as ordered. Review of the Control Substance Records (narcotic sheets for each resident) revealed the following documentation for Resident #52: a. On 6/2/24 at 6:00 AM and 5:00PM, one 5 milligrams tablet of oxycodone was removed (and no 2.5 milligram tablet) and at 12:00 PM two 5 milligrams oxycodone tablets were removed. There was no documentation of wasting any of the narcotic medication indicating that Resident #52 was undermedicated for two doses and over medicated for one dose per the documentation. b. On 6/3/24 at 6:00 AM, two 5 milligrams tablets of oxycodone were removed. There was no documentation of wasting any of the medication. c. On 6/3/24 at 12:00 PM and 5:00 PM there was no documentation that any oxycodone tablets had been removed from the narcotic cabinet for Resident #52. In an interview on 6/3/24 10:15 AM, Resident #52 stated the facility ran out of 2.5 milligram tablets of their oxycodone, so they only get 5 milligrams sometimes and they told the nurse to do what some of the other nurses do and cut one tablet in half. In an interview on 6/3/24 at 1:45 PM, Registered Nurse Manager #3 stated they were out of 2.5 milligram tablets and that what Licensed Practical Nurse #5 signed off on the narcotic sheet did not match what they signed off as administered on 6/2/24 and 6/3/24, as it appeared that 10 milligrams of oxycodone were removed at 6:00 AM and administered (versus the ordered 7.5 milligrams). In an interview on 6/4/24 at 1:04 PM Licensed Practical Nurse #5 stated Resident #52 ran out of 2.5 milligrams tablets of oxycodone, so they gave two 5 milligram tablets and did not document any waste. In an interview on 6/6/24 at 9:45 AM Nurse Practitioner #1 stated that not receiving the ordered dose or a partial dose of pain medication could cause increase anxiety and increased pain. There was no documented evidence that the Licensed Practical Nurse #5 was suspended pending a thorough investigation related to multiple narcotic medication errors for Residents #42 and #52. 3. Resident #100 had diagnoses that included dementia, hypertension, and diabetes. The Minimum Data Set Resident assessment dated [DATE] revealed Resident #100 was severely impaired cognitively. Review of Physician orders dated 5/18/24 revealed Resident #100 was prescribed ceftriaxone (antibiotic) intramuscularly for three days for pneumonia, with a start date of 5/18/24. Review of the May 2024 Medication Administration Record revealed the first dose of ceftriaxone that was scheduled to be given on 5/18/24 was not documented as administered and was coded at 17 (hold per MD order) and that Resident #100 only received a total of two doses of antibiotic versus the three doses ordered. In a nursing progress note dated 5/18/24 at 9:22 PM Licensed Practical Nurse #4 documented that the ceftriaxone was awaiting pharmacy delivery. There was no documentation that the medical team was notified of the missing dose of antibiotic or that the medical team had ordered to hold the first dose of Resident #100's antibiotic. During an interview on 5/31/24 at 11:04 AM, the Corporate Infection Prevention Nurse said when an antibiotic is ordered, nurses can get a dose out of the Cubex (machine that securely stores and dispenses medications) which usually contains ceftriaxone (in order to give it immediately) or they can call the Pharmacy to get an antibiotic delivered immediately. If unable to get a medication, staff should notify the medical provider. The Corporate Infection Prevention Nurse stated there was no order for the antibiotic to be held and that it appeared as though Resident #100 had not received the full course of antibiotics as ordered and that they would consider that a significant medication error. During a telephone interview on 6/6/24 at 9:41 AM, Nurse Practitioner #1 stated they ordered ceftriaxone for Resident #100 for three days on 5/18/24 and that ceftriaxone should be available from the facility's emergency supply (for that first dose). They said that they had never been notified about the antibiotic being unavailable and should have been. 4. Resident #37 had diagnoses that included dementia, hypertension, and depression. The Minimum Data Set Resident assessment dated [DATE] revealed Resident #37 was moderately impaired cognitively and received antipsychotic and antidepressant medications. Review of the May 2024 Medication Administration Record revealed no documented evidence that Resident #37 had received the following prescribed medications on 5/3/24 and/or 5/12/24: a. atorvastatin (medication for high cholesterol) - 5/3/24 and 5/12/24. b. melatonin (medication for sleep) - 5/3/24 and 5/12/24. c. mirtazapine (medication for depression) - 5/3/24 and 5/12/24. d. trazodone (medication for depression) - 5/3/24 and 5/12/24. e. quetiapine (antipsychotic medication used to treat schizophrenia, bipolar and depression) - 5/3/24 and 5/12/24. f. metoprolol (medication used to treat high blood pressure) - 5/12/24. g. sennosides-docusate (medication used to treat constipation) - 5/12/24. h. acetaminophen (Tylenol) - 5/12/24. Review of nursing progress notes dated 5/3/24 and 5/12/24 did not reveal any documentation that the medications had been administered, that the medications had been unavailable, or that the medical provider had been notified. During an interview on 6/6/24 at 10:55 AM, Registered Nurse Manager #1 said when administering residents' medication, the nurse should make sure that the medications were available, that some medications are in-house stocked medications, and some ordered through a pharmacy and the nurses should order them when they are down to the last column of pills in the blister pack. If unavailable an order would be needed from the medical provider (to hold). Registered Nurse Manager #1 said a blank box on the Medication Administration Record may indicate missing documentation. The nurses scheduled for 5/3/24 and 5/12/24 were not available for interview. In an interview on 6/6/24 at 1:38 PM, Director of Nursing stated there would be no reason for a resident to receive an extra dose of a narcotic beyond what is ordered. The Director of Nursing stated if a medication was not available, nurses should see if it is stocked and available, call the pharmacy or notify the nurse manager or themselves (Director of Nursing) and let the provider know. The Director of Nursing said a blank box on the Medication Administration Record would indicate nothing was done (administered). 10 NYCRR 415.12(m)(2) 47642

Based on observations and interviews conducted during the Recertification Survey, the facility did not provide for safe and secure storage of medications and ensure that medications were labeled in accordance with currently accepted professional standards for two (3rd and 4th floor resident units) of two medication rooms and two (3rd and 4th floor) of four medication carts and one clean utility room (3rd floor) reviewed Specifically, medications were observed stored in an unlocked clean utility room, resident specific medications were not labeled, and medication carts contained several unidentified loose pills, and were unclean. This is evidenced by but not limited to the following: The facility policy, Storage of Medications, dated [DATE] documented that drugs and biologicals used in the facility were stored in locked compartments under proper temperature, light, and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. The nursing staff were responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. During an observation on [DATE] at 1:07 PM, the 3rd floor resident unit clean utility room was unlocked and unsupervised (no staff in view). It contained cleaning supplies and an open cabinet with multiple bottles of over-the-counter medications and topical creams. During an observation and interview on [DATE] at 1:26 PM, the 3rd Floor resident unit medication room contained several bottles of insulin that were open and undated as to when opened or when expired. When interviewed at the time, Licensed Practical Nurse #5 stated any insulin bottle that was not dated should be thrown away. During an observation on [DATE] at 3:49 PM, with the 4th Floor Registered Nurse Manager #1, several opened and expired insulin pens were stored in the medication refrigerator. During an observation on [DATE] at 11:56 AM a 3rd Floor medication cart contained two unlabeled inhalers, multiple loose unidentified pills (medications), spilled red liquid on the bottom of the drawer, and a significant amount of dust and debris. During an observation on [DATE] at approximately 12:00 PM a 4th floor medication cart drawer contained approximately 40 loose unidentified pill medications. When interviewed at the time, Licensed Practical Nurse #6 said the night shift nurse was responsible for organizing the medication room and cleaning the medication carts. During an interview on [DATE] at 3:21 PM and again on [DATE] at 10:13 AM the Director of Nursing said medication cart audits and room audits should be completed weekly and all nurses should manage the cleanliness of these areas on a daily basis. The Director of Nursing said all medications should be kept behind locked doors and/or cabinets. 10 NYCRR 415.18(d)(e) (,d+[DATE])

Based on observations, interviews, and record reviews conducted during the Recertification Survey, the facility did not ensure the facility was 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. Specifically, the facility did not provide housekeeping or maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; did not ensure all allegations of resident abuse and injuries with unknown origin were thoroughly investigated; did not ensure that residents who required assistance with activities of daily living received the necessary services to maintain good grooming and personal hygiene; did not ensure that each resident received necessary behavioral health care and services; did not ensure all residents were free of significant medication errors; and the facility did not properly maintain all essential mechanical, electrical, and resident care equipment in safe operating condition. This is evidenced by the following: Refer to the following citations: F584: Safe/Clean/Comfortable/Homelike Environment F610: Investigate/Prevent/Correct Alleged Violations F677: Activities of Daily Living (ADL) Care Provided for Dependent Residents F740: Behavioral Health Services F760: Residents are Free of Significant Medication Errors F908: Essential Equipment, Safe Operating Condition Review of the Facility Assessment, dated 5/15/24, revealed the facility's average daily census was 120 residents. Information regarding the residents based on facility characteristics included Minimum Data Set Resident Assessment results from 1/20/23. Services and care offered by the facility included, but was not limited to, assistance with activities of daily living, management of medical conditions and medication-related issues causing psychiatric symptoms and behavior, the administration of medications that residents needed, and the prevention of abuse and neglect. The Assessment included the facility resources needed to provide competent support and care daily to its residents included, but were not limited to; Administration (e.g., Administrator, Environmental Services, and Social Services), behavioral, psychiatric, and mental health providers, and support staff (e.g., maintenance and housekeeping staff). The staffing plan to meet the needs for care and support of the residents did not include positions such as social work, maintenance staff, and housekeeping staff. Additionally, the Assessment did not include a process to ensure the adequate supply, appropriate maintenance, or the replacement of physical equipment and other physical plant needs. For five (1st, 2nd, 3rd, 4th, and 5th floors) of five occupied resident-use floors and one of one basement, the facility did not provide housekeeping or maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, hot water was not maintained above 90 degrees Fahrenheit ( F), floors, walls, and ceilings were dirty and/or in disrepair, bathrooms and shower rooms were dirty and in disrepair, ventilation exhaust in bathrooms, showers, and soiled utility rooms were not functioning resulting in foul odors, ice machines were dirty, ready stand lifts were dirty, plumbing fixtures were not maintained and/or working properly, there were ceiling plumbing leaks, overhead lights were not functional or functioning properly, light lenses and covers were missing, there were damaged electrical fixtures with exposed wiring, there was standing water on floors, and furniture and window blinds were in disrepair and dirty. During an interview on 5/31/24 at 10:45 AM, the Corporate Maintenance Director stated that for maintenance it was just themself, because one of the maintenance staff was out on medical leave and the other one left about two weeks ago. For six residents reviewed for allegations of resident abuse and injuries with unknown origin, the facility could not provide evidence that the allegations were thoroughly investigated. During an interview on 6/3/24 at 10:05 AM, the Corporate Infection Preventionist stated it was identified in either February or March 2024 that investigations were missing, likely due to changes in facility leadership. For three residents reviewed the facility did not ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene as related to nail care, shaving, bathing, hair washing and hair trimming. Resident #52 did not receive consistent psychiatric services, did not receive medication changes as recommended, and did not have a comprehensive care plan that included an individualized person-centered approach to address their behavioral health needs. During an interview on 6/4/24 at 9:57 AM, the Corporate Director of Resident Services stated that there had been a discrepancy with telepsychiatry visits as the telepsychiatry providers called and cancelled due to the facility not having clinical staff to sit with the residents during their appointments and issues with the providers not being made aware of the telepsychiatry recommendations. For four residents reviewed for medication administration, the facility did not ensure that the residents were free from significant medication errors as they related to omissions of significant medications being administered and incorrect doses of narcotic pain medication being administered. For five of five occupied resident-use floors and one of one basement the facility did not properly maintain all essential mechanical, electrical, and resident care equipment in safe operating condition. Specifically, laundry equipment, hot water boilers, a mechanical dish washing machine, patient care lifts, and ventilation systems were not maintained in working order. Observations on 5/31/24 at 11:12 AM included one of the three commercial dryers and a smaller residential style washing machine in the first-floor laundry room were not functional. During an interview at that time, a laundry staff member stated the middle dryer had not worked in about a year and the smaller residential style washing machine (used for resident personal clothing) had not worked in about three to four weeks. During an interview on 6/4/24 at 11:05 AM, the Corporate Director of Maintenance stated that they were not aware of any issues with the exhaust ventilation in the building. Observations in the presence of the corporate maintenance director at 11:16 AM included two exhaust motors on the roof were not functional. During an interview on 6/6/24 at 10:13 AM, with the Administrator and Director of Nursing, the Administrator stated they were aware of environmental concerns due to turnover and had been working to address the areas of concern and continued to recruit maintenance staff. The Administrator stated they were not aware of concerns related to investigations of alleged abuse and that the facility had a process in place that once an incident was reported the facility completed and documented a thorough investigation. The Director of Nursing stated there had previously been a backlog of investigations, however, the facility was now current in their investigations. The Director of Nursing stated there was an ongoing Quality Assurance and Performance Improvement initiative to ensure that activities of daily living (including nail care, hair care, and showers) were being maintained and documented. The Director of Nursing stated they were aware the facility had concerns related to medication errors. When an error was discovered, each case was investigated and staff were given the opportunity to improve their performance, and if no improvement was achieved, the staff member would be terminated. 10 NYCRR 415.26

Based on observations, interviews, and record review conducted during the Recertification Survey, it was determined that for five (1st, 2nd, 3rd, 4th, and 5th floors) of five resident use floors and one of one basement the facility did not properly maintain all essential mechanical, electrical, and resident care equipment in safe operating condition. Specifically, laundry equipment, hot water boilers, a mechanical dish washing machine, patient care lifts, an oxygen concentrator, and ventilation systems were not maintained in working order. The findings are: Observations during the initial tour of the facility on 5/28/24 from 9:52 AM to 2:30 PM included multiple exhaust vents in the ceilings were not drawing air out of the following rooms, which included, but were not limited to: the 3rd, 4th and 5th floor soiled utility rooms across from the nurse stations, bathroom in room [ROOM NUMBER], and the 2nd floor shower room near 218. There were significant urine and fecal odors noted throughout the facility on all five resident-use floors. Additionally, the main fire alarm annunciator panel behind the reception desk in the 1st floor lobby displayed several supervisory trouble signals related to the penthouse exhaust fans for toilets and lounges. In an interview on 5/28/24 at 9:47 AM resident #42 stated that it was difficult to breathe. It was observed at this time that an oxygen concentrator was running and set at 8-liters and was connected to resident #42 via tubing. The licensed practical nurse read the pulse oximetry of resident #42 at a concentration of 86% and stated that a lot of equipment does not work. The licensed practical nurse then and attached a mask to an oxygen cylinder for the resident and the pulse oximetry of resident #42 was observed to immediately increase to a concentration of 96%. Observations on 5/28/24 at 11:30 AM included two hoyer lifts in the 5th floor shower room (between the dining room and the nurse station) were marked with tags listing broken. There was no documentation to show that the lifts were taken out of service or were being repaired. During an interview on 5/31/24 at 10:45 AM, the regional maintenance director stated that currently two of the three hot water boilers are working and they are waiting on a circulating pump that has been ordered to fix the other one. Further observations included that the basement hot water boilers serve the entire facility. The regional maintenance director also stated that for maintenance it is just themself, because one of the maintenance staff is out on medical leave and the other one left about two weeks ago. Further record review at 2:52 PM revealed another maintenance technician was hired 5/2/24 and was terminated from employment 5/21/24. Observations on 5/31/24 at 11:12 AM included one of the three commercial dryers and a smaller residential style washing machine in the 1st floor laundry room were not functional. During an interview at this time, a laundry staff member stated that the middle dryer has not worked in about a year and the smaller residential style washing machine (used for resident personal clothing) has not worked in about three to four weeks. During an interview on 6/3/24 at 11:40 AM the Director of Dining Services stated that on Sunday 5/26/24 they reported no hot water to the New York State Department of Health. The Director of Dining Services also stated that they (the kitchen) had their own boiler, but something happened on Sunday, and they went to serving meals on paper because their boiler was being shared with the rest of the building and had to be turned down. The Director of Dining Services also stated that their dish machine was not getting hot enough to sanitize the dishes. During an interview on 6/4/24 at 11:05 AM the regional director of maintenance stated that they were not aware of any issues with the exhaust ventilation in the building. Observations in the presence of the regional maintenance director at 11:16 AM included two exhaust motors on the roof were not functional. 10NYCRR: 415.29, 415.29(b), 415.29(f)(3), 415.29(h), 415.29(j)(1), 415.29(k)(9)

47641 47642 Based on observations, interviews, and record review conducted during a Recertification Survey and Complaint Investigations (NY318393, NY00323935, NY00328756, and NY00343607) for three (Residents #52, #76, #87) of nine residents reviewed the facility did not ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene. Specifically, Resident #52 was not provided with the assistance to obtain a haircut, Resident #76 was observed with uncut nails and unshaven facial hair and Resident #87 had oily and unwashed hair. This is evidenced by the following: The facility policy Supporting Activities of Daily Living dated March 2018, documented that residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out Activities of Daily Living and the date and time of fingernail care, shaving and hair shampooing should be documented in the resident's medical record. 1. Resident #87 had diagnoses including Lewy body dementia (a type of dementia characterized by changes in sleep, behavior, and movement), chronic obstructive pulmonary disease (a chronic inflammatory lung disease), and major depressive disorder (a mood disorder characterized by a persistent feeling of sadness). The Minimum Data Set Resident assessment dated [DATE] documented that Resident #87 was severely impaired cognitively and required assistance with personal hygiene. Review of the current Comprehensive Care Plan and Kardex (care plan used for Certified Nursing Assistants for daily care) revealed Resident #87 required extensive assistance of staff with showering and personal hygiene. During an interview on 5/28/24 at 1:30 PM Resident #87 and a visitor stated that the resident had only had a few showers since they had been admitted (approximately six months) and wished they could have their hair washed in the shower (versus a no water cap that staff had been using). Resident #87 stated staff wipe them down (with a cloth) for washing but that they would really like a shower. During an interview on 6/5/24 at 11:56 AM Certified Nursing Assistant #5 stated that residents received hair washing on their shower day (weekly) which they documented (in the computer) and if a resident refused care, they documented the refusal and informed the nurse. During an observation on 6/6/24 at 9:30 AM, Resident #87 was observed in the dining room and their hair appeared stringy, oily, and unwashed (despite the previous day being the resident's assigned shower day). Review of Resident #87's electronic health record revealed no documented evidence that the resident had received any showers for the previous thirty days and no documented evidence of refusals. During an interview on 6/6/24 at 8:33 AM, Licensed Practical Nurse #3 stated that washing hair was usually done with residents' showers but sometimes there were not enough staff, and that the water (hot) temperature has been an issue. During an interview on 6/6/24 at 9:05 AM, Certified Nursing Assistant #6 stated Resident #87 did not like their hair greasy. 2. Resident #76 had diagnoses of Alzheimer's disease, legal blindness, and hypertension. The Minimum Data Set Resident assessment dated [DATE], revealed Resident #76 was severely impaired of cognitive function. Review of the current Comprehensive Care Plan and Kardex revealed Resident #76 required the assistance of staff to complete personal hygiene and nail trimming and required verbal cues and encouragement to complete the tasks. In an observation on 5/28/24 at 9:17 AM, Resident #76 had long nails and several days growth of facial hair. Resident #76 stated at the time that they needed to be shaved. During an observation and interview on 5/30/24 at 11:13 AM, Resident #76 was in the dining room and remained unshaven and with long nails. Resident #76 stated they were not growing out their beard and needed to shave but needed somebody to do it. During observations on 5/31/24 at 4:37 PM, 6/2/24 at 5:19 PM, 6/3/24 at 12:11 PM, and 6/4/24 at 2:21 PM, Resident #76 continued to be unshaven and had long nails. Review of the May 2024 Treatment Administration Record revealed that showers were scheduled for Resident #76 weekly on Monday evenings. There was one shower documented for the month of May on 5/27/24. During an interview on 6/5/24 at 11:56 AM, Certified Nursing Assistant #5 stated that on shower days resident's nails should be cut and facial hair shaved, and this should be documented in the computer when provided or if a resident refused. Certified Nursing Assistant #5 they were a float from another unit and the surveyor would have to ask a unit Certified Nursing Assistant why it had not been completed for Resident #76. During an observation and interview on 6/6/24 at 10:55 AM, Registered Nurse Manager #1 stated the nurses have a section in the electronic health record to document showers and should document if refused. Registered Nurse Manager #1 said that shaving should be offered on shower days and that Resident #76 should have been assisted with shaving. When observed Resident #76 remained with facial hair and several jagged nails. Registered Nurse Manager #1 asked Resident #76 if they wanted a shave and Resident #76 stated yes. 3. Resident #52 had diagnoses that included ankylosing spondylitis (a rare type of autoimmune disease that causes arthritis in your spine), hypertension, and schizoaffective disorder (a mental health condition). The Minimum Data Set Resident assessment dated [DATE], revealed that Resident #52 was cognitively intact and was dependent upon staff for grooming and personal hygiene. Review of the current Comprehensive Care Plan and Kardex revealed Resident #52 required set-up help for personal hygiene. During an observation and interview on 5/28/24 at 12:20 PM, Resident #52 was in bed. Their hair touched their shoulder. Resident #52 stated they have wanted a haircut for awhile but there was no stylist in the facility and added that their family was trying to get them a haircut for their birthday. During an interview on 6/6/24 at 8:59 AM, the Activities Director stated that the last barber had left the facility over a month ago and the facility has not hired anyone yet. The Activities Director stated that they do not keep a list of requests for haircuts and had not been aware that Resident #52 wanted a haircut. 10 NYCRR 415.12(a)(3)

Based on record review and interviews conducted during the Recertification Survey and Complaint Investigation (NY00327022), for three (Residents #90, #116, #371) of four residents reviewed the facility did not ensure that notification of a discharge/transfer was provided to the resident and/or the resident's representative in writing, and in a language and manner they understood, as soon as possible when an immediate discharge/transfer was required by the resident's urgent medical needs. Additionally, the facility did not ensure a copy of the notice was sent to a representative of the Office of the State Long-Term Care Ombudsman. This is evidenced by the following: Review of the facility policy, Transfer or Discharge Notice, dated March 2021 revealed that residents and/or representatives would be notified in writing, and in a language and format they understood as soon as possible but before the transfer or discharge, when an immediate transfer or discharge was required by the resident's urgent medical needs. The policy included that a copy of the notice would be sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge was provided to the resident and representative. 1. Resident #371 had diagnoses including adult failure to thrive, spinal stenosis, and chronic kidney disease. The Minimum Data Set Resident assessment dated [DATE] revealed the resident was cognitively intact. In a medical team note, dated 3/21/24 Nurse Practitioner #2 documented that Resident #371 had a change in symptoms, difficulty swallowing, and required transfer to the emergency department. Review of Resident #371's electronic health record did not include any documentation that a written notice of the transfer had been provided to the resident and/or their representative. 2. Resident #90 had diagnoses including seizure disorder, dysphagia (difficulty swallowing), and dementia. The Minimum Data Set Resident assessment dated [DATE] revealed the resident had severe cognitive impairment. In a nursing progress note, dated 8/27/24 Licensed Practical Nurse #4 stated that Resident #90 was transferred to the hospital at approximately 4:40 PM to get their Percutaneous Endoscopic Gastrostomy (PEG) (a tube inserted directly into the stomach to provide nutrition for residents with swallowing difficulties) fixed. Review of Resident #90 electronic health record did not include any documentation that a written notice of transfer had been provided to the resident and/or their representative. 3. Resident #116 had diagnoses including chronic obstructive pulmonary disease (lung disease that makes it difficult to breathe), congestive heart failure, diabetes. A mental status interview, dated 3/18/24, revealed the resident was cognitively intact. In a nursing progress note, dated 3/19/24 Licensed Practical Nurse #8 documented that Resident #116 was transferred to the hospital by Emergency Medical Services and the family was to be notified. Review of Resident #116 electronic health record did not include any evidence that a written notice of transfer had been provided to the resident and/or their representative. The facility was unable to provide any documented evidence that a written notice of the transfers, to include the specific reason for the transfer, the date of the transfer, and the location of the transfer had been provided to any of the residents or their representatives. Additionally, the facility was unable to provide any documentation that the Office of the State Long Term Care Ombudsman office had been notified of the transfers per the regulations. During an interview on 6/5/24 at 11:39 AM, Registered Nurse Manager #3 stated when residents are transferred to the hospital nursing staff should complete an electronic alert that notifies all departments that a resident was being transferred and contact the family. Registered Nurse Manager #3 stated transfer notices were completed by the Receptionist or the Nursing Supervisor. During an interview on 6/5/24 at 11:58 AM, the Business Office Representative stated they did not have a role in the resident transfer or discharge process and did not provide any written notices to the resident, the resident representative, or the Ombudsman. During an interview on 6/5/24 at 12:12 PM, the Reception Supervisor stated nursing staff notified the Receptionist why a resident was being sent out and to where. Then the Receptionist would print the relevant medical documentation, complete an electronic alert that notified all departments that a resident was being transferred, and send an email to the Admission/Discharge team. When a resident was transferred during an off shift (i.e., night shift) the Nursing Supervisor was responsible for completing the process. The Reception Supervisor stated they were not involved in notifying the Ombudsman of any resident transfers or discharges and was not sure who was responsible. During an interview on 6/5/24 at 1:42 PM and again at 1:57 PM, the Director of Nursing stated the Business Office was responsible for completing notifications and providing the written notice to the resident and their representative when a resident was transferred to the hospital. The Director of Nursing later stated the Ombudsman's Office was notified of resident transfers and discharges once monthly via fax. Documentation for the notification of the Ombudsman was requested at this time. During an interview on 6/6/24 at 11:37 AM, Registered Nurse Manager #2 stated, on behalf of the Director of Nursing, the facility was unable to provide any documentation that notifications of transfers and discharges had been provided to the Ombudsman due to the inability to access the previous Social Worker's files. 10 NYCRR 415.3(i)(1)(iv)(a-e) 46880 49368

Based on interviews, and record reviews conducted during the Recertification Survey and Complaint Investigation (NY00318393) completed on [DATE], for four of five residents reviewed for advanced directives, the facility did not ensure that there was an organized system to ensure that resident wishes regarding Cardiopulmonary Resuscitation (CPR) and Do Not Resuscitate (DNR - do not initiate Cardiopulmonary Resuscitation in the event of acute cardiac or respiatory event) were followed. Specifically, Residents #22, #29, and #59 had discrepancies in their code status as identified on facility forms. Additionally, Resident #115 gave verbal consent on their Medical Orders for Life Sustaining Treatment (known as a MOLST) for Full Code (initiate Cardiopulmonary Resuscitation for acute cardiac and/or respiratory event) that was not signed by two witnesses. This is evidenced by, but not limited to the following: The facility policy Advanced Directives, revised [DATE], documented the resident's wishes are communicated to direct care staff and the physician by placing the advance directive documents in a prominent, accessible location in the medical record and discussing the resident's wishes in care planning meetings. The plan of care for each resident is consistent with his or her documented treatment preferences and/or advance directive. The interdisciplinary team will review annually with the resident, his or her advance directives to ensure that such directives are still the wishes of the resident. Such reviews will be made during the annual assessment process and recorded in the medical record. 1. Resident #59 had diagnosis including heart failure, wound infection, and diabetes. The Minimum Data Set Resident assessment dated [DATE] noted Resident #59 was cognitively intact. Current Physician orders for Resident #59 did not include any orders for the resident's wishes for advanced directives. Review of Resident #59's Medical Orders for Life Sustaining Treatment form dated [DATE] and signed by Nurse Practitioner #2 revealed the resident's wishes as Do Not Resuscitate (allow natural death). Review of Nurse Practitioner #2's notes on [DATE], [DATE], and [DATE] revealed Resident #59's code status was documented as Full Code. During an interview on [DATE] at 10:45 AM Nurse Practitioner #2 stated they were now aware that Resident #59 wishes were for Do Not Resuscitate and that their notes indicated the resident's wishes for Full Code. Nurse Practitioner #2 stated that because there were no medical orders for advanced directives it was presumed the resident was a Full Code. Nurse Practitioner #2 stated they had notified the previous Social Worker of the discrepancy and Resident #59 would be medically documented as a Full Code until the Medical Orders for Life Sustaining Treatment form was completed. Nurse Practitioner #2 stated they were not aware of the Medical Orders for Life Sustaining Treatment form from [DATE]. 2. Resident #22 had diagnoses that included heart failure, hypertension, and chronic obstructive pulmonary disease. The Minimum Data Set Resident assessment dated [DATE], documented the resident was cognitively intact. Review of Resident #22's Comprehensive Care Plan dated [DATE], documented the resident's wishes were Do Not Resuscitate. Resident #22's Medical Orders for Life-Sustaining Treatment dated [DATE] and signed by the resident and witnessed by a Registered Nurse and a family member documented Resident #22's wishes were for Cardiopulmonary Resuscitation. Review of interdisciplinary progress notes since admission revealed in multiple medical and nursing notes that Resident #22 was alert and oriented and able to make their needs known. During an interview on [DATE] at 1:33 PM, Licensed Practical Nurse Manager #1 stated they were made aware that day that Resident #22's care plan did not match their Medical Orders for Life-Sustaining Treatment form. Licensed Practical Nurse Manager #1 stated they were unaware that advanced directives were also in the Comprehensive Care Plan. In an interview on [DATE] at 2:31 PM, the Director of Nursing stated the Social Worker and nursing were responsible for advanced directives. The Director of Nursing stated that nursing should get the physician's orders and input it in the electronic health record and that the Social Worker should take care of the paperwork portion. The Director of Nursing stated that if a Medical Orders for Life-Sustaining Treatment form was changed then the order should be updated the same day. 3. Resident #29 had diagnoses that included depression, schizophrenia, and hypertension. The Minimum Data Set Resident assessment dated [DATE], included that Resident #29 was severely impaired cognitively and advanced directive wishes included Do Not Resuscitate. Review of Resident #29's Medical Orders for Life-Sustaining Treatment form dated [DATE] and signed by the resident revealed their wishes as Do Not Resuscitate. Additionally, Section F, which noted that a physician must review the form from time to time, did not include documentation that Resident #29's Medical Orders for Life-Sustaining Treatment had been reviewed by a medical provider since [DATE]. Current Physician orders included Do Not Resuscitate. In medical progress notes dated [DATE], [DATE] and [DATE] Nurse Practitioner #2 documented that Resident #29's code status as Full Code. Review of medical progress notes for approximately the previous three months revealed no documentation that the medical team had reviewed the resident's code status with the resident or their representative. During an interview on [DATE] at 10:23 AM, Nurse Practitioner #2 said when a resident is admitted to the facility, the Social Worker reviews the resident's code status with them (or their representative) and completes a Medical Orders for Life-Sustaining Treatment form. The form is then placed in a book for the medical provider to review. Nurse Practitioner #2 said a resident's code status is reviewed during care planning meeting or if it is requested and if there is a concern such as the resident's health is declining. Nurse Practitioner #2 stated they (medical team) are not involved in care plan meetings unless specifically asked. Nurse Practitioner #2 said residents' code status (Medical Orders for Life-Sustaining Treatment forms) are not reviewed by a medical provider with the resident or representative at regular intervals. Nurse Practitioner #2 said they would document a resident's code status in their visit note and did not know if Section F of the Medical Orders for Life-Sustaining Treatment forms are signed when reviewed or who was responsible for documenting that a resident's code status was reviewed. Nurse Practitioner #2 said Resident #29 was their patient and that the resident's code status was Do Not Resuscitate. When reviewed at this time and the code status discrepancies, Nurse Practitioner #2 said they use a program to dictate their visit notes and unless they specifically say a resident's code status, it automatically defaults to Full Code. 10 NYCRR 415.3(f)(1)(ii) 46880 47641 49368

Based on interviews and record reviews conducted during the Recertification Survey and Complaint Investigation (NY00326620), the facility did not ensure each resident was free from misappropriation of resident property and exploitation for two (Residents #28, #57) of four residents reviewed for missing property and for three (Residents #59, #99, and #108) residents interviewed during Resident Council. Specifically, the residents reported missing money, clothing, and personal items and the facility was unable to provide documentation that the missing property complaints had been investigated and/or any resolutions offered for the missing property. This is evidenced by the following: The facility policy Personal Property with a revised date of August 2022, documented the facility promptly investigates any complaints of misappropriation or mistreatment of resident property. The facility policy Lost and Found, dated of January 2008, documented the facility shall assist all personnel and residents in safeguarding their personal property. Resident or family complaints of missing items must be reported to the Director of Nursing, lost and found records will be maintained for one year, then destroyed and reports of misappropriation or mistreatment of resident property are immediately investigated. During Resident Council meeting on 5/30/24 at 10:30 AM several residents reported that they were missing personal items and that the facility had not provided any resolutions. Resident #59 stated they were missing an electric razor, and their cell phone was stolen approximately 6 months ago. Resident #99 stated they have had several items missing and have been asking staff about them for a long time. Resident #108 stated they were missing a cell phone charger and has had no follow-up. When requested the facility was unable to provide documentation regarding any resident's missing property and/or any resolutions for the past year. 1. Resident #28 had diagnosis including dementia, diabetes, and heart failure. The Minimum Data Set Resident assessment dated [DATE] included that Resident #28 was cognitively intact. During an interview on 5/31/24 at 12:34 PM Resident #28's Representative stated they label the resident's clothes, but they still get lost, and that the resident was missing three new tops, four pairs of shorts, and twenty bras within the last year. The Representative stated that they have told staff at the facility, filled out missing item reports, and gone to the laundry room themselves to look. 2. Resident #57 had diagnoses including, chronic kidney disease dependence on dialysis and diabetes. The Minimum Data Set Resident assessment dated [DATE] included that the resident was moderately cognitively impaired. In an interview on 6/4/24 at 10:54 AM Resident #57 stated that they were missing two sweaters, three dress shirts, the padding for their wheelchair, and a blanket. Resident #57 stated that they were also missing $60 a few months ago and the facility did not do anything about it. Resident #57 stated that they reported the missing items to several staff, but no paperwork had been filled out. During an interview on 5/31/24 at 9:44 AM Laundry Aide #1 stated unlabeled clothing should be put in a cart and sent downstairs. If a resident reported missing something they would go to the basement to look for the specific item and if unable to locate it, they would notify the supervisor. During an interview on 6/5/24 at 1:33 PM Licensed Practical Nurse Manager #1 stated that they were informed that day that Resident #57 was missing their wheelchair pillow but were not aware of the other items. Licensed Practical Nurse Manager #1 stated that they email everyone when there is a missing item reported and let staff and other nurse managers know to keep an eye out and to follow up on it. Licensed Practical Nurse Manager #1 stated that the Social Worker should get notified by email and start the paperwork and take care of the issue from there. In an interview on 6/5/24 at 2:31 PM the Director of Nursing stated they would expect staff to look for and report off any missing item and report it to the Social Worker and themselves. If the item was not found, then the item would be replaced. The Director of Nursing stated that they are usually involved with grievance forms and was not aware of Resident #57 missing any items. The facility Social Worker was not available for interview. 10 NYCRR 415.4(b)

Based on Observations, interviews and record review conducted during a Recertification Survey, the facility did not ensure that residents with limited range of motion received appropriate treatment, equipment, and services to increase range of motion and/or to prevent further decrease in range of motion for two (Resident #37 and #90) of two residents reviewed. Specifically, the residents were observed on multiple occasions not wearing their therapy recommended hand splints. This is evidenced by the following: 1. Resident #37 has diagnoses including dementia, malnutrition, and contractures (permanent tightening of the muscles and tendons causing joint stiffness and pain and loss of function). The Minimum Data Set Resident assessment dated [DATE] documented that the resident was moderately impaired of cognitive function and had no impairment in range of motion to their upper extremities (shoulder, elbow, wrist and hands). Review of Resident #37's current Comprehensive Care Plan and Kardex (care plan used by Certified Nursing Assistants for daily care) revealed the resident has contractures and required assist to don (put on) resting hand splints in the morning and doff (remove) at night. Review of an Occupational Therapy Discharge Summary dated 4/29/24 revealed a goal that the resident will tolerate having resting hand splints (one at a given time) to decrease pain and minimize contractures in both hands 100% of the time. The goal was identified as met on 4/29/24. During observations on 5/28/24 at 9:34 AM, 5/30/24 at 11:59 AM, on 6/4/24 at 11:57 AM and again at 3:38 PM Resident #37 was not wearing either hand splint which was observed on their bedside table and one on the floor. On 5/30/24 at 11:59 AM a sign was observed above the resident's bed that included directions to staff to don a splint in the morning and doff at night. In a medical progress note dated 5/6/24 Nurse Practitioner #1 documented that Resident #37 had pain in their hands and wrists due to joint stiffness. In an Occupational Therapy Progress notes dated January 2024 through April 2024 therapists documented that the residents hand splints are applied intermittently. During an interview on 6/4/24 at 12:30 PM Licensed Practical Nurse #2 stated that Resident #37 gets hand splints for straightening due to contractures and that therapy comes up and puts them on and if staff see them off, they will apply them. During an interview on 6/5/24 at approximately 9:30 AM the Certified Occupational Therapist Assistant #1 stated they trained the Certified Nursing Assistants, nurses, and the Nurse Managers on the floor to apply the splints once the residents are discharged from therapy. Certified Occupational Therapist Assistant #1 stated Resident #37 was discharged from therapy 4/29/24 with two hand splints and should have them applied in the morning and removed at night to prevent contractures and increased pain. In an interview on 6/5/24 at 10:12 AM Occupational Therapist #1 stated Resident #37 should have a right- and left-hand splint and a schedule to have one splint on at a time so the resident can have one hand free and to provide stretching. When applied at this time to the resident's left hand, Resident #37 stated the pain was less. In an interview on 6/6/24 at 8:59 AM Certified Nursing Assistant #4 stated Resident #37 has a left-hand splint that is supposed to go on in the morning and off at night and that they put it on when the resident asks and takes it off when the resident asks. 2. Resident #90 had diagnoses including a dementia, seizures, and a stroke. The Minimum Data Set Resident assessment dated [DATE] documented that the resident was severely impaired cognitively and had functional limitation in range of motion to the upper extremity on one side. Review of Resident #90's current Kardex revealed that the resident had a left resting hand splint with finger separators, to don in the morning and doff at night during care. Review of an Occupational Therapy Discharge summary dated 3/28/24 revealed a goal that the resident would follow a splint schedule 100% of the time with a comment that therapy will don the splint during therapy but that staff on the floor are non-compliant with donning the splint despite visual reminders in the resident care plan and in their room. The summary included that prognosis to maintain level of function was good with consistent staff follow-through. In a therapy progress note Certified Occupational Therapist Assistant #1 documented that the Nurse Manger was educated on how to don and doff the resident's hand splint. In observations on 5/28/24 at 12:29 PM, Resident #90 was up and dressed and in the hallway. There was no splint on either hand. During observations on 5/31/24 at 12:17 PM (splint observed on nightstand), on 6/3/24 at 4:07 PM and on 6/4/24 at 10:29 AM and again at 12:12 PM Resident #90 was not wearing their hand splint. A sign in the resident's room included a splint schedule and directions for placement of the splint with photo. During an interview on 6/4/24 at 12:15 PM CNA #2 stated that they forgot to put Resident #90's hand splint on. CNA #2 stated they did not have Resident #90 the previous days so did not know why the resident had not been wearing their hand splint. During an interview on 6/4/24 at 10:40 AM Occupational Therapist #1 stated Resident #90 has had contractures for a while and that in using the splints, they are trying to maintain the resident's level (of function). After they are discharged from therapy, the Certified Nursing Assistants are responsible for applying the splint. Occupational Therapist #1 stated that staff were educated (on applying the splint) in May and that Resident #90 does not refuse to wear the splint that they knew of. Occupational Therapist #1 said that the resident's current pain could be from lack of stretching due to not wearing the splint. During an interview on 6/7/24 at 1:38 PM the Director of Nursing stated that the residents care plan should be followed and if a resident refuses, this should be documented. 10 NYCRR 415.12(e)(2) 49368

Based on observations, record review, and interview conducted during the Recertification Survey, it was determined that the facility did not ensure compliance with all applicable State codes. Specifically, the facility was not in compliance with section 915 of the 2015 edition of the International Fire Code as adopted by New York State, which requires the use of carbon monoxide detection in a building that has fuel-burning appliances. The findings are: On 5/30/24 at 10:00AM, records for inspection and testing of facility carbon monoxide detectors were provided to the surveyor for review. The logs included a monthly signoff and listing of the locations of carbon monoxide detectors in the following areas: boiler room, kitchen, generator, and laundry. Observations on 5/31/24 from 11:10 AM to 11:24 AM included carbon monoxide detectors were not present in the first-floor laundry room and kitchen. Further observations at this time included three natural gas-powered dryers were in the laundry room and a natural gas range was present in the kitchen. During an interview at this time, a laundry employee stated that they did not know if they had carbon monoxide detectors in the laundry room. In another interview at this time in the main kitchen, the Assistant Food Service Director pointed at the wall and stated that there was one (a carbon monoxide detector) but it is not where it should be. The 2015 edition of the International Fire Code (IFC), requires carbon monoxide detection to be provided in an approved location between the fuel burning appliance and the dwelling unit, sleeping unit, or classroom; or on the ceiling of the room containing the fuel-burning appliance. 10NYCRR: 415.29(a)(2), 711.2(a)(1); 42 CFR: 483.70(b), 2015 IFC: Section 915, 915.1, 915.1.4, 915.3

Based on observations, interviews and record reviews conducted during the Recertification Survey the facility did not ensure the resident received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one (Resident #52) of one resident reviewed. Specifically, Resident #52 did not receive medication changes as recommended, did not have a comprehensive care plan that included an individualized person-centered approach to address their behavioral health needs, and did not receive consistent psychiatric services. This is evidenced by the following: The facility policy Behavioral Health Services, dated March 2019, included the facility will provide and the residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress, and potential safety risk to the resident and develop a plan of care accordingly. Interventions will be individualized and part of an overall care environment that supports physical, functional, and psychosocial needs, and strives to understand, prevent, or relive the resident's distress or loss of abilities. The facility policy Psychiatric Consultation dated 2/2/24, included the facility will have an established process to ensure residents receive appropriate psychiatric evaluation, treatment, and follow-up services when clinically indicated. Residents receiving psychiatric treatment will have their care plans updated to reflect the associated interventions, monitoring parameters and responsible disciplines. Resident #52 has diagnoses including schizoaffective disorder (a mental health condition), major depressive disorder with psychotic features, visual hallucinations, anxiety disorder, and insomnia. The Minimum Data Set Resident Assessment, dated 4/19/24, revealed the resident was cognitively intact, had moderate depression and was dependent on a wheelchair for mobility. During an interview on 5/28/24 at 11:59 AM Resident #52 stated that their motorized wheelchair was damaged in a flood from the floor above months before and was still not fixed. Resident #52 stated they would prefer to use their own wheelchair (versus a non-motorized one) due to increased pain. Physician orders dated 6/4/24 included Ambien (medication used to treat insomnia) at hour of sleep, lorazepam (antianxiety) three times daily, mirtazapine (antidepressant) at night, Seroquel (antipsychotic) at noon and at hour of sleep. Resident #52's Comprehensive Care Plan last revised on 4/17/24, included the resident had schizoaffective disorder, personality disorder, anxiety, visual and auditory hallucinations, and at times digs at their legs and arms. The interventions including to administer medications per order and to continue to see telepsychiatry for medication management. The Comprehensive Care Plan did not include person-centered interventions to address the identified issues. A Department of Telepsychiatry progress note dated 9/14/23, included recommendation to increase the Seroquel by adding 25 milligrams at noon and to continue 50 milligrams in the morning and 400 milligrams at hour of sleep and to follow-up in two months. Review of Physician orders history revealed that the noon dose of Seroquel 50 milligrams had not been added until 11/2/23 and the morning dose of Seroquel 50 milligrams had been discontinued on 11/8/23 with no explanations as to why the orders differed from the psychiatry recommendations. Review of a purchase order dated 1/25/24 for an evaluation of the resident's power wheelchair revealed a quote from a surgical supply company dated 2/5/24 for the repairs needed for Resident #52's power wheelchair. There was no mention when the power wheelchair would be repaired or if the quote had been accepted. The facility was unable to provide any evidence when the resident could expect their power wheelchair to be repaired and returned to them. In a Department of Telepsychiatry progress note dated 2/7/24 Psychiatric Nurse Practitioner #1 documented that this was the first routine follow-up since 9/14/23 (despite the recommendation for a two month follow up). Psychiatric Nurse Practitioner#1 documented that the recommended medication changes from 9/14/23 had not been made, that Seroquel 50 milligrams in the morning and olanzapine (an antipsychotic medication that the resident was on at the time) had been discontinued with reason unknown. Psychiatric Nurse Practitioner #1 documented they would not recommend any dose reductions of the resident's other psychotropic medications (medications used to treat mental illness) given significant potential for decompensation due to the resident's chronic mental illness. Psychiatric Nurse Practitioner #1 documented that Resident #52 continued to be reclusive in their room as their power wheelchair remained broken and that they reported fluctuation in their tactile, auditory, and visual hallucinations which triggered their anxiety. Recommendations included to increase the Seroquel to 50 milligrams in the morning, 50 milligrams at noon, and 400 milligrams at bedtime and within 10 to 14 days after increasing the Seroquel increase the mirtazapine to 22.5 milligrams at hour of sleep and to follow-up in 4-6 weeks. In a Department of Telepsychiatry progress dated 3/6/24 Psychiatric Nurse Practitioner #1 documented that the recommendations for medication changes made on 2/7/24 had not been implemented. Psychiatric Nurse Practitioner #1 documented Resident #52 continued to report ongoing anxiety, depression, and frustration with the disorganization of their care and the new onset of temporomandibular joint dysfunction (pain and compromised movement of the jaw joint and surrounding muscles). Psychiatrist Nurse Practitioner #1 documented that they had contacted Nurse Practitioner #1 (facility medical team) who had indicated that they had not received the psychiatrist's notes with the recommendations, that they were agreeable to instituting the medication changes as noted and a plan to follow up in four to six weeks. Review of a wound care note dated 3/26/24 revealed that Resident #52 had several wounds of varying sizes and depths in an area measuring 15 centimeters by 10 centimeters on their left lower leg and was reported by the resident that they dig and scratch due to their psychiatric condition. During an interview with Resident #52 on 5/28/24 at 12:19 PM, they stated that they had not seen telepsychiatry since 3/6/24 because the last two appointments on 4/2/24 and 5/17/24 had been missed due to not having the computer access required to meet with Telepsychiatry. Resident #52 stated that since their last appointment they have had two episodes of scratching themselves and that receiving psychotherapy services helped them a lot as they were able to create new coping skills for managing the hallucinations and the pain. When interviewed on 6/4/24 at 9:57 AM, the Corporate Director of Resident Services (acting Social Worker) stated that there had been a discrepancy with telepsychiatry visits as last week the telepsychiatry providers called and cancelled due to the facility not having clinical staff to sit with the residents during their appointments. The Corporate Director of Resident Services stated that the telepsychiatry providers are refusing to see residents without a clinical staff present due to the recommendations not being followed and the facility medical providers reporting that were not made aware of the recommendations. When asked about the repair of Resident #52's power wheelchair, the Corporate Director of Resident Services stated that the facility should have the power wheelchair fixed as it was due to a facility incident that it is inoperable. During an interview on 6/4/24 at 12:40 PM Registered Nurse Manager #3 stated the Social Worker sets up all telepsychiatry appointments and if there are recommendations they should be sent to their mailbox and then they review them, initial them, and make Nurse Practitioner #1 aware. Registered Nurse Manager #3 stated Nurse Practitioner #1 would make any medication changes themselves as they input their own orders into the electronic medical record. During an interview on 6/4/24 at 1:02 PM and on 6/6/24 at 10:25 AM Resident #52 stated they recalled speaking with telepsychiatry about increasing their Seroquel to help with the hallucinations but was not aware that the Seroquel dose had not been increased but that they had not noticed any improvements in the hallucinations either. Resident #52 stated they used to get out of bed more often when they had their power wheelchair and would use it a lot more if they had it. Resident #52 said that they also used to receive psychotherapy (group therapy or talk therapy) but have not received any since last year and has not been offered any since then. Resident #53 said that the facility staff do not keep them informed of medication changes and that what they are taking for depression is not working and does not feel that the facility is meeting their psychiatric needs. When interviewed via telephone on 6/6/24 at 9:35 AM, Nurse Practitioner #1 stated that they do not change psychiatric medications without being told to and that they do not review the telepsychiatry notes and knew nothing about the recommendations for Resident #52 until this week. During an interview on 6/6/24 at 11:11 AM, Nurse Manager #3 stated that Resident #52's care plan is not individualized to meet the residents needs. When interviewed on 6/6/24 at 10:15 AM, the Administrator (with Director of Nursing present) stated that the previous Social Worker had left employment without providing any notice and the regional Social Worker was providing services until a replacement is found. 10 NYCRR 415.12 47642

Based on observations, interviews, and record review conducted during the Recertification Survey and Complaint Investigation (NY00318393) it was determined that for one (Resident #52) of one resident reviewed, the facility did ensure the resident's pain was managed to the extent possible in accordance with the comprehensive assessment and plan of care, current professional standards of practice and the resident's goals and preferences. Specifically, Resident #52's pain medication was not administered as ordered on multiple occasions without Physician notification and the resident did not have a comprehensive care plan for chronic pain that included measurable goals and person centered interventions. This is evidenced by the following: The facility policy Pain - Clinical Protocol dated March 2018, included that with input from the resident to the extent possible, the physician and staff will establish goals of pain treatment. The physician will order appropriate non-pharmacological and medication interventions to address the individual's pain. Resident #52 had diagnoses including ankylosing spondylitis (an inflammatory disease that can cause some of the bones in the spine to fuse), complex regional pain of left lower limb, cervicalgia (neck pain), arthropathic psoriasis (a form of arthritis), temporomandibular joint dysfunction (pain and compromised movement of the jaw joint and surrounding muscles), and schizoaffective disorder (a mental health condition) with hallucinations. The Minimum Data Set Resident assessment dated [DATE], revealed the resident was cognitively intact and had pain that was rated as 9 out of 10 almost constantly making it hard for them to sleep at night, limited their participation in rehabilitation therapy sessions, and limited their day-to-day activities. Resident #52's Comprehensive Care Plan last revised on 4/17/24 included the resident takes pain medication due to history of chronic pain with interventions to monitor for effectiveness of pain medication and document adverse reactions. The care plan did not include person centered goals or any non-pharmacolgical person centered interventions. During an interview on 5/28/24 at 12:11 PM Resident #52 stated they were in alot of pain both in their back and their legs. The resident was observed in bed on multiple occasions throughout the day shift. Current Physician orders included Tylenol twice daily and as needed at night for jaw pain, Lyrica (pain medication) twice daily for neuropathy (nerve damage outside the brain and spinal cord that causes pain or numbness), and oxycodone (narcotic pain reliever) three times daily for pain. Review of the Medication Administration Records for April 2024 and May 2024 revealed that on 4/21/24 there was no documented evidence that Resident #52 had received their morning prescribed doses of Tylenol or oxycodone and on 5/29/24 there was no documented evidence that the resident received their evening prescribed doses of Lyrica and oxycodone. Review of the June 2024 Medication Administration Records along with the Control Substance Count (narcotic) sheets for Resident #52's oxycodone revealed the following: - On 6/2/24 the records documented that Resident #52 received less than the prescribed dose in the [NAME] and more than the prescribed dose for the afternoon and evening doses. There was no documentation that any of the oxycodone had been wasted. - On 6/3/24 at 6:00 AM the records documented that Resident #52 received more than the prescribed dose. There was no documentation that any of the oxycodone had been wasted. There is no documentation of any oxycodone being removed at the 12:00 PM or 5:00 PM scheduled times. When interviewed on 6/4/24 at 1:02 PM and again on 6/6/24 at 10:31 AM Resident #52 stated that recently they were unable to receive their Lyrica medication (unavailable) and only received a partial dose of their oxycodone which caused them to have an increase in pain which caused an increase in their hallucinations. Resident #52 stated that they had pain in their back described as throbbing and sometimes stabbing, had bursitis (painful swelling in the joints) in both hips, neuropathy (nerve pain) of their left leg and foot, neck pain and recently they developed jaw pain. Resident #52 stated that the prescribed medications do help reduce the pain from a 9 to a 5 or 6 out of 10. The resident said staff do not offer them anything such as ice or heat therapy or any topical medications and that they used to get patches for their hips that helped but thought they were too expensive. During a telephone interview on 6/6/24 at 9:45 AM, Nurse Practitioner #1 stated if Resident #52 does not receive the correct dose or missed a dose of their pain medication, it could cause increased pain and anxiety for the resident. When interviewed on 6/6/24 at 11:11AM, Registered Nurse Manager #3 stated that the resident's care plan for pain was not individualized and knew from experience that Resident #52 had said nothing helps their pain and they were just looking for more pain medication. 10 NYCRR 415.12

Based on observations, interviews, and record review conducted during the Recertification Survey and Complaint Investigations (NY00315983, NY00318393), for one (Resident #42) of two residents reviewed for respiratory care, the facility did not ensure residents who needed respiratory care were provided such care consistent with professional standards of practice. Specifically, Resident #42 did not have a physician order in place for oxygen use, did not have a person-centered comprehensive care plan for oxygen, and was not provided a clean well-functioning oxygen concentrator. This is evidenced by the following: The facility policy, Oxygen Administration, dated October 2010 included to verify there was a physician's order, review the residen's care plan to assess for any special needs, check equipment to be sure it was in good working order, and document in the resident's medical record how the resident tolerated the oxygen. Resident #42 had diagnoses that included respiratory failure, congestive heart failure, and hypertension. The Minimum Data Set Resident assessment dated [DATE] revealed the resident was cognitively intact and received oxygen therapy while a resident in the facility. The current Comprehensive Care Plan reviewed on 5/28/24 did not include that Resident #42 was receiving oxygen therapy. Review of physician orders for oxygen therapy revealed an order to discontinue oxygen on 8/22/23. There were no further orders for oxygen therapy until 5/29/24 (after surveyor intervention) which included oxygen at 6 liters per minute continuously. During an observation and interview on 5/28/24 at 9:47 AM, Resident #42 was lying in bed and had complaints of difficulty breathing. They were wearing a nasal cannula (a device that delivers additional oxygen through a person's nose) connected to a concentrator (a device that filters air from a person's surroundings and delivers oxygen to breathe) set at 8 liters of oxygen per minute. Resident #42's oxygen saturation level as taken by Licensed Practical Nurse #5 at this time was 86 percent (considered a low level that may require medical attention). Licensed Practical Nurse #5 moved the nasal cannula tubing to an oxygen tank in the room and Resident #42's oxygen saturation increased to 96 percent. Licensed Practical Nurse #5 stated a lot of the equipment (oxygen concentrators) in the facility did not work. During an interview on 5/28/24 at 10:34 AM, Licensed Practical Nurse Manager #1 stated that Resident #42 had been using oxygen for a while but after review the the resident's orders, they stated the resident did not have a physician order in place for the oxygen. During an observation and interview on 5/28/24 at 11:10 AM, the oxygen concentrator in Resident #42's room had a filter that was covered with dust. Resident #42 stated the facility staff had just brought in that particular concentrator. During an interview on 5/31/24 at 2:52 PM, the Corporate Infection Preventionist stated there were no preventive maintenance inspections for patient care related equipment (including oxygen concentrators). During an interview on 6/4/24 at 1:15 PM, Registered Nurse Manager #3 stated Resident #42 had no care plan for oxygen and that they had been working with the Director of Nursing to make care plans better. During an interview on 6/6/24 at 10:13 AM with the Administrator and Director of Nursing, the Director of Nursing stated they were not aware of any concerns related to oxygen administration and that there was a quality assurance initiative in place that included ensuring the oxygen supply company was coming as scheduled and checking all concentrators to ensure they were serviced as needed. 10 NYCRR 415.12(k)(6)

Based on observation, interview and record review conducted during a Recertification Survey the facility did not ensure that proper treatment to maintain hearing abilities was provided for one (Resident #51) of one resident reviewed for hearing. Specifically, Resident #51 did not have their ears flushed per Physician orders. This is evidenced by: The facility policy, Activities of Daily Living, dated May 2018, documented residents will be provided with care, treatment, and services to ensure that their activities of daily living do not diminish unless the circumstances of their clinical conditions demonstrate that diminishing activities of daily living are unavoidable. Resident #51 had diagnoses including chronic obstructive pulmonary disease, diabetes, and hypertension. The Minimum Data Set Resident assessment dated [DATE] documented the resident was cognitively intact and did not require the use of a hearing device and that the resident's hearing was adequate. Review of the Comprehensive Care Plan initiated 1/1/23 documented that Resident #51 was able to communicate her needs effectively and to refer to Audiology for hearing consult as ordered. In a nursing progress notes dated 3/11/24 the Registered Nurse documented that Resident #51 was seen at their family's request to evaluate their ears for cerumen (ear wax). Using video otoscope, the Registered Nurse found the left ear contained a large amount cerumen and the right ear was impacted with cerumen. A large amount of cerumen was removed but canal remains occluded. Review of a medical progress note, and Physician orders dated 4/17/24 revealed that Resident #51 complained of having wax in their ears not relieved with ear drops and the Physician ordered both ears flushed. Review of Resident #51's April 2024 and May 2024 Medication Administration Records revealed an order to please flush ears bilaterally - cerumen impaction. There was no documentation that the ear flushed were ever completed (all boxes were 'x' out). Review of Resident #51's nursing and medical progress notes from 4/17/24 to 6/4/24 revealed no mention of whether Resident #51's ears had been flushed or any refusals. In an interview on 5/28/24 at 12:38 PM and again on 6/5/24 at 9:33 AM Resident #51 stated that they could not hear and asked the surveyor to yell. Resident #51 stated that they could not hear out of either of their ears and that not being able to hear bothered them and having to say what did you say? to everyone was annoying. During an interview on 6/5/24 at 1:33 PM Licensed Practical Nurse Manager #1 stated they did not know that there was an order to flush Resident #51's ears and an x in the Medication Administration Record would mean that it was not scheduled for that date and time. Licensed Practical Nurse Manager #1 did not know who could flush a resident's ears at this facility and would have to ask where the equipment was kept. In an interview on 6/5/24 at 2:31 PM the Director of Nursing stated that a Licensed Practical Nurse or a Registered Nurse could flush a resident's ears. The Director of Nursing did not know why Resident #51's ears had not been flushed and does not know how the order got missed. During an interview on 6/6/24 at 9:35 AM Nurse Practitioner #1 stated when orders are put in (the system) the nurses are supposed to carry them out and that any nurse could flush a resident's ears. Nurse Practitioner #1 stated that if the nurses wanted medical to flush Resident #51's ears then they should have let them know and that they would have needed notice to bring their own otoscope and curettes as to their knowledge the facility does not have either available. 10 NYCRR 415.12 (a)(3)(b)(1-3)

Based on observation, interviews, and record reviews conducted during an Abbreviated Survey (#NY 267) completed on [DATE], the facility failed to ensure that residents had the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advanced directive for 14 (Residents #1, #2, #3, #4, #5, #6, #8, #9, #10, #11, #12, #13,#14, and #15) of 97 residents reviewed. Specifically, Resident #1 was admitted [DATE] and had Full Code wishes via a Medical Orders for Life Sustaining Treatment (MOLST). The resident changed their wishes to (Do Not Resuscitate) DNR (via a new MOLST) on [DATE], was hospitalized on [DATE] and returned to the facility on [DATE] maintaining their DNR wishes. The post hospital physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A MOLST was eventually found after (Emergency Medical Services) EMS arrived indicating DNR status and CPR was discontinued, and the resident expired. Upon further review, it was identified that there were multiple residents residing in the facility who would receive CPR or not receive CPR due to the facility incorrectly identifying Resident's wishes. The facility used multiple identifiers (orders, care plans, wristbands, door dots and MOLSTs) and despite the facility claiming they did a full house audit following the [DATE] incident, Residents were found with incorrect wristbands, incorrect dots on their room doors, and MD orders different than indicated on their MOLSTs. Interviews of staff on [DATE] revealed multiple staff (Licensed Practical Nurses (LPNs) and Registered Nurses (RNs)) were not knowledgeable regarding the facility policy for identifying a resident's code status, where to find such information and were not knowledgeable regarding what the dots meant, including one LPN who stated to the surveyor that a resident was a DNR because they had a red dot on their door and wristband and the resident loudly stated They (staff) have to do CPR on me (in accordance with their MOLST). This resulted in Immediate Jeopardy with the likelihood for serious harm to residents' health and safety. Findings include but not limited to the following: The facility's policy Advanced Directives and MOLST dated with a review/revision date of [DATE], documented that it will be the policy for the medical provider to review with the resident or surrogate to determine each resident's preference for advanced directives, complete a MOLST form and to update this information periodically. After MOLST completion nursing will take off the order or obtain necessary verbal order and then email to the advanced directive group. The MOLST and supportive documentation will be filed in the patient's chart. The policy did not document identifying the residents wishes with or without red dots on wristbands or resident doors or in the Electronic Medical Record (EMR). The policy did not document instructions for or what a Code Blue meant and did not document filing the MOLST forms in a unit binder. When interviewed on [DATE] at 5:20 p.m., 8:40 p.m., and again at 9:20 p.m., the Assistant Administrator stated that residents whose wishes are for Full Code (including Cardiopulmonary Resuscitation or CPR) are to be identified by a red dot on their wristbands and a red dot on their room doors and that both places should match the Resident's Advanced Directives and medical orders. 1.Resident #1 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) Assessment, dated [DATE], revealed the resident had moderate cognitive impairment. The Comprehensive Care Plan, dated [DATE], documented that Resident #1 had an Advanced Directive which identified their wishes for Full Code. A Social Work progress note, dated [DATE], documented a meeting with Resident #1's family to discuss the resident's code status including a change in the Advanced Directives. The note included that a new MOLST was completed with DNR code status. Resident #1 MOLST form (completed in the facility) documented wishes for 'Do Not Attempt Resuscitation (Allow Natural Death)', with a check in the verbal consent box dated [DATE] at 12:28 p.m. and signed by Resident #1's Health Care Proxy. A Hospital Discharge Summary following an acute care stay ([DATE]-[DATE]), dated [DATE], documented Resident #1's code status was DNR/DNI (Do Not Intubate). The facility physician Readmission Progress Note, dated [DATE], documented Resident #1 was a full code (CPR). Resident #1's Medical Orders, dated [DATE], (active orders as of [DATE]) documented Advanced Directives: Full Code. Review of facility Incident/Accident Summary, dated [DATE], documented that Resident #1 had a change regarding their Advanced Directives and the Medical Orders were not rewritten to identify this change. Subsequently, Resident #1 received CPR when facility staff found Resident #1 unresponsive and appeared deceased for an undisclosed period until Emergency Medical Services (EMS) arrived. A MOLST was eventually produced, and CPR was discontinued by EMS and the resident expired. The Incident/Accident Summary included that staff had checked Resident #1's Medical Orders and called a Code Blue and CPR was initiated. 2.Resident #2 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Assessment, dated [DATE], documented the Resident #2 had moderately impaired cognition. Review of Resident #2's medical record documented no MOLST. Current Medical Orders included Advanced Directives: Full Code. During observations on Unit 5 between 10:00 a.m. to 12:00 p.m., Resident #2 was not wearing a wristband and did not have a red dot on their door (indicating Resident #2 was a DNR). 3.Resident #3 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Assessment, dated [DATE], documented the resident had moderately impaired cognition. Review of Resident #3's medical records documented a MOLST form, dated [DATE], that documented DNR wishes. Current Medical Orders included Advanced Directives: DNR. Observations on Unit 5 on [DATE] between 10:00 a.m., and 12:00 p.m., revealed Resident #3 had a red dot on their wrist band and had a red dot on their door (both indicating CPR status). 4.Resident #6 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Assessment, dated [DATE], documented the resident had moderately impaired cognition. Review of Resident #6's medical records documented a MOLST form, dated [DATE] at 9:50 a.m., that included wishes for CPR. Current Medical Orders revealed Advanced Directives: Full CPR. In an observation on Unit 4 on [DATE] at 2:14 p.m., Resident #6 had a red dot on their wristband and a red dot on their door (indicating CPR status correctly). When interviewed at this time Licensed Practical Nurse (LPN)#1 stated that the red dot meant that Resident #6 was a DNR. Resident #6 overheard LPN #1 and corrected the LPN stating they (staff) have to do CPR on me. During an immediate interview, LPN#1 stated they were not sure what the red dot meant and thought it meant DNR status. 5.Resident #12 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Assessment, dated [DATE] documented the resident was cognitively intact. Review of Resident #12's medical record revealed no MOLST form. Current Medical Orders documented Advanced Directives: Full Code. During an observation on Unit 6 on [DATE] at approximately 2:30 p.m., Resident #12 did not have a red dot on their wristband and did not have a red dot on their door (both indicating DNR status). In an interview on [DATE] at 11:05 a.m., CNA #1 stated they would check the resident's wrist band to identify the resident's code status. CNA #1 stated a red dot would probably be DNR. In an interview on [DATE] at 11:27 a.m., LPN #1 stated that the code status is identified in a binder at the nursing station, and it is supposed to be in the computer. The LPN stated that in their experience other areas of identification in the facility may differ, so they check the MOLST to be sure. In an interview [DATE] at 11:30 a.m., the LPN Nurse Manager (NM) #1, stated that they look at the resident's MOLST to identify their code status. The LPN/NM #1 stated that the status is also in the computer but there is so much room for error in the computer that they always check the MOLST. The LPN/NM #1 stated that every resident has a MOLST in a binder at the nurse's station and that the facility has never implemented dots on resident wristbands or doors to identify a resident's code status. The LPN/NM #1 stated that the admission nurse fills out the MOLST when the resident arrives and the Social Worker (SW) follows-up. The LPN/NM #1 stated if a resident goes out of the facility the MOLST is copied to be left in the binder and the original goes with the resident. The LPN/NM #1 stated that they have not had any recent education regarding Advance Directives. In an interview [DATE] at 12:51 p.m., the Director of Nursing (DON) stated that the SW fills out the MOLST form. The DON stated that staff have been educated to look at the resident's bracelet first to identify if the resident is a DNR or Full Code and if staff are not sure of the code status, they should initiate CPR. The DON stated every resident has a MOLST unless they refuse to complete one. The DON stated during a code all staff are delegated to check the MOLST to ensure the wristband is correct. The DON stated the expectation is for everything to match- the door, the wristband, the MOLST, and the medical orders. The DON stated that the facility policy states that every resident should have a MOLST and if not, staff should look at the medical orders. The DON stated that the admitting nurse does the wristbands, and the nurse puts dots on the door. The DON stated re-education was completed with staff on [DATE] (due to the incident with Resident #1), including dots on wristbands and doors. In an interview on [DATE] at 3:20 p.m., the SW stated that they initiate the Advance Directives. The SW stated if a resident has a MOLST the SW would review it and makes sure it is the resident's current wishes. If the resident lacks capacity SW would discuss DNR status with the resident's responsible party. The SW stated the expectation is to have the MOLST in Unit binders and uploaded into the EMR. The SW stated they were not sure who puts the red dot for full code on the resident's wristbands or doors, but it is the responsibility of the SW to make sure they all match. The SW stated the facility policy is for all residents to have a MOLST. The SW stated that the resident's door, wrist band, MOLST and Medical Orders in the EMR should match so that there is no confusion. On [DATE], the Immediate Jeopardy was removed based on the following: a) All current residents Advanced Directives/MOLST/ medical orders evaluated for accuracy and any inaccuracies immediately corrected. b) Facility policy was revised to streamline the process used by staff to identify a resident code status. c) All nursing staff educated both on-site and as staff come to work with competencies evaluated with post-tests. All dots from all wristbands and doors had been removed. d) Audits to be completed weekly on all residents. [10NYCRR 415.3 (e)(1)(i)]

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one of one resident reviewed for medically related Social Work services, the facility did not provide medically related social services to attain or maintain the highest practical, mental, and psychosocial well-being of each resident. Specifically, Resident #46 did not receive Social Work services following the loss of his power wheelchair which impacted his ability to visit his mother independently in the community. This resulted in a decline of his mental and psychosocial well-being which led to suicidal ideation requiring evaluation at the hospital and resulted in psychosocial harm. This is evidenced by the following: Resident #46 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 4/30/19, revealed the resident was cognitively intact, was feeling tired or having little energy daily, and scored a 3 of 27 on the PHQ-9 mood assessment (mood assessment to determine level of depression). The MDS Assessment, dated 7/31/19, revealed that the resident was cognitively intact, feeling tired or having no energy daily, feeling down, depressed, and hopeless daily, having trouble falling asleep or staying asleep or sleeping too much daily, and trouble concentrating on things daily. The resident scored a 12 of 27 on the PHQ-9 from minimal to moderate depression. The Comprehensive Care Plan (CCP) for Activities of Daily Living and self-care performance, last updated by physical therapy on 7/9/19, and the current Certified Nursing Assistant (CNA) Kardex revealed that the resident required supervision with power wheelchair mobility within the facility and outside the facility. An Occupational Therapy (OT) note, dated 7/23/19, revealed that the resident was assessed for safe use of a power wheelchair, demonstrated unsafe use of the power wheelchair, and it was removed. The OT note revealed that following the session, the resident was re-approached by the Director of Rehabilitation and Social Worker #1 (the resident's assigned Social Worker), and it was explained to the resident that he was unsafe, the power wheelchair was being removed from use due to his inability to demonstrate skills to remain safe. Additionally, it was documented that it was explained to the resident that his refusal to wear his oxygen and his low oxygen levels were making him fall asleep. The resident began to make a self-harm statement; however, he did not follow through and banged his right arm on the armrest of the chair. It was explained to the resident that he could earn the power wheelchair back if he demonstrated consistent use of oxygen over the next few days. SW #1's behavior notes, dated 8/5/19, revealed that she was called to the therapy department due to the resident refusing to leave as he was upset that his power wheelchair had not been given back to him. During the conversation, the resident stated four times that he was going to harm himself and that he was going to take a knife and would stab himself in the chest. SW #1 verified with the resident that he was serious and that if he did not get his chair back, he would harm himself. The Nurse Practitioner (NP) note written on 8/5/19, revealed that the NP had been called to the unit due to the resident being actively suicidal and had reported to several staff his plan was to kill himself with a knife. The NP said that the resident had stated that he was upset that he no longer had his power wheelchair and that, it would be so easy to cross over to the other side. Following evaluation, the resident was sent to the psychiatric emergency department for evaluation at approximately 1:00 p.m. Licensed Practical Nurse (LPN)#1 documented on 8/5/19 that the resident returned from the hospital at 5:25 p.m., was placed on one to one care at the nursing station, and was provided with plastic utensils for dinner. The resident's room was checked for ropes and sharp objects and nothing was found. The resident verbalized that he was, being held hostage and being prevented by staff from seeing his mother. LPN #1 told the resident to make the arrangements by picking a date, asking for an employee companion to go with him, and the facility would cater to his needs. The resident verbalized understanding. The behavior notes written by Registered Nurse Manager (RNM) #1, dated 8/6/19, revealed the resident was maintained on one to one per order and denied suicidal ideation, plan or intent and stated, I just want my wheelchair and to see my mother. LPN #2's progress note, dated 8/9/19, revealed that the resident was calling out for his mother and asked the nurse to get him dressed so that he could go see his mother. Nurse Manager #2 documented on 8/10/19 that the resident had increased behaviors that shift, was noted crying in his room and talking to himself, and continued to ask for his mother. LPN #3's progress note, dated 8/17/19, revealed that the resident was yelling out in the morning and ordering staff to his room, yelling, I want to see my mother now. During an interview on 8/14/19 at 3:25 p.m. and on 8/21/19 at 9:30 a.m., the Director of Rehabilitation said the resident's oxygen saturation levels were dropping and he had been falling asleep in his power wheelchair. She said the new manual chair was difficult for him to self-propel but once he shows us, that he can wear the oxygen continuously, then therapy will re-evaluate him for the use of the power wheelchair. Later she said, that there was no plan in place to reevaluate the resident's use of the power wheelchair or oxygen use. She said the resident's biggest concern was that he wanted to visit his mother, so she offered him an option to take Medi-cab, but he was pushing back. There was no documentation regarding Medi-cab. During an observation and interview on 8/15/19 at 9:15 a.m., the resident was sitting in his wheelchair at the nursing station, talking on the phone to his mother. He was speaking loud enough to be overheard telling his mother that he loves her, misses her so much every day, and cannot wait to see her and wants to be near her. After he hung up, he said he wanted to be with his mother so he could hold her hand when she dies and was teary eyed. When interviewed on 8/15/19 at 11:55 a.m., on 8/20/19 at 9:29 a.m., and on 8/21/19 at 3:54 p.m., RNM #1 said SW #1 was working on assisting the resident to visit his mother. She said she offered to go with the resident, but SW #1 did not follow up with her. RNM #1 said the resident has been compliant with oxygen use, and she thought therapy was responsible to develop a plan for the return of the power wheelchair. She said the resident was now perseverating more on seeing his mother than before. When interviewed on 8/20/19 at 8:56 a.m. and on 8/21/19 at 4:10 p.m., the resident said he was using his oxygen at all times. He said he did not know what the plan was to re-evaluate him for the use of the power chair. The resident said he has not had a suicidal ideation in many years, and the most important thing to him was his mother. He said he last saw his mother about a month and a half ago. Durign an interview on 8/20/19 at 11:25 a.m. and on 8/21/19 at 11:35 a.m. and 2:13 p.m., SW #2, covering for the SW #1, said that a meeting should have been held to discuss concerns of self-harm and the use of the power wheelchair. SW #2 said that she reviewed the resident's medical record and there was no documentation regarding a plan to return the power wheelchair or to visit his mother. She said that they could not have him escalating to such a level of frustration that he expresses suicidal intent related to not seeing his mother. SW #2 said that the resident really does not have any other behaviors, other than the suicidal ideation related to not seeing his mother. She said the resident's mother was his world and the only thing he cares about. She said the resident visited his mother on Saturdays several times a month. SW #2 said that she spoke with SW #1 by telephone the previous evening and reported that SW #1 said she forgot to update the care plan or to provide an alternative way for the resident to visit his mother. When interviewed on 8/21/19 at 10:36 a.m., the NP said it would be appropriate to offer the resident an opportunity to try the power wheelchair again especially in relation to visiting his mother. The NP said she heard the resident talking to his mother on the phone and he cries and gets anxious. The NP said she discussed his needs with the SW #1, but it does not seem as though anything was done. During an interview on 8/21/19 at 3:10 p.m., CNA #2/Primary Evenings said that since the resident's power wheelchair was taken away, he is spending more time in bed, sleeps half the shift, and talks frequently about his mother and visiting her. When interviewed on 8/21/19 at 3:35 p.m., LPN #1/Evenings said it has been over a month since the resident has seen his mother, and he is extremely upset. During an interview on 8/22/19 at 8:01 a.m., SW #1 said that prior to leaving for vacation on 8/9/19, she spoke with the resident and told him that they would talk about him visiting his mother when she returned. She said that therapy should have addressed the use of the power wheelchair. She said she was responsible to address everything else. SW #1 said she asked that the resident be sent to the hospital because he stated he might as well die when they took the power chair away. SW #1 stated she was the only one who could take him to see his mother, and she told him they would figure something out when she returned from vacation. (10 NYCRR 415.5(g)(1)(i-xv))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for two of two residents diagnosed with [REDACTED]. Specifically, the facility did not ensure that Resident #133 received implementation of psychiatric recommendations, an individualized behavioral care plan, and/or monitoring of behaviors. This led to an increase in self-mutilating behaviors resulting in mental and psychosocial harm. Additionally, Resident #78 did not receive recommended psychiatric services or timely individual mental health counseling sessions. This is evidenced by the following: 1. Resident #133 was originally admitted to the facility on [DATE] following an inpatient psychiatric hospital stay for [MEDICAL CONDITION] with a history of [MEDICAL CONDITION] disorder with psychotic features, depression, failure to thrive, Chron's disease, loss of appetite, and functional decline. The Minimum Data Set (MDS) Assessment, dated 7/23/19, revealed the resident was cognitively intact, no behaviors, and daily use of an antipsychotic, antidepressant and an opioid. The resident had mood symptoms of feeling down, depressed and hopeless, tired, poor appetite, and feeling bad about herself. A Pre-Admission Screening and Resident Review (PASRR) Level II mental illness evaluation, dated 5/30/19, recommended a written person-centered psychiatric plan of care, ongoing psychiatric consultations and medication management by a psychiatrist or licensed prescriber, weekly recovery-oriented clinical counseling, and weekly therapeutic group interventions. A hospital discharge summary and psychiatric assessment, dated 5/30/19, included that the resident continued to lack motivation to get out of bed or participate in therapy and preferred to sit in bed in a darkened room most of the day. Recommendations included to open drapes in her room between 9:00 a.m. to 9:00 p.m., monitor and document sleeping patterns, continue [MEDICATION NAME] (antidepressant) 30 milligrams (mgs) nightly, [MEDICATION NAME] (antipsychotic) 200 mgs nightly, [MEDICATION NAME] (antidepressant) 10 mgs daily, and to consider the use of [MEDICATION NAME] 5 mgs twice a day. Recommendations included that Psychiatric Consultation Liaison Services would continue to follow the resident and the contact information was included. The Social Work (SW) notes provided in the summary, dated 5/15/19 to 6/3/19, included the community therapist contact information. The Certified Nursing Assistant (CNA) Kardex, dated 7/16/19, included instructions that to avoid scratching keep the resident's fingernails short, to monitor, document and report adverse reactions to antidepressant therapy, and to monitor behaviors. The Kardex did not include resident specific targeted behaviors or interventions such as keeping the room curtains open as recommended by the hospital psychiatric note. Review of medical notes following admission to the facility included two acute visit notes, dated 6/4/19 and 6/11/19 signed by Nurse Practitioner (NP) #1, addressing gastrointestinal concerns. The resident was re-hospitalized , from 6/12/19 through 6/25/19. A facility History and Physical admission note, dated 6/26/19, included that the resident was there for rehab, had a history of [REDACTED]. There was no further mention of any psychiatric recommendations or services. Physician admission orders [REDACTED]. On 7/26/19, [MEDICATION NAME] was increased to 20 mgs daily, and on 8/1/19, [MEDICATION NAME] ([MEDICAL CONDITION]) 3 mgs was added at bedtime. There were no orders for any psychiatric consult or clinical counseling services. The Comprehensive Care Plan (CCP), dated 8/14/19, did not include resident specific targeted behaviors, mood symptoms or interventions related to the use of an antidepressant medication or the recommended PASRR Level II mental and behavioral health care services. A review of the resident's electronic medical record, from 6/4/19 to 8/15/19, did not include any psychiatry or clinical counseling notes, specific resident behaviors or mood symptoms, or interventions other than noncompliance related to smoking. Review of all SW notes, from 6/4/19 through 7/25/19, revealed no mention of mental health issues, services recommended and/or current behaviors until a 7/25/19 MDS Assessment review that included the resident reported depression, and a [DIAGNOSES REDACTED]. A note later in the day documented a discussion about the smoking policy. There were no further SW notes. In an observation and interview on 8/13/19 at 11:14 a.m., the resident was in her room which was dark and the curtains were closed. She had a scarf wrapped around her head. The resident said she was unable to sleep, was pulling her hair out, and biting her nails. On 8/15/19 at 9:48 a.m., the resident stated she had not seen a psychiatrist or received any counseling services since admission, and really needed those services because she was so depressed. During an interview on 8/15/19 at 12:03 p.m. and on 8/20/19 at 8:59 a.m., the Registered Nurse Manager (RNM) said the resident had escalated in her depression and behaviors, such as pulling out her hair, and required medication changes. The RNM said the Nurse Practitioner (NP) had ordered a psychiatric consult on 8/6/19 which she had transcribed on 8/7/19, but did not know if it had been ordered because SW was responsible for that. After review of the resident's CCP and CNA Kardex, the RNM said they were generic, did not include specific resident behaviors, and needed to be more specific to be helpful to staff in assisting and monitoring the resident. When interviewed on 8/16/19 at 9:14 a.m. and on 8/19/19 at 2:23 p.m., the resident said she came to the nursing home following an in-patient psychiatric stay because she had stopped eating. She said while at the hospital she had received daily counseling therapy and met with a psychiatrist. She said she felt those services helped her a great deal. She said she had a psychiatrist and a therapist in the community, and when she asked the hospital staff if she would see a psychiatrist at the nursing home, they told her she would. The resident said she was depressed, and her anxiety was worse causing her to bite her fingernails to the tip (causing painful hangnails) and to pull her hair out. The resident said that she was awake all night, slept during the day, and was feeling sad and alone. She said she discussed that with the NP and reported that she needed more [MEDICATION NAME] due to not sleeping. She said the NP told her he did not feel comfortable changing her anxiety medications, but did increase her antidepressant and wanted to add [MEDICATION NAME] before increasing the [MEDICATION NAME]. The resident said she has been sick for [AGE] years and knows that [MEDICATION NAME] does not work. The resident said that when she pulled her hair out in the past, [MEDICATION NAME] helped. She said that she has not pulled her hair out for two years. At that time, the resident removed her scarf and there was a 3 to 4 inch wide patch of missing hair from her forehead to the back of her head and from ear to ear. The resident started to cry and stated that it was embarrassing. The resident then picked up a pair of tweezers and started picking at her legs and pulling out hairs. The resident stated that was a new thing. The resident said that she showed the NP her hair about three weeks ago, and he had said he would put in a psychiatric referral. She said no one, including SW, had gotten back to her until recently when she was offered tele-psychiatry services which she agreed to. She said her community therapist was available and she would like to see him for counseling. During an interview on 8/16/19 at 9:22 a.m., Licensed Practical Nurse/Clinical Coordinator (LPN/CC) #1 said there are times when the resident lies on the couch opposite the nurses' station all day long, biting her nails, in deep thought. She stated that the resident did tell her I'm having a [MEDICAL CONDITION] moment but thought she was joking. LPN/CC #1 said she knew the resident had been twisting and pulling out her hair because she showed her the bare scalp. She said that behaviors were supposed to be documented by nursing in the medical record. When interviewed on 8/16/19 at 9:58 a.m. and on 8/19/19 at 1:25 p.m., NP #2 said he was unaware of the resident's recent psychiatric inpatient stay and thought her primary reason for admission to the facility was related to abdominal surgery. He said he was not familiar with the PASRR Level I or Level II mental illness evaluation process. NP #2 said he first saw the resident on 7/23/19, noted she had [MEDICAL CONDITION] disorder, and she seemed to be tolerating her medications. NP #2 said staff had not reported any behavior symptoms to him. He said the resident told him she was not sleeping, was pulling out her head hair, and biting her nails so he adjusted her medications. NP #2 said he ordered a psychiatric consult on 7/27/19 but did not recall why, and the referral was sent to Health Information Management for scheduling. He said he reordered the psychiatric consult on 8/6/19 because the resident had not been seen, and he made a referral to the resident's community-based therapist on 8/16/19 after the resident provided him with contact information. During an interview on 8/16/19 at 10:29 a.m., the Admission Social Worker stated the facility has not had psychiatric services since (MONTH) (YEAR) so she had no one to contact for a referral. When interviewed on 8/16/19 at 10:56 a.m., the physician said she did not recall the resident having an in-patient stay for suicidal ideation, but she knew the NP had written an order for [REDACTED]. During an interview on 8/19/19 at 10:32 a.m. during a telephone interview and on 8/22/19 at 8:21 a.m., the Director of Social Work (DSW), who was the assigned Social Worker for the resident, said she had spoken to the resident regarding her [MEDICAL CONDITION] disorder but had not documented. She said the resident never told her she was pulling her hair out and not sleeping. She said that tele-psychiatric services have now been confirmed for 9/5/19. She said she made out a referral for the psychologist for counseling services but never sent it. She said she informed Administration of the need for additional psychological services because the current psychologist has not been able to address all the referrals. The DSW said that PASRR Level II recommendations should have been part of the resident's care plan. When interviewed on 8/19/19 at 11:28 a.m., the Medical Director said that she was aware that facility psychiatric services stopped in (MONTH) (YEAR), and she had worked with facility Administration to get a new system in place. She said tele-psychiatric services are scheduled to start in (MONTH) 2019. The Medical Director said that residents admitted with PASRR Level II recommendations should have had mental health services in place at the time of admission, and the facility should have utilized community services when it was unable to provide their own providers. During an interview at 1:49 p.m., a Health Information Management assistant said she was responsible to schedule out of facility appointments with specialists. She said she received the order, dated 8/16/19, and had made an appointment for 8/30/19 for the resident to see her community mental health counselor. She said the order for 7/27/19 was in the computer but somehow got missed, and she could not find the order for 8/6/19. 2. Resident #78 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 3/6/19, revealed the resident had moderately impaired cognition, felt down, depressed, hopeless, had trouble sleeping, felt tired with little energy, had poor appetite, had behavioral symptoms directed towards herself that did not have asignificant impact on the resident, had rejection of cares, and daily use of an antidepressant. A PASRR Level II evaluation, dated 6/20/18 (completed while at another facility), recommended the development of a written, person centered psychiatric plan of care, on-going psychiatric consultations and medication management by a psychiatrist or licensed prescriber, on-going psychiatric consultations every four to six weeks to monitor psychiatric symptoms and impact on [MEDICAL CONDITION] medications, weekly recovery oriented clinical counseling, and weekly therapeutic group interventions. A review of a CHE Behavioral note (psychological service provider), dated 4/23/19, revealed that it was the first counseling session, and the plan was to continue psychotherapy treatment to reduce depression, anxiety, and improve coping skills. The frequency of visits was not identified in the note. Additional psychologist notes were dated 5/9/19 and 5/30/19 with the same treatment plan but no identified frequency. A review of the electronic medical record, from 2/27/19 through 8/15/19, did not include any psychiatric consultations. During an interview on 8/20/19 at 1:33 p.m. and on 8/21/19 at 8:18 a.m., the RNM said she had found another CHE note, dated 7/30/19. The note directed on-going services, one to four times a month. The RNM said the services identified on the PASRR Level II evaluation should have been in place at the time of the resident's admission. The RNM said that directed weekly recovery oriented clinical counseling and psychiatry services had not been provided timely upon admission to the facility. (10 NYCRR 415.12(f)1))

Based on interviews and record reviews conducted during an Abbreviated Survey (complaint #NY 438) completed on [DATE], it was determined that for one of three residents reviewed for Advance Directives and Cardio [MEDICAL CONDITION] Resuscitation (CPR) quality of care, the facility did not provide the necessary care and services to attain/maintain the resident's highest level of physical functioning. Specifically, the facility staff failed to provide cardiopulmonary resuscitative measures in a timely manner when unable to determine a pulseless resident's code status (Resident #1). This resulted in actual harm that is not immediate jeopardy and is evidenced by the following: Resident #1 was admitted to the facility on [DATE] from the hospital status [REDACTED]. This resident's additional [DIAGNOSES REDACTED]. Review of the hospital discharge summary, dated [DATE], revealed that it did not include advance directives. The current pink Medical Orders for Life Sustaining Treatment (MOLST) form currently in the record only included the resident's name, address, and date of birth. A copy of a MOLST form, dated [DATE] from a previous admission, included a CPR order. A Social Work progress note, dated [DATE] at 4:01 p.m., revealed that the resident was a full code. A Registered Nurse (RN) progress note, dated [DATE], documented that the RN Supervisor was paged to the unit at approximately 5:05 p.m., as the resident was unresponsive and was a full code. The resident was lifted from the chair to the floor, and chest compressions were started. A Blue 100 was called while CPR was being done, and the emergency response services (EMS/911) was called. Timeframes were not documented. Review of the CPR log, dated [DATE], revealed that the resident's condition was discovered at 5:10 p.m., chest compressions started at 5:35 p.m., EMS/911 was notified at 5:44 p.m. and arrived at 5:50 p.m., and the resident was intubated by EMS/911 at 6:10 p.m. All of the staff in attendance during the code signed the CPR log form. Review of the facility's investigation, dated [DATE], revealed that the staff failed to follow facility policy related to the communication of the resident's code status, which resulted in a delay of initiation of CPR for this resident after it was determined that he was without a pulse. The physician admission orders [REDACTED]. Review of footage of the seventh floor on [DATE] of two different facility video surveillance cameras and the facility surveillance notes revealed the following: a) At 5:22 p.m., a Certified Nursing Assistant (CNA) entered the resident's room, exited approximately 20 seconds later, and approached the Licensed Practical Nurse (LPN). b) At 5:23 p.m., the LPN entered the room, left the room [ROOM NUMBER] seconds later, and is seen checking the medical record and approaching the telephone. c) At 5:25 p.m., the LPN goes back to the resident's room, exits the room [ROOM NUMBER] seconds later, and returned to the nurses' station. d) At 5:26 p.m., the RN Supervisor arrives by elevator and reports to the nurses' station. The RN Supervisor and the LPN continue to look at the chart. e) At 5:33 p.m., both nurses leave the camera view. They can be seen on the other camera entering the resident's room at 5:34 p.m. f) At 5:35 p.m., RN #2 entered the room, and the CNA brought the emergency cart into the resident's room at 5:36 p.m. g) At 5:38 p.m., the CNA brought oxygen into the resident's room. h) At 5:39 p.m. and 5:41 p.m., other staff members respond to the room. i) At 5:46 p.m., EMS/911 arrives. Interviews conducted on [DATE] included the following: a) At 10: 07 a.m., the Social Worker (SW) stated that the resident was a late admission on Friday, [DATE], and there were other admissions. She said that the facility is short a SW. She stated she wrote a progress note that the resident was a full code, did not place a red dot on the spine of the chart or on the resident's door, and did not update the full code list or email the full code status to the advance directive group (key personnel). She said all of these steps are her responsibility, and she got busy and forgot to complete the steps. The SW said she spoke directly to the LPN/Assistant Nurse Manager (ANM) about the resident's code status. The SW stated since this incident, the full code list is now being reviewed twice a week. She said previously it was only updated with any changes. b) At 10:40 a.m., the LPN/ANM stated he assisted the Physician Assistant (PA) in completing the admission orders [REDACTED]. The LPN/ANM stated that Social Work reviews the advance directives/code status with residents and families and then reports the code status to nursing. He said he does not recall getting code status information from the SW. He said, if the SW does not contact nursing with a code status, then it would have been his responsibility to follow up, as he was admitting the resident. The LPN/ANM said he remembers seeing a full code order when reviewing the electronic record. He said he reviewed the physician orders [REDACTED]. He said he should have followed up with medical and updated the order. He said that nursing would have placed a red dot on the bracelet if the resident was a full code. He said he did not place the bracelet on the resident. He said there was a breakdown in communication regarding this resident's code status. c) At 10:50 a.m., the RN Manager (RNM) stated that she completed the physical assessment for this resident on admission, and the LPN/ANM helped the PA enter the physician admission orders [REDACTED]. She said when a resident has a history of a previous admission, the prior physician orders [REDACTED]. She said the code status should have been reviewed and updated during this admission. The RNM said that both Social Work and nursing are responsible for reviewing the code status/MOLST with the resident/representative on admission. She said if the resident is a full code, then the secretary places a red dot on the binder of the chart, name plate on the resident's door, and on the resident's identification band. She said she did not review the resident's MOLST on admission; however, the process is that the nurse transcribing the code status order enters it into the electronic medical record and then sends an email to the advance directive group. She said she did not receive an email alert regarding a full code status for this resident. The RNM added that if the resident's code status is unknown, then they would be considered a full code, and an advance directive email should have been sent. She said the SW is responsible for updating the full code list, and in her absence nursing completes this list. d) At 11:35 a.m., the File Clerk stated that she prepared the resident's admission chart and ID band. She said if the resident had been at the facility before, she would have put a copy of the MOLST in the chart if it was available. She said Social Work reviews advance directives, and she puts the name bracelets together with the chart. The File Clerk said she would only put a red dot on the bracelet if she receives an advance directive email, alerting her that a resident is a full code, and then she would check the physician orders, the MOLST, and check for other red dots before providing a new ID band. She said there was no red dot on this resident's wristband, as she did not receive an advance directive email notification that the resident was a full code. e) At 12:00 p.m., by telephone, the RN Supervisor stated that the LPN notified her at approximately 5:20 p.m. that the resident had no pulse, and she immediately responded to the unit. She said she reviewed the chart and the full code list and was unable to find advance directives. She said there was no red dot on the spine of the chart, and the MOLST was blank, which means full code. She said RN #1 called her from another unit asking if her relief arrived, and she informed RN #1 of the emergency. The RN Supervisor said she and the LPN then went to the resident's room to position him on the floor, and RN #1 started compressions upon her arrival at approximately 5:30 p.m. The RN Supervisor said she then paged a Blue 100 and then called EMS/911. She said the 911 operator told her she was the second call for this same incident, and she told 911 that she was the real call. She said time is critical in an emergency, she felt things went quickly, and she did not want to push on someone's chest without orders. She said she helped to complete the CPR log, and she did not feel like there was any delay in the process. f) At 12:39 p.m., by telephone, the assigned CNA said that the resident did not look good, and she could not get any response, so she called out to CNA #2, who was across the hall, and then notified the LPN immediately. She said the LPN called the RN Supervisor, and both nurses were unable to locate the resident's code status. She was unsure about timeframes but thought CPR was started at approximately 5:35 p.m. by RN #1. The CNA said that her personal cell phone was used to call EMS/911 by RN #1, and the call was placed at 5:39 p.m. g) At 1:10 p.m., the LPN on the unit at the time of the code, stated when she tried to give medications to the resident at approximately 5:10 p.m., he was wearing a headset and appeared to be sleeping. She said she tapped his hand, which was warm, to try and wake him. She said there was nothing alarming, so she thought she would return to give him his medications. The LPN said approximately 10 minutes later, both CNAs reported the resident had no pulse. She said she went into the resident's room, and he had no pulse. She said she then went to the nursing station to check the chart for the resident's code status and call the RN Supervisor. She said the resident did not have an identification band, the MOLST form was blank, and there were no red dots on the spine of the chart or nameplate outside the resident's room. She said she just happened to see an icon on the computer screen that read full code list, so she clicked on the icon, and the resident's name was not on the list. She said she did not know about that full code list before this incident. The LPN said the resident had a physician order [REDACTED]. The LPN said after the RN Supervisor hung up the phone, the two of them went to the resident's room and put the resident on the floor. She said RN #2 came into the room and started chest compressions, sent the CNAs for the emergency cart, and she provided rescue breaths using the ambu bag. The LPN stated that RN #1 called 911 from the resident's room using the assigned CNA's personal cell phone. She said it seemed like EMS/911 arrived quickly. The LPN said that she was aware of the red dot system for full codes and stated nothing was in place for this resident. She said she thought if there were no red dots and nothing was written, that the resident was a DNR (Do Not Resuscitate). She said the Assistant Director of Nursing came to the facility after the code and reviewed the process with her. h) At 2:00 p.m., the PA reviewed the resident's record in the electronic medical record and stated that the resident was a full code, and she remembers seeing that information in the hospital discharge paperwork. The PA reviewed some hospital paperwork and was unable to locate a code status. She said she did not see a MOLST for this resident on admission. She said nursing was reviewing and completing the advance directive orders. The PA said in this facility, the MOLST is completed by Social Work and/or nursing, then given to medical for review, when the physician completes the history and physical exam. The PA said nursing notifies medical when an order is needed for a code status. i) At 3:30 p.m., RN #1 stated she was the day supervisor on [DATE], covering the third floor as a staff nurse on evenings until her relief arrived. She said she called the RN Supervisor, after she completed the first medication pass at approximately 5:30 p.m., to see if her relief had arrived. RN #1 stated that the RN Supervisor told her she had an emergency and was unable to locate a code status. RN #1 said she told the RN Supervisor if the MOLST is blank, CPR was to be started, and she immediately reported to the unit, checked the resident's chart, then went to the room to start compressions. She said the LPN used the ambu bag for breaths. She said she had no idea how long the resident was unresponsive, as she had just responded to help the RN Supervisor. She said she never heard a code blue paged, so it had to occur while she was doing compressions because some other nurses responded. She said she called 911 (5:39 p.m.) from the resident's room after another nurse arrived and took over the compressions. She said she helped the RN Supervisor complete the CPR log. RN #1 said a code should be called when a resident is found unresponsive, so that others respond to the unit to help in the emergency and figure things out. She said EMS/911 should be called as soon as possible. She said that the resident's code status should be reviewed and updated with each admission. j) At 3:55 p.m., the Director of Nursing (DON) stated that when a resident is readmitted , she expects that medical will review the code status and verify and update if needed. She said that currently staff are provided with advance directive/full code training in orientation, but since this incident, it will be added to annual mandatory training. She said the full code list used to be posted on the units, but it is now on all the computer desktops in the facility and that is part of the code blue training. The DON stated that too much time passed before compressions started. When interviewed on [DATE] at 8:55 a.m., CNA #2 stated that he worked a double shift (day/evening) on [DATE], and the resident had been fine. He said just before dinner, the assigned CNA screamed, and he ran across the hall and checked for a pulse; there was no pulse. He said he immediately notified the LPN, and she called the RN Supervisor. Review of the facility's policy, CPR/Code Blue Identification of Resident Code Status, updated in [DATE], revealed that any employee finding a resident unresponsive will immediately initiate a code blue alert, paging overhead. Upon arrival at the scene, the nurse will determine code status, and if the code status cannot be determined immediately, licensed staff will initiate CPR. Residents with full code status will have a red dot on the name plate by their room, identification band, and spine of the chart. A red dot is full code. The code status is also in the electronic record. There is also a list of full code residents on the desktop icon of all facility computers. On admission and when a resident's code status changes, the medical provider will write or provide a verbal order to nursing staff. The nurse taking or transcribing the order will email the advance directive group, which consists of Social Work, Unit Secretaries, Nurse Managers, and Nursing Supervisors. The Unit Secretary will update the resident's chart tag, room tag, and identification band. Social Work will update the full code list. Review of the facility's policy, Advance Directives/MOLST, updated on [DATE], revealed that on admission the resident will be asked goals of care and about any previous or existing advanced directives. If none exist, they will be asked to complete a MOLST. After the MOLST is completed, nursing takes off the physician order [REDACTED]. (10 NYCRR 415.12)

Based on interviews and record reviews conducted during an Abbreviated Survey (complaint #NY 988) completed on 9/18/15, it was determined that for one (Resident #1) of three residents reviewed for [MEDICAL TREATMENT], the facility did not provide the necessary services to meet the resident's highest level of physical functioning. Specifically, the facility did not ensure that the resident was transported to scheduled [MEDICAL TREATMENT] treatments on 9/10/15 and 9/12/15. This resulted in hospitalization and urgent [MEDICAL TREATMENT] treatments to correct critically high potassium levels. This is evidenced by the following: Resident #1 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set Assessment, dated 8/24/15, revealed that the resident was cognitively impaired. According to the current Comprehensive Care Plan and Treatment Administration Record, the resident goes to the [MEDICAL TREATMENT] center on Tuesdays, Thursdays, and Saturdays for [MEDICAL TREATMENT]. [MEDICAL TREATMENT] treatments were scheduled for 9/10/15 and 9/12/15. Review of the progress notes from the electronic medical record included the following: a. A 9/10/15 Registered Nurse Manager (RNM) #1 note documented that medical transportation did not arrive that morning to take the resident to [MEDICAL TREATMENT]. The medical transportation provider was contacted and reported there was an issue with Medicaid, and transportation services could not be provided. The [MEDICAL TREATMENT] center was contacted, as the Social Worker (SW) for the [MEDICAL TREATMENT] center coordinates transportation. The [MEDICAL TREATMENT] team was notified and awaiting a return call to the facility. b. The facility's 9/10/15 Social Work note revealed that the resident's financial caseworker and agency in the community were contacted regarding the resident's Medicaid spend down. The agency is to pay the resident's spend down for September. There is no mention of [MEDICAL TREATMENT] transportation. c. In a late entry progress note, dated 9/17/15 at 9:27 a.m. and for 9/11/15 at 11:25 a.m., RNM #1 documented that the resident was transferred from Unit Two to Unit Five at 11:30 a.m. RNM #1 noted that the floor nurse and RNM #2 were informed that the resident missed his [MEDICAL TREATMENT] treatment on Thursday, 9/10/15, due to a transportation issue. The resident's next [MEDICAL TREATMENT] treatment was scheduled for Saturday, 9/12/15. Follow-up was needed with the [MEDICAL TREATMENT] center. The facility's SW was looking into a medical spend down issue related to the lack of transportation. d. In a late entry progress note, dated 9/17/15 at 9:31 a.m. and for 9/11/15 at 2:28 p.m., RNM #1 noted that the [MEDICAL TREATMENT] center left a message that day (9/11/15) stating that the arrangement for the resident's transportation for the Saturday 9/12/15 [MEDICAL TREATMENT] treatment was made. e. In a 9/12/15 (2:57 p.m.) entry, the RN Nursing Supervisor documented that the resident was not picked up for [MEDICAL TREATMENT] at 5:30 a.m. on 9/12/15 because payment for transportation had not been arranged. The [MEDICAL TREATMENT] center was contacted and had not returned a call to the facility. At 11:00 a.m., the RN again contacted the [MEDICAL TREATMENT] center and was told that the Nurse Practitioner (NP) was working on transportation, and the resident was scheduled for [MEDICAL TREATMENT] at 3:10 p.m. At 2:15 p.m., no transportation had arrived. The RN again called the [MEDICAL TREATMENT] center and was told there was no transportation available, and there would be no [MEDICAL TREATMENT]. The oncall NP was called, and the situation was explained. Blood work was ordered to be done on Monday (9/14/15), and medical was to evaluate the resident on 9/14/15. f. On 9/12/15 (3:23 p.m.), a Licensed Practical Nurse (LPN) documented that the resident's blood pressure was 178/102 and pulse was 76. g. On 9/12/15 (9:57 p.m.), a LPN note revealed that the resident was nauseous and felt as though he was going to pass out and requested to go to the hospital. The vital signs were recorded as follows: blood pressure 201/110, pulse 78. The blood pressure was rechecked and documented as 197/108 and pulse of 76. The on call NP was notified, and the resident was sent to the hospital (7:10 p.m.). There is no documentation that shows the resident's physician was notified of the missed [MEDICAL TREATMENT] treatments. Review of the hospital laboratory report, dated 9/12/15 (11:12 p.m.), revealed a potassium level of 9 (normal 3.5 to 5). Review of the hospital summary, dated 9/16/15, revealed that the resident was admitted to the hospital on [DATE] with severe [MEDICAL CONDITION] (elevated potassium) and accelerated hypertension (high blood pressure) in the setting of two missed [MEDICAL TREATMENT] sessions. Nephrology was consulted, and the resident was dialyzed urgently. The initial follow-up potassium was 5.4, and the following morning it was 6.8, and the resident was dialyzed again. He was started on a low potassium diet, but his potassium that morning was 5.7. He was again sent to [MEDICAL TREATMENT]. It was planned to discharge the resident back to the nursing facility after [MEDICAL TREATMENT], however, transportation to [MEDICAL TREATMENT] as an outpatient was not arranged. The hospital SW was asked to look into why the resident was not taken to [MEDICAL TREATMENT] for the last two sessions. Considering a safe discharge plan was not solidified, the resident was transferred out of the intensive care unit to the general medicine floor. A nursing progress note, dated 9/16/15 (3:30 p.m.) documented the resident was readmitted to the facility. Interviews conducted on 9/17/15 included the following: a. At 10:05 a.m., the RN Nursing Supervisor stated she worked days on 9/12/15 and that the resident did not make it to [MEDICAL TREATMENT] due to transportation issues. She said she called the [MEDICAL TREATMENT] center and was told the NP was working on getting transportation for a 3:10 p.m. appointment. She said at approximately 2:15 p.m., no one arrived to pick up the resident, and so she again called the [MEDICAL TREATMENT] center and was told that there was no transportation. The RN Supervisor stated she called the oncall NP and reported the situation, including that the resident had missed two [MEDICAL TREATMENT] sessions. She said she did not notify the facility administration of the situation. She said since it was a medical concern, she addressed it with the oncall NP. b. At 10:20 a.m., RNM #1 stated that when she arrived to work on 9/10/15, the resident had not been picked up by [MEDICAL TREATMENT] for a 5:30 a.m. appointment, so she called the [MEDICAL TREATMENT] center. She said she asked to speak with the [MEDICAL TREATMENT] SW, but she was not in, so she spoke to the [MEDICAL TREATMENT] nurse. RNM #1 said she reported to the [MEDICAL TREATMENT] nurse that she was unsure what was going on with transportation, as the [MEDICAL TREATMENT] SW coordinates transportation. The [MEDICAL TREATMENT] nurse said they would try to reschedule later in the day or the next day. RNM #1 stated she asked the facility SW about spend down and reported in morning report that the resident missed [MEDICAL TREATMENT] and that she was working on transportation. She said the [MEDICAL TREATMENT] center called her back the following day (9/11/15) and reported transportation was set for Saturday (9/12/15). The RNM said on Friday morning (9/11/15), the resident moved from Unit Two to Unit Five, she reported to the RNM and floor nurse that the resident missed [MEDICAL TREATMENT] the previous day (9/10/15) due to transportation. The [MEDICAL TREATMENT] center called that day (9/11/15) and reported transportation should be set for Saturday (9/12/15). c. At 10:45 a.m., the facility SW stated that she worked on 9/10/15 and was not made aware that the resident missed [MEDICAL TREATMENT] due to transportation. She said she became aware of two missed [MEDICAL TREATMENT] sessions on Monday (9/14/15). She said on 9/14/15, the resident was still in the hospital, and she became involved in coordinating transportation to [MEDICAL TREATMENT] before the resident could be readmitted back to the facility. She said if transportation is a problem, with supervisor approval, she could have the bill sent to the facility until things are sorted out. d. At 11:00 a.m., RNM #1 stated she is not sure if she let the facility SW know the resident had missed [MEDICAL TREATMENT] on 9/10/15. The RNM stated she was in contact with [MEDICAL TREATMENT], they were comfortable with the resident missing [MEDICAL TREATMENT] on 9/10/15, and assured her that transportation was set for Saturday (9/12/15). She said she felt the situation was handled and passed the information along to the fifth floor. e. At 11:55 a.m. by telephone, the [MEDICAL TREATMENT] center SW stated that if a resident is on Medicaid, standing orders are coordinated for transportation. The SW stated that because the resident was spending down Medicaid, and his representative payee was an outside agency in charge of paying his spend down, it is the responsibility of the nursing home and the representative payee to ensure that the resident's insurance stays active. The [MEDICAL TREATMENT] SW said that she contacted the outside agency on 9/11/15 and did not get a return call. She said she worked at a different clinic on Friday and did not learn that the resident missed a second [MEDICAL TREATMENT] session until Monday (9/14/15). f. At 1:50 p.m., LPN #1 said that she worked on the fifth floor on 9/11/15 when the resident was transferred to the unit. She said RNM #1 did not inform her that the resident missed [MEDICAL TREATMENT] on 9/10/15, or of any transportation concerns. g. At 2:10 p.m., RNM #1 stated that if there is a major issue, she would contact the Director of Nursing (DON). She said the plan was to monitor the resident daily; his vital signs are checked on [MEDICAL TREATMENT] days. She said that she did not speak to the DON, ADON, or NP, as [MEDICAL TREATMENT] reported it was not critical that the resident missed [MEDICAL TREATMENT] on 9/10/15. RNM #1 did not know who she spoke with at the [MEDICAL TREATMENT] center. h. At 2:50 p.m., the ADON said that he would expect staff to notify medical, monitor vital signs, and report any changes. He said the [MEDICAL TREATMENT] center, SW, and medical were aware. He said it would not hurt to notify the ADON/DON; it is an RN judgement call. i. At 2:56 p.m., RNM #2 stated that when the resident was transferred to the unit on 9/11/15, RNM #1 did not mention a missed [MEDICAL TREATMENT] session. j. At 3:10 p.m., LPN #2 said that she worked evenings on 9/12/15, and it had been reported that the resident missed two [MEDICAL TREATMENT] sessions. She said the resident stated he felt rough, he did not eat and drink well, his respirations became labored, and his blood pressure was still high. She said she called the oncall NP, and the resident was sent to the emergency room for evaluation. Interviews on 9/18/15 included the following: a. At 9:00 a.m., the ADON stated in hindsight, everything that occurred on 9/15/15 to coordinate the resident's transportation to [MEDICAL TREATMENT] should have occurred on 9/10/15. b. At 9:20 a.m., the facility NP stated that she did not know the resident had been hospitalized until he returned to the facility on Tuesday. She said she worked on 9/10/15 and did not realize the resident missed [MEDICAL TREATMENT]. The NP said often, [MEDICAL TREATMENT] tries to schedule the resident later in the day or the following day. The NP also stated she would have been asking about transportation, even if the facility had to absorb the cost. She said residents get very sick when a [MEDICAL TREATMENT] session is missed. She said that she did not have any discussion with RNM #1 regarding this resident missing [MEDICAL TREATMENT] or a plan to monitor. c. At 9:50 a.m., LPN #3 stated she came in to work days on 9/12/15, and it was reported to her that the resident was not picked up for [MEDICAL TREATMENT] that morning (5:30 a.m. pick up). She said the RN Supervisor reported she had made several calls to the [MEDICAL TREATMENT] center and was told near the end of the shift that there was no transportation. She said the RN contacted the oncall NP, blood work was ordered for Monday (9/14/15), and the resident was put on the list to be evaluated by medical on Monday. LPN #3 said that she reported the elevated blood pressure (178/102) to the RN, who said the resident's blood pressure was elevated because he needs to be dialyzed. d. At 10:10 a.m. by telephone, the [MEDICAL TREATMENT] Center Coordinator (DCC) stated that when the resident did not show for [MEDICAL TREATMENT] on Saturday (9/12/15) morning, the nurse attempted to contact the facility three times, with no answer. At approximately 10:00 a.m., a facility nurse contacted the [MEDICAL TREATMENT] nurse, and was told if the resident cannot get to the [MEDICAL TREATMENT] center, then he needs to go to the emergency room . The DCC said there is no documentation that the [MEDICAL TREATMENT] nurse spoke to anyone at the facility on 9/10/15 and 9/11/15. She said the [MEDICAL TREATMENT] center would not say that it is fine to miss a [MEDICAL TREATMENT] session; the plan would be to reschedule. e. At 11:00 a.m. by telephone, the [MEDICAL TREATMENT] nurse that was working on 9/10/15 and 9/12/15 stated that the facility Director of Social Work (DSW) called on 9/11/15 to discuss the resident's smoking. She said she asked the DSW, if she was aware the resident missed [MEDICAL TREATMENT] on 9/10/15, and she responded yes. The [MEDICAL TREATMENT] nurse said she told the DSW that the resident cannot miss his sessions. The [MEDICAL TREATMENT] nurse said then Saturday (9/12/15) arrives and the resident is a no show. She said the facility nurse called her around 10:00 a.m. (9/12/15), and she told the nurse, if the resident cannot get any transportation, he needs to get to the hospital. She said the facility nurse stated she thought the [MEDICAL TREATMENT] NP was working on transportation. The [MEDICAL TREATMENT] nurse said that the NPs do not coordinate transportation. f. At 11:22 a.m. by telephone, the facility DSW said that she was unaware the resident missed two [MEDICAL TREATMENT] sessions because of transportation until 9/14/15. She said she spoke with the [MEDICAL TREATMENT] nurse on 9/11/15, and she mentioned the Medicaid spend down related to transportation for the resident. She said the facility SW had been working with the outside agency regarding the Medicaid spend down. She said that RNM #1 reported she had talked to [MEDICAL TREATMENT], but she did not know the reason the resident missed [MEDICAL TREATMENT]. g. At 11:35 a.m., the RN Supervisor stated that the [MEDICAL TREATMENT] nurse commented during the conversation at 2:15 p.m. on 9/12/15 that if you want you can send the resident to the hospital. She said she called the oncall NP with intent to send the resident to the hospital, but instead the NP ordered the blood work and follow up with medical on 9/14/15. She said that LPN #3 did not report a high blood pressure, she said she would have written it in the note and reported it to the NP. h. At 1:00 p.m., the oncall NP stated that she received a call from the facility on 9/12/15 at 3:15 p.m., from the RN Supervisor stating the resident did not have transportation to [MEDICAL TREATMENT]. The NP said the she asked the nurse why there was no transportation, and she reported it was due to insurance. The NP asked if there was a family member that could transport, and she was told no. She said she told the nurse to check blood work on Sunday 9/13/15. She said her plan was to complete blood work on Sunday (9/13/15) and based on the labs, evaluate if the resident needed to go to the hospital for [MEDICAL TREATMENT]. The NP said that she was not told that the resident missed [MEDICAL TREATMENT] on 9/10/15. She said if she had that information, she would have immediately sent the resident to the hospital to be dialyzed. She said she did not ask for vital signs, and none were provided. She said she thought the resident had just missed his session that day (9/12/15). The NP said she then received another call at 7:30 p.m. (9/12/15), from the facility nurse who reported the resident was experiencing hypertension, nausea, and dizziness. She said she immediately sent the resident to the hospital. The NP said this could have been avoided if it was communicated that the resident missed two [MEDICAL TREATMENT] sessions. The facility admission agreement includes under Services not included in the daily rate that the resident may obtain other diagnostic therapeutic services on a fee for service basis provided that such services are prescribed by your physician and arranged by the facility. Such services include, but are not limited to, the following: transportation, including ambulance or chairmobile. The facility's policy, [MEDICAL TREATMENT], last reviewed 10/23/13, does not include any guidance related to a resident's need for transportation. (10 NYCRR 415.12)