Every finding on record at Manhattanville Health Care Center

Based on observation, record review, and interviews during the Recertification Survey conducted from 06/04/2025 to 06/11/2025, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections. This was evident in 1 (Resident #152) of 1 resident reviewed for Transmission-Based Precautions out of a total sample of 38 residents. Resident #152, who was diagnosed with Clostridium Difficile, was not cohorted and was sharing a room with another resident who was not infected with Clostridium Difficile. The findings are: The facility's policy and procedure titled Clostridium Difficile reviewed on 02/2025 documented that measures are taken to prevent the occurrence of Clostridium Difficile Infections among residents. Residents with Clostridium Difficile Infections are placed in a private room if available, or cohorted in the [NAME] oom with other residents with Clostridium Difficile Infections. If cohorting is not possible, they can be placed in rooms with residents who are at low risk for Clostridium Difficile acquisition. Resident #152 was admitted to the facility with diagnoses include Deep Venous Thrombosis, Diabetes Mellitus, and Neurogenic Bladder. The Annual Minimum Data Set, dated [DATE] documented Resident #152 had intact cognition and was dependent for toileting. Laboratory findings documented stool tested for Clostridium Difficile on 05/28/2025 and result showed positive for Clostridium Difficile on 05/30/2025. The Nursing Note dated 05/30/2025 documented stool tested positive for Clostridium Difficile, and physician ordered antibiotic for 10 days. The Physician's Order revealed that Resident #152 was placed on Contact Precaution for Positive Clostridium Difficile on 06/01/2025. A review of Resident #152's medical record revealed no documented evidence that the facility attempted to isolate Resident #152 with Clostridium Difficile infection to a single room or that Resident #11 was temporarily placed in a different room. On 06/10/2025 at 11:40 AM, an interview was conducted with Certified Nursing Assistant #3. Certified Nursing Assistant#3 stated Resident #152 is dependent for toileting and requires incontinent care. Resident #152 initially had an episode of loose, watery stool and was placed on Contact Precautions for Clostridium Difficile and currently still on Contact Precautions. Certified Nursing Assistant #3 stated they follow the Contact Precautions procedure when Resident #152 requires assistance. They will wash hands, wear gown, mask, gloves prior to entering the room and discard Personal Protective Equipment in the bin prior to exiting the room. They stated, however, Resident #11 who is the roommate, does not have any precautions. They stated they do not utilize the personal protective equipment when assisting Resident #11 since they were only changing Resident #11's bed sheets. On 06/10/2025 at 11:58 AM, Registered Nurse #2 stated they were notified that Resident #152 was having diarrhea. Stool was collected and turned out positive for Clostridium Difficile on 05/30/2025. Antibiotic was ordered for 10 days by the physician. Resident #152 was also placed on Contact Precaution as per order. Registered Nurse #2 further stated Resident #11 who was the roommate, is also dependent in toileting and requires incontinent care. They stated staff does not require to wear full Personal Protective Equipment if they are not in contact with Resident #152. On 06/11/2025 at 12:11 PM, an interview was conducted with Director of Nursing who is also the Infection Preventionist. The Director of Nursing stated Resident #152 tested positive for Clostridium Difficile, and was ordered antibiotic for 10 days, and placed on Contact Precautions. The Director of Nursing stated Resident #152 was not removed from the shared room with Resident #11 because there was no private room available at the time. 10 NYCRR 415.19(b)(1)

Based on observation, record review, and interviews during the Recertification Survey conducted from 06/04/2025 to 06/11/2025, the facility failed to ensure food were stored in accordance with professional standards for food service safety. This was evident in 1 (Unit 3) of 3 units observed. Specifically, expired frozen food were stored in Unit 3 pantry refrigerator. The findings are: The facility policy and procedure titled Storing of Food Brought in by Families with a reviewed date of 06/2025 documented if a family member brings in food for a resident, the food must be labeled with the resident's name and date it was put in the fridge to ensure it is not stored for too long. All food that is stored in the fridge and not consumed within 72 hours will be disposed of. On 06/09/2025 between 12:47 PM to 12:57 PM, the refrigerator in the Unit 3 pantry was observed, with: 1.) an opened box of fish sticks with a best by date of 05/10/2025, the box was labeled with a resident's name and had a handwritten date of 03/15/2025. 2.) An unopened box of honey roasted turkey breast with a best by date of 08/21/2024, the box was labeled with a resident's name and had a handwritten date of 03/15/2025. During an interview on 06/09/2025 at 1:03 PM, the Assistant Dietary Manager stated food brought in by families must be kept in the refrigerator and discarded in 3 days. During an interview on 06/09/2025 at 1:08 PM, Registered Nurse #3 stated expired food items in the refrigerator must be discarded because it can cause food poisoning. During an interview on 06/11/2025 at 2:18 PM, the Director of Dining Services stated it is the unit nurses' responsibility to dispose expired items in the unit pantry refrigerator. During an interview on 06/11/2025 at 2:21PM, the Director of Nursing stated expired food items found in the refrigerator should be discarded because it can cause illnesses. They stated family members of residents who bring in food for the residents are educated that food is kept only for 72 hours. 10 NYCRR 415.14 (h)

Based on observation, record review, and interviews during the Recertification Survey conducted from 06/05/2025 to 06/11/2025, the facility failed to store all drugs and biologicals in locked compartments and under proper temperature controls. This was evident in 1 (Unit 3) of 5 medication storage areas observed. Specifically, 1.) Calcitonin spray was kept in the medication cabinet and was not refrigerated, 2.) The medication refrigerator was not locked, and 3.) An opened vial of haloperidol had no date of when it was first opened. The findings are: The facility's policy titled Medication Storage which was last reviewed in 2025 documented medications requiring refrigeration will be stored in a separate locked refrigerator. All medications, including treatment items, are stored in a locked cabinet or room inaccessible to residents and visitors. On 06/11/2025 at 12:59 PM, the Unit 3 medication room was observed with Registered Nurse #3. A bottle of unopened calcitonin spray with a label that stated refrigerate was observed in the medication cabinet and was not refrigerated. There was an opened vial of haloperidol injection that has no date when it was first used/opened. The medication refrigerator was observed with no lock. Inside the refrigerator were multiple vials of insulin, eye drops, and purified protein derivative skin test solution. During an interview on 06/11/2025 at 1:09 PM, Registered Nurse #3 stated vials should be labeled with date when it was first opened. They stated that the medication room is kept locked, however, the refrigerator never had a lock since they started working in the unit. During an interview on 06/11/2025 at 1:44 PM, Registered Nurse #4 stated they are not sure if the calcitonin needs to be refrigerated and that they need to check the physician's order. They stated no one is allowed to enter in the medication room but the licensed nurses. Registered Nurse #4 stated the haloperidol vial should have been labeled with the date it was opened. They stated they lock the medication refrigerator if they store morphine inside. During an interview on 06/11/2025 at 3:01 PM, the Pharmacist stated calcitonin nasal spray must be refrigerated. During an interview on 06/11/2025 at 2:05 PM, the Director of Nursing stated the calcitonin nasal spray should be placed in the refrigerator and that the licensed nurse should have put the date on the haloperidol vial when it was first opened. 10 NYCRR 415.18(e)(1-4)

Based on observation, record review, and interview during the Recertification Survey conducted from 06/04/2025 to 06/11/2025, the facility failed to ensure that residents are free of any significant medication errors. This was evident in 1 (Resident #151) of of 8 residents reviewed during the Medication Administration Task. Specifically, Resident #151 was not administered 5 milliliters of Ferrous Sulfate 300 milligram/5 milliliters as ordered by the Physician. The findings are: The facility policy titled Medication Administration which was last reviewed on 04/2025 documented that medications are administered by the licensed nurse in accordance with the physicians order. Whenever medications are administered, the dose, frequency, timing and route of administration are consistent with the order. Resident #151 had active diagnoses of Iron Deficiency Anemia, Chronic Kidney Status, and Gastrostomy Status. A Care Plan titled Anemia/Hematology last updated on 04/10/2025 documented that Resident #151 had alteration in hematological system related to anemia and is below normal hemoglobin with a hemoglobin level of 8.8 gram/deciliter and hematocrit of 25.9% as of 04/02/2025. The facility interventions included to administer medications as ordered, assess effectiveness and monitor untoward effects. The most recent diagnostic laboratory result dated 04/02/2025 documented Resident #151 had a red blood cell count of 3.08 (normal range: 4.63 - 6.08), hemoglobin of 8.8 (normal range: 13.7 - 17.5) and hematocrit of 25.9 (normal range: 4.01 - 51.0). A physician's progress note dated 05/27/2025 documented that Resident #151 had anemia and should continue with Ferrous Sulfate. A physician's order renewed on 05/27/2025 documented to give 5 milliliters (300 milligram) of Ferrous Sulfate 300 milligram (60 milligram iron)/ 5 milliliters oral liquid by gastrostomy-tube route once daily every day at 10:00 AM for Iron Deficiency Anemia. On 06/10/2025 at 9:48 AM, Licensed Practical Nurse #1 was observed pouring 5 milliliters of Ferrous Sulfate 220 milligram/5 milliliters into a pill cup. The Medication Administration Record stated to administer 5 milliliters (300 milligram) by gastrostomy tube route once daily for Iron deficiency Anemia. On 06/10/2025 at 9:55 AM, the Surveyor asked Licensed Practical Nurse #3 about the inconsistency between the actual Ferrous Sulfate dose on the bottle and the dose prescribed by the physician. Licensed Practical Nurse #3 stated they did not realize Resident #151 should be getting 5 milliliters of a 300 milligrams/5 milliliter concentration rather than 5 milliliters of 220 milligram/5 milliliters. Licensed Practical Nurse #1 further stated that the Ferrous Sulfate 220 milligram /5 milliliter is the usual house stock and is not supplied by the pharmacy. On 06/10/2025, at approximately 10:08 AM the Licensed Practical Nurse #1 proceeded to administer 5 milliliters of Ferrous Sulfate 220 milligram/5 milliliters to Resident #151 via gastrostomy tube and then flushed with 5 milliliters of water afterwards. On 06/10/2025 at 10:18 AM, the Registered Nurse #3 was interviewed and stated that the medication nurse is responsible for double checking medications before administering them to residents. They stated if there is a difference in the dosing prescribed and what's in the cart, then the dosing must be recalculated through use of a formula. Staff are aware to recalculate dosing if there is a difference in what is ordered compared to what is present in the cart. However, nurses should always be double checking the medications in the cart against the Medication Administration Record before administering them to residents. On 06/11/25 at 11:57 AM, Physician #1 was interviewed and stated that Resident #151 has a history of anemia and is chronically anemic. They stated they are trying to maintain Resident #151 levels of hemoglobin so that it does not drop further. Physician #1 further stated that if the Resident #151 does not get the prescribed dose of medication as ordered, the resident can get even more anemic. On 06/11/2025 at 10:19 AM, the Director of Nursing Services was interviewed and stated medication nurses are responsible for checking medications every time before administering them to resident. The nurses are responsible to ensure that the resident's name, dose, frequency and amount of medications to be given is accurate. The Director of Nursing stated for a resident with anemia and low hemoglobin levels, it is important that the resident receives the dose as prescribed by the physician as the dosing is intended to cure or stabilize the resident's condition. If the dose prescribed is not given, the resident is at risk for complications as the anemia is not being properly treated and the resident may become more unstable. 10 NYCRR 415.12 (m) (2)

Based on observation, record review, and interviews during the Recertification Survey conducted from 06/04/2025 to 06/11/2025, the facility failed to ensure that a resident who is administered enteral tube feedings, received the appropriate treatment and services to prevent complications. This was evident in 1 (Resident #151) of 2 residents reviewed for Tube Feeding and 1 of 8 residents reviewed during the Medication Administration Task. Specifically, during observation on 06/09/2025 at 9:50 AM, Resident #151's enteral tube feeding formula that was being administered was not labeled with the resident's name, the date and start time of the administration, or the flow rate. Additionally, during medication administration observation conducted on 06/10/2025, Licensed Practical Nurse #1 did not verify the functioning of Resident #151's gastrostomy tube before administering medications. The findings are: The facility's policy and procedure titled Enteral Tube Feedings with a reviewed date of 06/2025 documented that enteral tube feedings will be ordered by the physician for the purpose of providing optimal nutritional intake for those residents who are unable to consume food and fluids. All feedings will be given as ordered by the physician. The physician's order for enteral tube feedings will be written on the tube feeding order in the electronic medical record. Orders for tube enteral feedings will specify formula/rate/number of hours, start time, end time, and formula amount per feeding. A new tube feeding set will be supplied by the nurse at the beginning of the tube feeding each day and discarded at the end of the feeding. It is labeled, dated, and initialed. The nurse documents in the electronic medical record the administration of enteral tube feedings. The policy also documented checking for placement must be done before the start of each feeding, before reconnection of tube and prior to giving medications every time. The steps to check for tube placement include to unclamp the tube, place clean stethoscope head on the abdomen over the stomach and push the plunger that of the syringe and listen to the air to confirm placement. Resident #151 was admitted to the facility with diagnoses that included Cerebral Infarction and Dysphagia. The Minimum Data Set assessment dated [DATE] documented that Resident #151 had severely impaired cognition and received 51 percent or more of feedings and 501 milliliters or more of fluids through a percutaneous endoscopic gastrostomy tube. A care plan for tube feeding was initiated for Resident #151 on 04/04/2024. The care plan documented that Resident #151 was on tube feeding due to dysphagia and was at risk for aspiration secondary to tube feeding. The facility interventions include to check feeding tube for placement and patency before each fluid, feeding, and medication administration; and to assess resident for complication related to feeding tube. 1. On 06/09/2025 at 9:50 AM, Resident #151 was observed in bed. The enteral feeding formula of Jevity 1.5 was being administered via a continuous pump at a rate of 70 milliliters per hour. The 1000 milliliters enteral feeding formula bottle contained a remaining 500 milliliters of formula and was observed with an affixed label that was blank that did not document the resident's name, the date and start time of the administration, or the flow rate of the enteral tube feeding formula. On 06/10/2025 at 9:37 AM, Resident #151 was observed in bed. The enteral feeding formula of Jevity 1.5 was being administered via a continuous pump at a rate of 70 milliliters per hour. The 1000 milliliters enteral feeding formula bottle contained a remaining 700 milliliters of formula and was observed with an affixed label that was blank that did not document the resident's name, the date and start time of the administration, or the flow rate of the enteral feeding formula. A nutritional assessment dated [DATE] documented that Resident #151 was on a tube feeding of Jevity 1.5 to be administered at a rate of 70 milliliters per hour for 18 hours. A physician's order dated 04/02/2025 documented a tube feeding administration order of Jevity 1.5 to be administered at a rate of 70 milliliters per hour for 18 hours. The start time is 4:30 PM and end time at 10:30 AM. The formula amount per feeding is 1260 milliliters. On 06/10/2025 at 9:40 AM, Registered Nurse #3, who was the Charge Nurse, was interviewed and stated that they are unsure of what time, or which nurse hung Resident #151's enteral tube feeding formula that was currently being administered. Registered Nurse #3 also stated that 2 bottles of formula are administered to Resident #151 every day and they are unsure which bottle is currently being administered because there is no documentation on the formula bottle or in the medication administration record. Registered Nurse #3 further stated that it is the responsibility of the nurse who administers the feeding formula to document the details of the feeding on the formula bottle and record the administration in the medication administration record. On 06/10/2025 at 9:59 AM, Registered Nurse #4, who was the nursing supervisor, was interviewed and stated that it is the policy of the facility that every nurse who starts the administration of enteral tube feeding should label the formula bottle with the resident's name, the date and time when administration was started and the flow rate of the formula. On 06/11/2025 at 2:28 PM, The Director of Nursing was interviewed and stated that once the enteral tube feeding formula bottle is hung to be administered, the bottle has to be labeled with the resident's information and details of the prescribed feeding. 2.) A Physician's order dated 03/31/2025 documented to check the placement of tube before each feeding. However, there were no active physicians' orders to check the placement of the Gastrostomy tube prior to administration of medications. During medication administration observation conducted on 06/10/2025 between 10:00 AM-10:15 AM, Licensed Practical Nurse #1 administered medications to Resident #151 via gastrostomy tube without verifying the functioning of the gastrostomy tube before administering the medication. On 06/10/2025 at 10:14 AM, Licensed Practical Nurse #1 was interviewed and stated they did not confirm the placement of the gastrostomy tube for Resident #151 prior to administering medications today and that they are supposed to check the placement of the Gastrostomy tube by listening with a stethoscope for a swoosh sound. Licensed Practical Nurse #1 further stated it is important to check the placement to ensure the tube is in the right place. On 06/10/2025 at 10:18 AM, the Registered Nurse #3 was interviewed and stated it is important to use the stethoscope and listen for a gurgling sound to confirm functioning of gastrostomy tube prior to medication administration. If the placement of the gastrostomy tube is not confirmed prior to medication administration, then the medications can leak through, and resident can potentially suffer from aspiration. On 06/11/2025 at 10:19 AM, The Director of Nursing Services was interviewed and stated that the standard way to check the placement of the gastrostomy tube is by placing the stethoscope on the abdomen of the resident, pushing the plunger of syringe and listening to the air to confirm placement. The Director of Nursing Services stated that it is important to check the functioning of the gastrostomy tube, prior to administration of medications, to ensure it is not malfunctioning. The Director of Nursing Service further stated that medication competencies are done upon hire and annually for nurses. When asked if there were any updated policies on how to verify the functioning of the Gastrostomy tube, the Director of Nursing Services stated they were not sure and would have to check the state regulations. 10 NYCRR 415.12(g)(2)

Based on record review and interviews during the Recertification Survey conducted from 06/04/2025 to 06/11/2025, the facility failed to ensure that the binding arbitration agreement provides for the selection of a venue that is convenient to both parties. This was evident in 3 (Resident #36, #141, and #289) of 38 total sampled residents. Specifically, the Binding Arbitration Agreement signed by Residents #36, #141, and #289 did not contain documented evidence that the agreement addresses the selection of a venue that is convenient to both parties. The findings are: The facility's Arbitration policy with a last revised date of 01/05/2025 documented that the agreement shall provide for the selection of a venue that is convenient for the selection of a neutral venue arbitrator. The Voluntary Agreement to Arbitrate signed by Residents #36, #141, and #289 documented in Article 8 that the seat or place of arbitration shall be the State of New York, [NAME] County. On 06/10/2025 at 2:42 PM, the Admissions Director was interviewed and stated that the arbitration agreement is included in the admission package. The residents have the option to select a neutral arbitrator and that the place of Arbitration is in [NAME] County, New York. On 06/10/2025 at 3:00 PM, the Administrator was interviewed and stated that the place for arbitration as stated in the agreement is in [NAME] County in the State of New York. The Administrator stated they have not had any residents go into arbitration, but if they do the arbitrators must select the location. They stated they were not saying that the arbitration must take place in a specific place and that [NAME] County must have been given by accident. 10 NYCRR 415.30

Based on observation, interviews, and record review conducted during an abbreviated survey (NY00304506) the facility failed to implement their policy and procedure on reporting an alleged violation involving abuse to local law enforcement immediately, but no later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. This was evident in 1 out of 3 residents reviewed (Resident #1). Specifically, Resident #1 reported to the Social Worker (SW) and Licensed Practical Nurse (LPN) #1, on 10/26/2022, that Certified Nursing Assistant (CNA) #1 was rough with them during care and hit them on their upper body and on their arms. The facility investigated the allegation and concluded that there was reasonable cause to believe that resident abuse had occurred. The facility did not report the reasonable suspicion of abuse to law enforcement. The Findings include: The facility's Policy and Procedure titled Abuse Prevention protocol reviewed on 02/2022 under Reporting documented that In response to allegation of abuse, neglect, exploitation, or mistreatment, the facility must ensure that: all allegations of abuse must be immediately reported to the administrator and no later than 2 hours to other officials (including to the State Survey Agency) after the allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury. The alleged violations must be reported no later than 24 hours to the State Survey Agency if the events that caused the allegation do not involve abuse and do not result in serious bodily injury. The Policy further documented that. The facility will follow Federal Law 1150B of Social Security Act, which requires any individual employee having reasonable suspicion that crime has occurred against a resident is required to report the suspicion to Law Enforcement and State Survey Agency. Resident #1 was initially admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus type 2 and Mood disorder. The Minimum Data Set (MDS, a resident assessment tool) dated 09/30/2022 documented that Resident #1 had a Brief Interview of Mental Status exam and scored 15 indicating intact cognitive status. The facility's Incident Report Summary dated 10/31/2022 documented that on 10/26/2022 at about 3:00 PM Resident #1 reported to the charge nurse and the Social Worker that on 10/24/2022 during the night shift a staff member answered a call bell and Resident #1 requested a brief change. The staff member said that they would be back however no one showed up until 4:30 AM. At 4:30 AM the assigned CNA #1 came into the room and proceeded to change Resident #1's brief. Resident #1 stated that CNA #1 was rough, hitting them on their upper body and arms. Resident #1 reported that they screamed out for help, but no one came in. Resident #1 stated that CNA #1 left the room and came back shortly after and apologized to them for their behavior. Resident #1 who has impaired vision (legally blind) was able to identify CNA #1 by voice as the accused staff member. Resident #1's roommate was interviewed and stated that they heard commotion and could hear someone slapping Resident #1, but they did not see anything. On 10/27/2022 Resident #1 was examined by the nursing supervisor and found with old scars. Resident #1 denied pain. Resident #1 requested to remove CNA #1 from their assignment and was reassured of their safety in the facility. Resident #1 was seen and examined by the Nurse Practitioner and the psychiatrist with no new orders recommended. The facility investigation concluded that there was reasonable cause to believe that Resident abuse had occurred. On 02/27/2023 at 10:42 AM, Resident #1 was interviewed and stated that the incident happened in September 2022. Resident #1 stated that during the night shift they asked their assigned CNA #1 to change their soiled brief and the CNA left the room and returned one and a half hours later. Resident #1 stated that CNA #1 began pulling their brief open and was handling them roughly. Resident #1 stated that CNA #1 hit them on their arms, shoulders, and face. Resident #1 stated that they yelled out for help, but no one came. Resident #1 stated that their roommate heard them screaming and told to CNA #1 to leave them alone and stop hitting them. Resident #1 stated that CNA #1 walked out of the room and returned shortly after, rested their face on Resident #1's chest and apologized. On 02/28/23 at 02:23 PM, the Director of Nursing (DON) was interviewed and stated that the allegation was investigated, and the facility concluded that there was reasonable cause to believe abuse had occurred. However, they did not call the police because Resident #1 did not have any physical marks. The DON stated that they only call the police when there are physical marks or injury. On 02/28/23 at 3:13 PM, the Administrator was interviewed and stated that they don't remember when they were notified of the incident. The Administrator stated that they are saying that they cannot rule out abuse and if they are going to take away someone's job and food, they must be very careful. The Administrator stated that if abuse had occurred, the police would have been called, but in this case, there was no abuse. 10 NYCRR 415.4(b)

Based on interviews and records review conducted during an abbreviated survey (NY00304506), the facility failed to protect residents from further potential abuse, neglect, exploitation, or mistreatment while an investigation of an alleged violation of abuse was in progress. This was evident for 1 out of 3 residents sampled (Resident #1). Specifically, Resident #1 reported to the Social Worker (SW) and Licensed Practical Nurse (LPN) #1, on 10/26/2022, that Certified Nursing Assistant (CNA) #1 handled them roughly during care and hit them on their upper body and arms on 10/24/2022 at approximately 4:30 AM. Although, the facility's Investigation Report, dated 10/31/2022, concluded that there was reasonable cause to believe that abuse had occurred, CNA #1 remained on the Staffing Schedule and continued to provide care to residents. CNA #1 was suspended for two days, 11/04/2022 and11/05/2022. The findings were: The facility Policy entitled Abuse Prohibition dated 02/2022 documented The facility will protect all Residents during any abuse investigation by removing staff from direct care and/or removing from schedule pending conclusion. The facility will provide counseling and support for Resident as needed. The findings are: Resident #1 was initially admitted to the facility with diagnoses including type 2 Diabetes Mellitus and Mood disorder. The Minimum Data Set (MDS, a resident assessment tool) dated 09/30/2022 documented that Resident #1 had a Brief Interview of Mental Status exam and scored 15 indicating intact cognition. A Nurse's Note dated 10/26/2022 written by the Licensed Practical Nurse, (LPN) #1 documented that Resident #1 reported that on Monday morning at around 1:30 AM Resident #1 called for their brief to be changed and someone (CNA #1) responded at 4:30 AM. Resident #1 stated that the CNA #1 to provided incontinent care and treated them roughly. CNA #1 used their hands to hitting Resident #1 on Resident #1's upper body and arms. Resident #1 reported that they sustained starches on their arms from CNA #1's rough handling. Resident #1 also reported calling for help, but no one came. in. Resident #1's roommate was interviewed and stated they did not see the incident, but they heard Resident #1 calling out for help and told the CNA to stop hitting the Resident. Resident #1's roommate also stated that they heard the noise as if someone was hitting a person. The Registered Nurse Supervisor (RNS) and the Assistant Director of Nursing (ADON) were notified. A Facility Daily Staffing sheet dated 10/26/2022, revealed that CNA #1 was scheduled to work the 12:00 AM to 8:00 AM shift on the 5th floor (Resident #1's unit). A unit assignment sheet dated 10/26/2022, revealed that CNA #1 worked on 10/26/2022 and was assigned to Resident #1. A Facility Daily Staffing sheet dated from 10/27/2022 to 11/02/2022, revealed that CNA #1 was scheduled to work on the 12:00 AM to 8:00 AM shift on the 6th floor. A unit assignment sheet dated from 10/27/2022 to 11/02/2022, documented that CNA #1 worked on the 6th floor and was assigned to provide resident care. A facility Incident Report Summary dated 10/31/2022 documented that on 10/26/2022 at about 3:00 PM, Resident #1 reported to the charge nurse and the Social Worker that on 10/24/2022 during the night shift a staff member answered a call bell and Resident #1 requested a brief change. The staff member said that they would be back however no one showed up until 4:30 AM. At 4:30 AM the assigned CNA #1 came into the room and proceeded to change Resident #1's brief. Resident #1 stated that CNA #1 was rough, hitting them on their upper body including their arms. Resident #1 screamed out for help, but no one came in. Resident #1 stated that CNA #1 left the room and came back shortly after and apologized to them for their behavior. Resident #1 with impaired vision ( legally blind) was able to identify CNA #1 by voice as the accused staff member. Resident #1's roommate was interviewed and stated that they heard commotion and could hear someone slapping Resident #1, but they did not see anything. On 10/27/2022 Resident #1 was examined by the nursing supervisor and found with old scars. Resident #1 denied pain. Resident #1 requested that CNA #1 be removed from their assignment. Resident #1 was reassured of their safety in the facility. Resident #1 was seen and examined by the Nurse Practitioner and the psychiatrist with no new orders recommended. CNA #1 was re-assigned to other units and suspended for two days starting on 11/4/2022. CNA #1 was re-educated on Abuse after return to work. The facility investigation concluded that there is reasonable cause to believe that Resident abuse has occured. On 02/27/2023 at 10:42 AM Resident #1 was interviewed and stated that during the night shift they asked their assigned CNA #1 to change their soiled brief and CNA #1 left the room and returned one and a half hours later. Resident #1 stated that CNA #1 was rough while CNA #1 was pulling their brief opened. Resident #1 stated that CNA #1 hit them on their arms, shoulders, and face. Resident #1 stated that they yelled out for help, but no one came. Resident #1 stated that their roommate heard them screaming and told to CNA #1 to leave them alone and stop hitting them. Resident #1 stated that CNA #1 walked out of the room, came shortly after, and rested their face on Resident #1's chest and apologized. On 02/28/23 at 02:23 PM, the Director of Nursing (DON) was interviewed and stated that Resident #1, who is visually impaired, reported to SW #1 and Licensed Practical Nurse (LPN) #1 on 10/26/22 at 3:00 PM, that on 10/24/22 on the 12:00 AM to 8:00 AM shift, Resident #1 rang the call bell and a staff member, identified as CNA #1, came to their room and Resident #1 asked CNA #1 to change their brief. The DON stated that Resident #1 reported that CNA #1 told Resident #1 that they would be back, but that CNA #1 returned to the room at 4:30 AM. The DON stated that Resident #1 reported that CNA #1 proceeded to change their brief and was rough with them. The DON stated that Resident #1 verbalized that CNA #1 hit them on their hands, arms, and upper body. The DON stated that Resident #1 stated that they were calling for help and their roommate told CNA #1 to leave Resident #1 alone and CNA #1 left the room. The DON stated that Registered Nurse Supervisor (RNS) #1 assessed Resident #1 on 10/27/2022 with some old scars. The DON stated that Resident #1 identified CNA #1, by the CNA's voice, as the perpetrator. The DON stated that CNA #1 was removed from Resident #1's assignment and was placed on another unit. The DON stated that Resident #1's roommate was interviewed and stated that they heard staff came into the room and Resident #1 asked for their brief to be changed. The roommate stated that they heard a commotion and someone slapping Resident #1. The roommate also stated that Resident #1 was calling for help. The DON stated that the roommate also reported asking what's the problem there and told CNA #1 to leave Resident #1 alone. The DON stated that they investigated the allegation and concluded there was reasonable cause to believe that abuse had occurred. The DON stated that CNA #1 remained on the schedule and continued to work on another unit and was suspended from 11/04/22 to 11/05/22. The DON stated that they only have 2 CNAs to 40 residents and if they had terminated CNA #1, there would have been 1 CNA to 40 residents on the night shift. The DON stated that they did what they had to do. On 02/28/23 at 3:13 PM, the Administrator was interviewed and stated that they are saying that they cannot rule out abuse. The Administrator also stated that if they are going to take away someone's job and food, they must be very careful. They cannot take the word of one resident and terminate a staff. The Administrator further stated that Resident #1 does not like anyone, and only likes people like the Resident. The Administrator also stated that there were no concreate evidence and they moved CNA #1 to another unit. 10 NYCRR 415.4(b)(1)(i)

Based on record review and interview conducted during the Recertification survey from 3/9/23 and 3/16/23, the facility did not ensure that resident's comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. Specifically, the Comprehensive Care Plans (CCPs) for residents with significant weight loss were not updated and revised. This was evident for 3 of 6 residents reviewed for Nutrition out of 38 sampled residents. (Residents #18, #17, and #22,). The finding is: The facility Policy for Comprehensive Care Planning dated 11/1997, last revised 01/2023 documented that A Comprehensive Care Plan for each resident shall be developed through an interdisciplinary team approach. A Comprehensive Care Plan (CCP) team has been established to review each resident's own unique personal needs in an integrated and coordinated manner. Reviews are conducted on initial admission, readmission, hospital return, significant change of status and quarterly thereafter. 1. Resident #18 was admitted to the facility with diagnoses including Coronary Artery Disease and Dementia. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #18 was severely cognitively impaired, had a weight loss of 5% or more in the last month or a loss of 10% over the previous six months, and was not on a physician prescribed weight loss program. A Dietary Progress Note dated 10/12/22 at 1:16 PM documented that Resident #18 was triggered for undesired/unplanned significant weight loss for three months. The Quarterly MDS assessment dated [DATE] documented that Resident #18 was severely cognitively impaired, had a weight loss of 5% or more in the last month or a loss of 10% in the previous six months, and was not on a physician prescribed weight loss program. The Dietary Progress Note dated 12/28/22 documented that Resident #18 is triggered for unexpected/undesirable significant weight loss for six months. There was no documented evidence that the CCP for nutrition had been reviewed and revised after the MDS assessments on 10/7/22 and 12/30/22 which indicated that resident had a significant weight loss. 2. Resident #71 was admitted to the facility with diagnoses that include Anxiety Disorder, Bipolar Disorder, and Dementia The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that Resident # 71 was severely cognitively impaired, had a weight loss of 5% or more in the last month or a loss of 10% over the previous six months, and was not on a physician prescribed weight loss program. A Dietary Note dated 10/8/22 at 12:59 PM documented that Resident #71 is triggered for undesired/unplanned significant weight loss x 3 month. The Quarterly MDS assessment dated [DATE] documented that Resident #71 was severely cognitively impaired, had a weight loss of 5% or more or loss of 10% or more in last 6 months and was not on a physician-prescribed weight-loss regimen. A Dietary Progress Note dated 12/27/22 at 2:04 PM documented that Resident #71 weight loss is possibly related to disease progression. A Comprehensive Care Plan titled Nutrition Status was initiated on 2/28/17 and was last revised on 2/10/22. There was no documented evidence that the CCP for nutrition had been reviewed and revised when resident was identified with significant weight loss and after MDS assessments on 10/1/22 and 12/21/22. On 03/15/23 at 2:45 PM, an interview was conducted with the Registered Dietician (RD) who stated that care plans are updated after every assessment and when there is a significant nutritional change. The RD also stated Resident #71 was triggered for significant weight loss, so the care plan was updated on 3/13/23 with no new interventions added. On 03/16/23 at 9:55 AM, an interview was conducted with the Director of Nursing (DON) who stated that the Dietician is responsible for updating the nutrition care plan. The DON also stated that the regional consultant is responsible for overseeing the Dietician and the care plans are supposed to be updated every quarter, and after a significant change. 40565 3. Resident #22 was admitted to the facility with diagnoses that included Coronary Artery Disease, Cerebrovascular Accident, Non-Alzheimer's Dementia, and Depression. The Quarterly Minimum Data Set (MDS) dated [DATE] documented the resident had severe impairment in cognition with long and short-term memory problems. The MDS documented the resident is required extensive assistance of staff for most activities of daily living including eating and that the resident holds food in mouth/cheeks. The Annual MDS dated [DATE] and Quarterly MDS dated [DATE] documented that Resident #22 had a weight loss of 5% or more in the last month or loss of 10% or more in last 6 months documented, and was not on a physician-prescribed weight-loss regimen. The Comprehensive Care Plan (CCP) for Nutritional Status dated 12/16/2013, last updated 2/17/2022, documented that Resident is on the therapeutic diet secondary to Significant weight, loss: x 3 months (~ -12.37%), 6 months (~-14.62%). Goals included: - Resident will be adequately nourished as evidenced by absence of significant weight loss; Resident laboratory report(s) will be clinically stable per MD. Resident will continue to consume >75% of meals served x 90 days. The Long Term Care Survey Process (LTCSP) weight calculator documented On 09/13/2022, the resident weighed 152 lbs. On 03/06/2023, the resident weighed 123 pounds which is a -19.08 % Loss. This weight loss occurred over a 6 month period. The LTCSP weight calculator also documented On 02/22/2023, the resident weighed 129.6 lbs. On 03/06/2023, the resident weighed 123 pounds which is a -5.09 % loss. This weight loss occurred over a 12-day period. Progress Notes Dietary dated 12/24/2022 documented: Quarterly Assessment: .Current nutritionally pertinent medication includes . mirtazapine, Prilosec. Note: Mirtazapine - may increase appetite. There are no current nutrition related labs.Current Wt:131.5 (12/5) Ht: 66 in. Past Weight: 126.6 lbs. (11/14), 138 lbs. (10/14), 138 lbs. (9/30), 157.8 lbs. (8/16), 157.4 lbs. (7/19), 156 lbs. (6/21), 154.2 lbs. (5/31). Current BMI: 21.2 - WNL - low for geriatric age. Continues to trigger for unplanned/undesirable weight loss in 3 months ~12.37% and 6 months ~14.62% There was no documented evidence that the nutrition care plan was reviewed and revised since 2/17/2022 after MDS assessments or to reflect the documented weight loss or interventions to address the weight loss. On 03/14/23 at 11:08 AM, an interview was conducted with the Certified Nursing Assistant (CNA) #1 who stated that Resident #22 had been noted with some weight loss when transferred to the unit a few months ago and this was reported to the nurse. On 03/14/23 at 11:41 AM, an interview was conducted with the Charge Nurse, Licensed Practical Nurse (LPN) #1 who stated that the Resident's meal intake is documented by the CNAs in the CNA Accountability Record (CNAAR). LPN #1 also stated that Resident #22 was noted with some weight loss when transferred to the unit. LPN #1 further stated that any weight loss is discussed with the dietician who is responsible for reviewing and updating the resident's nutrition care plan. On 03/14/23 at 12:03 PM, an interview was conducted with the Registered Dietitian (RD) #1 who stated that the first assessment and quarterly evaluation was done in December 2022. RD #1 stated that when the nurses document the weight in the electronic medical record, at the end of the month, it is checked, and the weight is put in the meal tracker to generate a report. When the meal tracker was checked at the end of January, no changes were identified with Resident 22's weight loss. RD #1 further stated that they had planned to re-assess the resident at the end of the next quarter, which is currently due, and then update the CCP. RD #1 stated that they were not aware that the resident's care plan should be updated at every assessment. On 03/16/23 at 08:55 AM, an interview was conducted with the Registered Nurse Supervisor (RNS) #1. RNS #1 stated that monthly weight is done for a stable resident, and any resident observed with weight loss of 5% from the previous weight is reported to the dietician and then reported to the doctor for further intervention. The resident's weight will be monitored weekly until the weight is stabilized. RNS #1 stated that it is the responsibility of the dietician to update the nutrition care plan whenever there is significant weight change. RNS #1 further stated that they did not know that the resident's CCP for nutrition was not being updated. On 03/16/23 at 09:21 AM, an interview was conducted with the Director of Nursing (DON) who stated that if a resident is observed with significant weight loss, nursing staff will notify the doctor and the dietician. A calorie count will be recommended and ordered, and depending on the physician, the resident may be given appetite stimulant, and weekly weight monitoring. It will also be discussed by the interdisciplinary team. The DON also stated that the care plan must be updated by the dietician. The DON further stated that every discipline is required to update their care plan based on their clinical areas. 415.11(c)(2)(i-iii)

Based on record review and staff interviews conducted during the Recertification survey from 3/9/23 to 3/16/23, the facility did not ensure that comprehensive person-centered care plans were developed and implemented for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychological needs that are identified in the comprehensive assessment for 2 of 10 residents (Resident #26, Resident #29) reviewed for Accidents out of a total sample of 38 residents. Specifically, a Comprehensive Care Plan (CCP) had not been developed for safety measures related to smoking for Resident #26 and Resident #29. The findings are: The facility's policy and procedure titled Comprehensive Care Planning reviewed 1/23 documented Comprehensive Care Plan (CCP) shall be developed through an interdisciplinary team approach and CCP team review each resident's own unique personal needs in an integrated and coordinated manner. 1. Resident #26 was admitted to the facility with diagnoses of Depression, Non-Alzheimer's Dementia, and Diabetes Mellitus. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #26 had severely impaired cognition and required supervision for locomotion on and off unit. The Social Services progress note dated 6/20/22 documented that the Social Worker reviewed the facility's smoking policy with Resident #26 and resident's signature was obtained. Family was contacted and notified via voicemail. Review of the electronic medical record revealed that there was no documented evidence that a CCP for smoking was developed. 2. Resident #29 was admitted to the facility with diagnoses of Non-Alzheimer's Dementia, Schizophrenia, and Diabetes Mellitus. The Annual Minimum Data Set (MDS) assessment dated [DATE] documented cognition was moderately impaired and required supervision with locomotion on and off the unit. The Social Service progress note dated 7/20/22 documented Social Worker met with Resident #29 who stated that resident previously smoked years ago and wished to resume smoking again. Smoking policy was reviewed and signed by the resident. Review of the Comprehensive Care Plan (CCP) revised 12/26/22 revealed there was no documented evidence that CCP for smoking was developed. On 3/14/23 at 11:36 AM, Social Worker (SW) #1 was interviewed and stated that they are responsible for initiating and updating care plans for cognition, mood, advance directives, discharge planning, COVID-19, and abuse. For a resident who is identified as a smoker, they will also have a smoking care plan that is initiated and updated by the social worker. SW #1 also stated that when a resident is identified as a smoker, the social worker will review the smoking policy and obtain a signature from the resident to ensure resident agrees to the smoking policy. SW #1 further stated that there are not too many smokers in the facility and therefore, SW #1 did not realize that a care plan had not been created and this was an oversight. On 3/13/23 at 12:50 PM, the Director of Social Work (DSW) was interviewed and stated the care plan for smoking is to be initiated when a resident is identified as a smoker. The resident and their family are educated on the facility's smoking policy and once they agree, signatures are obtained. The DSW was asked to review the smoking care plan for Resident #26, Resident #29 and after reviewing the medical record, the DSW acknowledged that a CCP for should have been developed for both residents once they were identified as smokers. 415.11(c)(1)

Based on interviews and record reviews conducted during a Recertification and Complaint survey (NY#00301808) conducted 3/9/23 to 3/16/23, the facility did not ensure that resident remained free of accident hazards. Specifically, a Certified Occupational Therapist Assistant (COTA) applied a hot pack to Resident #104's right shoulder, resulting in a second degree burn. This was evident for 1 of 10 residents reviewed for Accidents out of total sample of 38 residents. (Resident #104). The findings are: The facility policy and procedure titled Hydrocollator Packs (Hot Packs) revised 2/1/22 documented the physical/occupational therapist and therapy assistant will use hydrocollator packs as an adjunct to therapy. The hydrocollator is thermostatically controlled with the water temperature being maintained at 144 to 160F. The unit is checked monthly by the Rehab/Maintenance Department. Procedure as follows: remove hot pack from hydrocollator and place in hot pack cover, then cover with another 4 to 8 layers of toweling. Apply to the area for 10 to 20 minutes, periodically inspect area(every 3 to 5 minutes), inspect the skin upon removal. The facility policy and procedure titled Risk Management Program - Accidents/Incidents revised 2/23 documented that an individualized care plan of care will be formulated in conjunction with the Interdisciplinary Team that identify risk factors and interventions for prevention of accidents/incident. Resident #104 was admitted to the facility with diagnosis of Essential Hypertension, Multiple Ischemic Stroke with Right Sided Hemiparesis, and Central Pain Syndrome. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented cognition is intact and required extensive assistance of one staff for bed mobility and personal hygiene, and extensive assistance of two staff for transfer. The MDS also documented that resident had a burn of unspecified degree of right shoulder and was receiving application of nonsurgical dressings. The Comprehensive Care Plan (CCP) for Impaired Skin Integrity related to actual second-degree burn on 9/4/22, reviewed 2/15/23 documented interventions which included to provide good skin care daily, skin check every shift, report any abnormality to MD and use draw sheet to turn and position. The undated Accident/Incident Report documented the date of occurrence was 9/4/22 at 9 AM when Certified Nursing Assistant (CNA) observed Resident #104 with a red area on the right shoulder. CNA immediately notified the supervisor who notified the family and MD (Doctor) about the burn on the right shoulder. The Nursing note dated 9/4/22 documented resident was noted with a 6.0 cm x 4.0 cm skin opening on the right shoulder, raw skin exposed with slight bleeding on the edges. Resident #104 verbalized that they got it on Friday (9/2/22) after they were given a heat pad while in rehab. NOK (Next of Kin) and attending physician were made aware. Resident was offered pain medication and ordered Bacitracin for wound treatment. The physician note dated 9/5/22 documented resident was seen 9/4/22, noted to have skin wound at the right shoulder. Resident stated it occurred after physical therapy two days prior. The skin injury with no blister, treat wound with Silvadene cream. The physician note dated 9/6/22 documented resident seen again for right shoulder burn, noted that it is a 2nd degree burn. The Investigation Summary dated 9/7/22 concluded that there is reasonable cause to believe that an accident related to heating pad took place. It documented that the COTA who applied the heat pad and Certified Nursing Assistant (CNA) who failed to report the redness observed on 9/3/22 were given disciplinary action. The facility also initiated competency for use of heating pad, re-initiated Stop and Watch program to staff for plan of actions to prevent occurrence. The application of heating pad was discontinued and used therapeutic massage as an alternative treatment for Resident #104. The Employee Disciplinary Action dated 9/7/22 documented COTA who applied hot moist pack, leading to burn on Resident #104's right shoulder, was given disciplinary action for unsatisfactory work. The Employee Disciplinary Action dated 9/9/22 documented CNA who observed redness on the right shoulder following the day after rehab, was given disciplinary action for failure to report change in skin condition while providing care. On 3/16/23 at 9:16 AM, Certified Nurse Assistant (CNA) #2 was interviewed and stated Resident #104 was observed with redness on their shoulder in the morning of 9/3/22. CNA #2 also stated that Resident #104 did not complain of pain or discomfort related to the redness. CNA #2 acknowledged that it was not reported to the nurse on the day when Resident #104 was observed with redness and that they were working short staffed on this day therefore, it was missed by mistake. During an interview with Licensed Practical Nurse (LPN) #2 on 3/16/23 at 9:25 AM, they stated that they were notified by the CNA regarding Resident #104's burn on 9/4/22. Resident #104 did not have any pain related to the burn and was able to verbalize that the burn was from the heat pack used during rehab. LPN #2 notified the supervisor on duty who initiated the incident report. Resident #104's burn was treated and dressed as per physician's order. On 3/14/23 at 9:05 AM, the Director of Rehab (DR) was interviewed and stated that the Certified Occupational Therapy Assistant (COTA) no longer works in the facility. The DR also stated that the Hot Moist Pack (HMP) was used for Resident #104 on an as needed basis and that this was an isolated incident. As per COTA, the HMP was used on that day as it is normally applied and was applied correctly. The DR was first made aware of the burn injury on 9/5/22. The DR stated that they are responsible to oversee all rehab staff including COTA and that COTAs are professionally trained to use hot packs as an adjunct to therapy. New COTAs will be introduced to different modalities used in the facility and instructions for proper applications are provided. The DR further stated that staff were not evaluated for competency for the use hot pack prior to this incident and that competency for the use of heat packs was initiated post resident's burn as a plan of correction. The DR stated that they were no other incidents of burns related to heating pad and re-emphasized that it was an isolated incident. On 3/14/23 at 11:58 AM, an attempt was made to contact the Registered Nurse Supervisor (RNS #2) who was the nurse on duty at the time of the incident and completed the occurrence report, however RNS #2 did not answer or return the call. On 3/16/23 at 12:02 PM, the Director of Nursing (DON) was interviewed and stated the facility was first made aware of Resident #104's injury on 9/4/22 when a CNA notified the nurse. The nurse supervisor immediately assessed the injury and obtained information from Resident #104, who verbalize that the injury was from the heating pad used during a rehab session. The DON also stated that the injury was not related to abuse since resident verbalized that the burn was from the heating pad used in rehab, therefore, it was not reported immediately to the New York State Department of Health (NYS DOH). 415.12(h)(2)

Based on record review and staff interviews, the facility did not ensure that residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range. Specifically, the facility did not effectively monitor a resident that was at risk for weight loss and weight fluctuations with a weight loss of 19.08 % in 6 months, and 5.09% in less than 1 month. This was evident for 1 of 6 residents reviewed for Nutrition out of a sample of 38 residents investigated. (Resident # 22). The findings are: The facility's policy titled Weights dated 05/06, last revised 01/2023 documented: A loss or gain of 3lbs a week and 5lbs a month will be communicated by CNA to the Charge Nurse and a reweigh will be done in the presence of the Charge Nurse for validation. A confirmed weight loss or gain will be communicated to MD/NP, RD, NOK and documented in the CCP (Comprehensive Care Plan) with corresponding intervention. Resident #22 was admitted with diagnoses that included Cerebrovascular Accident (CVA), Non-Alzheimer's Dementia, and Depression. The Quarterly Minimum Data Set (MDS) dated [DATE] documented the resident had severe impairment in cognition with long and short-term memory problems. The MDS also documented that the resident was extensive assistance of staff for most activities of daily living including eating. The MDS further documented that Resident #22 holds food in mouth/cheeks, and had a loss of 5% or more in the last month or loss of 10% or more in last 6 months and was not on a physician-prescribed weight-loss regimen. The Comprehensive Care Plan (CCP) for Nutritional Status dated 12/16/2013, last updated 2/17/2022, documented that Resident is on therapeutic diet secondary to Significant weight loss: x 3 months. Goals included that Resident will be adequately nourished as evidenced by absence of significant weight loss, resident's laboratory report(s) will be clinically stable per MD, and resident will continue to consume >75% of meals served x 90 days. Interventions included check lab values on a routine basis, monitor intake and tolerance to diet, monitor weight, observe for visual signs and symptoms of poor nutrition or hydration status, and provide diet per MD order (NAS diet, with chopped consistency and honey thick liquids). The Long Term Care Survey Process (LTCSP) weight calculator documented On 09/13/2022, the resident weighed 152 lbs. On 03/06/2023, the resident weighed 123 pounds which is a 19.08 % loss. This weight loss occurred over a 6 month period. The LTCSP weight calculator also documented On 02/22/2023, the resident weighed 129.6 lbs. On 03/06/2023, the resident weighed 123 pounds which is a -5.09 % loss. This weight loss occurred over a 12-day period. Progress Notes Dietary dated 12/24/2022 documented: Quarterly Assessment: .Current nutritionally pertinent medication includes . mirtazapine, Prilosec. Note: Mirtazapine - may increase appetite. There are no current nutrition related labs.Current Wt:131.5 (12/5) Ht: 66 in, Past weight: 126.6 lbs. (11/14), 138 lbs. (10/14), 138 lbs. (9/30), 157.8 lbs. (8/16), 157.4 lbs. (7/19), 156 lbs. (6/21), 154.2 lbs. (5/31). Current BMI: 21.2 - WNL - low for geriatric age. Continues to trigger for unplanned/undesirable weight loss in 3 months ~12.37% and 6 months ~14.62% Progress Note Medical dated 12/20/2022 documented that resident was seen and examined secondary to exposure to COVID-19, weights documented by MD are 131.5lbs (12/05/22); 126.6lbs (11/14/22); 138lbs (10/14/22, and 157.8lbs (8/16/22). This was a 16.67 % loss between 8/16/22 and 12/5/22. There was no documented evidence of interventions to address the resident's significant weight loss of over 16% in 4 months. Progress note Medical -Physician's Monthly Progress dated 3/13/2023 documented that Resident seen and examined 3/13/2023 for monthly follow up. Weight loss, Aphasia, dementia; At risk for malnutrition secondary to multiple comorbidities, weight 123 pounds. There was no documented evidence of interventions to address the resident's significant weight loss and risk for malnutrition. On 03/14/23 at 11:08 AM, an interview was conducted with Certified Nursing Assistant (CNA) #1 who stated that Resident #22 can feed self with tray set up and has been completing between 25% and 75% of meals served. CNA #1 also stated that resident has been noted with some weight loss when transferred to the unit a few months ago and this was reported to the nurse. On 03/14/23 at 11:41 AM, an interview was conducted with the Charge Nurse, Licensed Practical Nurse (LPN) #1 who stated that Resident #22's meal intake is documented by CNA in the CNA Accountability Record (CNAAR). If a resident consumes less than 25% for 3 days, the dietician is notified to do a calorie count and weekly weights are recommended. LPN #1 also stated that based on the resident's weight, Resident #22 was noted with some weight loss when transferred to the unit. LPN #1 further stated that they do not remember doing a calorie count for the resident recently, and weekly weights had not been recommended by the dietician or by the Physician. On 03/14/23 at 12:03 PM, an interview was conducted with the Registered Dietitian (RD) who stated that per documentation reviewed, resident requires assistance of staff for eating and has been consuming over 75% of the meals based on the data generated from the CNAAR. The RD also stated that they had never observed the resident eating during meals, and the first assessment and quarterly evaluation was done in December. The RD further stated that as per the assessment, resident was triggered for undesired weight loss, probably due to the worsened dementia, as at that time, it was documented that resident was consuming only about 25% of food. The RD stated that they planned to re-assess the resident at the next quarter, which is currently due. On 03/16/23 at 08:55 AM, an interview was conducted with the Registered Nurse Supervisor (RNS) #1. RNS #1 stated that monthly weight is done for a stable resident, and any resident observed with weight loss of 5% from the previous weight is reported to the dietician and the doctor so necessary interventions can be given. The resident's weight will be monitored weekly until the weight is stabilized. RNS #1 also stated that the dietician should have communicated the significant weight change of the resident to the doctor for new interventions to address the resident's weight loss. RNS #1 stated that they believe that the resident's weight loss was discussed with the dietician by nursing staff, but they did not know why the dietician had not implemented necessary interventions for the weight loss. On 03/16/23 at 09:21 AM, an interview was conducted with the Director of Nursing (DON) who stated that if a resident is observed with significant weight loss, the nursing staff will notify the doctor and the dietician. A calorie count will be recommended and ordered, and depending on the physician, the resident may be given an appetite stimulant, along with weekly weight monitoring. It will also be discussed by the interdisciplinary team. The DON also stated the care plan must be updated by the dietician. The DON further stated that every discipline is required to update their care plan based on their clinical areas. The DON stated that they were not aware that the resident's significant weight loss was not appropriately addressed. On 03/16/23 at 11:53 AM, an interview was conducted with the Medical Director (MD) who stated that when a resident is observed with significant weight loss, we ask dietary to see if we need to offer supplements and appetite stimulant, and to continue monitoring the weight weekly until the resident is stable. The MD also stated that based on the record review, the former dietician had documentation regarding the resident's weight loss in November last year but Resident #22's weight loss had not been properly followed up on by the current dietician and the Attending Physician. The MD further stated that they were surprised that this was not done and the issue will be discussed with the staff and the attending physicians to prevent reoccurrence. 415.12(i)(1)

Based on observation, record review and interview conducted during the Recertification survey from 3/9/23 to 3/16/23, the facility did not ensure that the medical care of each resident was supervised by a physician. Specifically, there was no documented evidence that the physician monitored changes in the resident's health status and provided interventions to address a resident's undesired significant weight loss over the period of 6 months. This was evident for 1 of 6 residents reviewed for Nutrition out of a sample of 38 residents investigated. (Resident # 22) The finding is: The facility's policy titled Physician dated 09/2016, last revised 02/2023, documented: Resident will be seen by Primary Physician/ Nurse Practitioner on Admission/ Readmission; Monthly (every 28-30 days); Significant Change; PRN/ as requested by resident/NOK The facility's policy titled Weights dated 05/06, last revised 01/2023, documented: A loss or gain of 3lbs a week and 5lbs a month will be communicated by CNA to the Charge Nurse and a reweigh will be done in the presence of the Charge Nurse for validation. A confirmed weight loss or gain will be communicated to MD/NP, RD, NOK and documented in the CCP (Comprehensive Care Plan) with corresponding intervention. Resident #22 was admitted with diagnoses that included Cerebrovascular Accident (CVA), Non-Alzheimer's Dementia, Hemiplegia, and Depression. The Quarterly Minimum Data Set (MDS) dated [DATE] documented the resident had severe impairment in cognition with long and short-term memory problems. The MDS also documented that Resident #22 required extensive assistance of staff for most activities of daily living including eating. The MDS further documented that Resident #22 holds food in mouth/cheeks, and had a loss of 5% or more in the last month or loss of 10% or more in last 6 months, and was not on a physician-prescribed weight-loss regimen. The Comprehensive Care Plan (CCP) for Nutritional Status dated 12/16/2013, last updated 2/17/2022, documented that Resident is on therapeutic diet secondary to Significant weight loss: x 3 months. Goals included that Resident will be adequately nourished as evidenced by absence of significant weight loss, resident's laboratory report(s) will be clinically stable per MD, and resident will continue to consume >75% of meals served x 90 days. Progress Notes Dietary dated 12/24/2022 documented: Quarterly Assessment: .Current nutritionally pertinent medication includes . mirtazapine, Prilosec. Note: Mirtazapine - may increase appetite. There are no current nutrition related labs.Current Wt:131.5 (12/5) Ht: 66 in, Past weight: 126.6 lbs. (11/14), 138 lbs. (10/14), 138 lbs. (9/30), 157.8 lbs. (8/16), 157.4 lbs. (7/19), 156 lbs. (6/21), 154.2 lbs. (5/31). Current BMI: 21.2 - WNL - low for geriatric age. Continues to trigger for unplanned/undesirable weight loss in 3 months ~12.37% and 6 months ~14.62% Progress Note Medical dated 12/20/2022 documented that resident was seen and examined secondary to exposure to COVID-19, weights documented by physician were 131.5lbs (12/05/22); 126.6lbs (11/14/22); 138lbs (10/14/22, and 157.8lbs (8/16/22) which represented a 16.67 % loss between 8/16/22 and 12/5/22. There was no documented evidence of interventions to address the resident's significant weight loss of over 16% in 4 months. The Long Term Care Survey Process (LTCSP) weight calculator documented On 09/13/2022, the resident weighed 152 lbs. On 03/06/2023, the resident weighed 123 pounds which is a -19.08 % Loss. This weight loss occurred over a 6 month period. The LTCSP weight calculator also documented On 02/22/2023, the resident weighed 129.6 lbs. On 03/06/2023, the resident weighed 123 pounds which is a -5.09 % loss. This weight loss occurred over a 12-day period. Progress note Medical -Physician's Monthly Progress dated 3/13/2023 documented that Resident seen and examined 3/13/2023 for monthly follow up. Weight loss, Aphasia, dementia; At risk for malnutrition secondary to multiple comorbidities, weight 123 pounds. There was no documented evidence of interventions to address the resident's significant weight loss and risk for malnutrition. On 03/14/23 at 11:41 AM, an interview was conducted with the Charge Nurse, Licensed Practical Nurse (LPN) #1 who stated that Resident #22's meal intake is documented by CNA in the CNA Accountability Record (CNAAR). If a resident consumes less than 25% for 3 days, the dietician is notified to do a calorie count and weekly weights are recommended. LPN #1 also stated that based on the resident's weight, Resident #22 was noted with some weight loss when transferred to the unit. LPN #1 further stated that they do not remember doing a calorie count for the resident recently, and weekly weights had not been recommended by the dietician or by the Physician. On 03/14/23 at 12:03 PM, an interview was conducted with the Registered Dietitian (RD) who stated that per documentation reviewed, resident requires assistance of staff for eating and has been consuming over 75% of the meals based on the data generated from the CNAAR. The RD also stated that they had never observed the resident eating during meals, and the first assessment and quarterly evaluation was done in December. The RD further stated that as per the assessment, resident was triggered for undesired weight loss, probably due to the worsened dementia, as at that time, it was documented that resident was consuming only about 25% of food. The RD stated that they planned to re-assess the resident at the next quarter, which is currently due. On 03/16/23 at 08:55 AM, an interview was conducted with the Registered Nurse Supervisor (RNS) #1 who stated that monthly weight is done for a stable resident, and any resident observed with weight loss of 5% from the previous weight is reported to the dietician and the doctor so necessary intervention can be done. The resident's weight will be monitored weekly until the weight is stabilized. RNS #1 also stated that the dietician should have communicated the significant weight change of the resident to the doctor for new interventions to address the resident's weight loss. The RNS stated that they believe that the resident's weight loss was discussed with the dietician by nursing staff, but they did not know why the dietician had not implemented necessary interventions for the weight loss. On 03/15/23 at 12:47 PM, an interview was conducted with the Attending Physician (AP) #1 who stated that Resident #22 was seen regularly. Resident #22's labs were reviewed, the most recent labs were normal, and resident was stable metabolically. AP #1 also stated that Resident #22's weight loss is due to multiple comorbidities and the last time the resident was seen, the resident was talking, and was noted to be clinically stable. AP #1 was unable to explain why there was no documented evidence of any planned interventions to address the resident's significant weight loss. On 03/16/23 at 09:21 AM, an interview was conducted with the Director of Nursing (DON) who stated that if a resident is observed with significant weight loss, the nursing will notify the doctor and the dietician, calorie count will be recommended and ordered, and depending on the physician, the resident may be given appetite stimulant, and weekly weight monitoring. It will also be discussed by the interdisciplinary team. The DON stated the care plan must be updated by the dietician. The DON further stated that every discipline is required to update their care plan based on their assigned care areas. On 03/16/23 at 11:53 AM, an interview was conducted with the Medical Director (MD) who stated that when a resident is observed with significant weight loss, we ask dietary to see if we need to offer supplements and appetite stimulant, and to continue monitoring the weight weekly until the resident is stable. The MD also stated that based on the record review, the former dietician had documentation regarding the resident's weight loss in November last year but Resident #22's weight loss had not been properly followed up on by the current dietician and the Attending Physician. The MD further stated that they were surprised that this was not done and the issue will be discussed with the staff and the attending physicians to prevent reoccurrence. 415.15(b)(1)(i)(ii)

Based on observations, record review, and staff interviews during the Recertification survey conducted from 3/9/23 to 3/16/23, the facility did not ensure that a Medication Regimen Review (MRR) performed by the Consultant Pharmacist was reviewed and acted upon by the attending physician or medical director in a timely manner. This was evident for 2 of 5 residents (Resident #26 and Resident #71) reviewed for Unnecessary Medications Review out of a total sample of 38 residents. Specifically, 1). the physician did not act upon the consultant pharmacist's recommendations to attempt a gradual dose reduction (GDR) for residents receiving antidepressant medication, and 2). A pharmacy consultant recommendation for a Psychiatry consult to evaluate symptoms of depression and the therapeutic goals of Cymbalta was not completed. The findings are: The facility's policy and procedure titled Pharmacy Services with last revised date 2/2023 that the medication regimen of each resident must be reviewed at least once a month by licensed pharmacist. The pharmacist must report any irregularities to the Attending Physician, the facility Medical Director and the Director of Nursing and these reports must be acted upon. 1. Resident #26 was admitted to the facility with diagnosis of Depression, Non-Alzheimer's Dementia, and Diabetes Mellitus. The medical order initiated 2/9/22, renewed 2/14/23 documented resident to receive Cymbalta 1 capsule (20 mg) once daily at 10 AM and Cymbalta 1 capsule (60 mg) once daily at 10 PM for Major Depressive Disorder. Medical Order initiated 3/11/22 documented Mirtazapine 15 mg tablet once daily which was discontinued on 8/24/22. The medical order initiated 8/24/22, renewed 2/14/23 documented resident to receive Mirtazapine 7.5 mg tablet by oral route once daily at bedtime at 10 PM for major depressive disorder, recurrent, mild. The Medication Administration Record dated February and March 2023 documented Resident #26 received Cymbalta 1 capsule (20 mg) at 10 AM, Cymbalta 1 capsule (60 mg) at 10 PM, Mirtazapine 0.5 tablet (7.5mg) at 10 PM, during the entire month of February and to current date of March 2023. The pharmacy's Medication Regimen Review (MRR) dated 2/15/23 documented resident has two psychotropic medication orders (Cymbalta, Remeron) for at least 3-12 months that are now potentially due for a Gradual Dose Reduction (GDR) based on CMS guidelines. Recommended to evaluate if resident is a candidate for GDR and consider reduction in the total daily dose of either of the two psychotropic medication orders. The physician's response dated 2/16/23 documented to order a psychiatric consult and have psychiatrist evaluate if resident is a candidate for GDR. Review of the interdisciplinary notes from 2/16/23 to 3/13/23 revealed there was no documented evidence that resident was evaluated by psychiatrist for Gradual Dose Reduction for the two psychotropic medication orders. On 3/13/23 at 2:15 PM, Pharmacist was interviewed and stated that Resident #26 receives two antidepressant medications. Pharmacist stated last GDR recommendation was made back in August 2022 and it was agreed to decreased Remeron from 15 mg to 7.5 mg. Pharmacist stated the monthly pharmacy reviews are emailed immediately to Director of Nursing, Assistant Director of Nursing, Medical Director, and the Administrator. Pharmacy stated that another GDR was recommended for Resident #26's MRR dated 2/15/23. Pharmacist did not know if it was considered and ordered since March Medication Regimen Review was not done as of 3/13/23. On 3/14/23 at 10:56 AM, Attending Physician (AP #2) was contacted and stated that they will call back but did not return the call. On 3/15/23 at 11:05 AM, the Psychiatric Nurse Practitioner (PNP) was interviewed and stated that once they receive a referral, the referred resident will be seen and evaluated within 3 days of receiving referral. It is electronically submitted and recorded in the electronic medical record. The PNP also stated that Resident #26 was referred to evaluate capacity on 1/14/23 and the resident was seen/evaluated on 1/16/23 according to their record. The PNP further stated that there was no other pending consult for Resident #26 since 1/16/23. On 3/14/23 at 9:57 AM, the Medical Director (MD) was interviewed and stated that they also provide care for residents and was the physician responsible to review the MRR for month of February for Resident #26. The MD stated that they reviewed the pharmacist's recommendation on 2/16/23 and planned to discontinue Remeron for Resident #26. The MD further stated that it was an oversight and that Remeron was just discontinued as an attempt for GDR on 3/14/23. 39136 2. Resident #71 was admitted to the facility with diagnoses that include Anxiety Disorder, Bipolar Disorder, and Major Depressive Disorder. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #71 had severely impaired and received antidepressants on five of seven days. A Medical Doctor Order (MDO) dated 04/28/22 documented that Resident #71 was to receive Cymbalta 30 mg capsule, delayed release, give one tablet (30 mg) by oral route once daily for Anxiety Disorder. A Pharmacy Consultant Note to Attending Physician/Prescriber dated 10/5/22 documented that Resident #71 has been on their current dose of Cymbalta since 4/8/22 and recommended to order a psychiatric consult and have the psychiatrist evaluate if the resident symptoms of depression and therapeutic goals are being adequately met by their current dose of Cymbalta. An MDO dated 11/10/22 documented a psychiatric consult was ordered to evaluate if the resident symptoms of depression and therapeutic goals are adequately met by their current dose of Cymbalta. Review of the medical records dated 11/11/22 to 3/16/23 revealed no documented evidence that Resident # 71 had received a psychiatric evaluation. On 03/15/23 at 12:35 PM, an interview was conducted with the Psychiatric Nurse Practitioner (PNP). The PNP stated that they have not seen Resident # 71 since they started working in the facility in November of last year. The PNP had a referral to see the Resident #71, but there was no consent, so they could not see them. The consent is obtained from the family or the resident if the resident has the capacity. They need new consent for the new year. An order to evaluate the use of the Cymbalta was received on 1/15/23 and 2/22/23. The Director of Nursing has been informed about the PNP's need for consent before they can see Resident #71. On 03/16/23 at 11:39 AM, an interview was conducted with the Attending Physician #3 (AP #3). AP #3 stated that they signed off on the recommendation but were unaware that the psychiatric provider had not seen Resident #71. AP #3 was not sure what had happened. AP # 3 was not aware that the psychiatric provider was waiting for a consent. On 03/16/23 at 11:11 AM, an interview was conducted with the Medical Director (MD). The MD does not know why the psychiatrist has not seen Resident # 71. They use an agency for psychiatry and psychology consults. If the psychiatric provider needs consent, they are responsible for obtaining it themselves. Any specialist must obtain their consent. The MD did not know that the NP did not see the resident because of consent. The PNP should have informed them they were waiting for consent before seeing the resident. On 03/16/23 at 10:01 AM, an interview was conducted with the Director of Nursing (DON). The DON stated they have a new PNP who started last year, in November. The PNP is asking for consent before they see the resident. The PNP informed them in January that they need consent for the resident. Resident # 71's Next of Kin (NOK) had been called about eleven times for a consent, but they had not yet responded. 415.18(c)(2)

Based on observations, record review, and staff interviews conducted during the Recertification survey from 3/9/23 to 3/16/23, the facility did not ensure infection control practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically, blood pressure (BP) cuffs were not cleaned/disinfected after use between residents. This was evident for 2 out of 6 licensed nurses observed during the Medication Administration task. The findings are: The facility's policy and procedure titled Cleaning and Disinfecting of Non-critical Medical Devices dated 03/17/2011, last revised 02/2023 documented: disinfect the blood pressure machine/cuff before each resident use by cleaning the blood pressure/cuff and wiping it with germicidal wipes. Always wear gloves when using germicidal wipes. On 03/13/23 at 09:26 AM, while observing Medication Administration on the 6th Floor, Licensed Practical Nurse (LPN) #1 was observed assessing Resident #147's blood pressure (BP) with a wrist BP cuff without sanitizing the cuff prior to use. LPN #1 then placed the cuff on the medication cart without sanitizing it. At 09:33 AM, LPN #1 approached Resident #50 and proceeded to check the resident's BP with the same BP cuff which had not been sanitized after use on the previous resident. On 03/13/23 at 9:40 AM, LPN #1 was interviewed and stated that the cuff is supposed to be sanitized before use on other residents but they forgot to sanitize it. On 03/13/23 at 09:59 AM, LPN #2 was observed during Medication Administration for Resident #24 on the 5th floor. LPN #2 checked the resident's BP with a wrist BP cuff without sanitizing the cuff prior to use on Resident #24 and placed the BP cuff on the medication cart after use without sanitizing it. At 10:10 AM, LPN #2 moved on to Resident # 94 and proceeded to check the resident's BP with the same BP cuff without sanitizing the cuff. On 03/13/23 at 10:15 AM, LPN #2 was interviewed and stated that the cuff should be sanitized between residents use but was not sanitized because they were nervous. On 03/16/23 at 08:46 AM, an interview was conducted with the Registered Nurse Supervisor (RNS) #1 who stated that the purple top sanitizer wipe is used to sanitize the BP cuff prior to use on the resident and in between resident's use. RNS #1 also stated that rounds are made around 5 times daily to monitor that staff are performing proper infection control practices while giving care to the residents and if any staff is observed not following proper protocol, in-service is given to ensure compliance. RNS #1 further stated that they have new nurses in the facility, and they will have to reinforce the education to ensure compliance. On 03/16/23 at 09:33 AM, an interview was conducted with the Director of Nursing (DON) who stated that the supervisors on the units are supposed to be monitoring the staff to ensure that the staff are practicing proper infection control. The DON also stated that they are surprised that the supervisors are not identifying these problems. The DON further stated that any staff observed not practicing the proper protocol is re-inserviced. 415.19 (b)(4)

Based on interviews and record review during an survey the facility did not ensure that medical records were maintained in accordance with accepted professional standards and practices that were complete and accurately documented for each resident. Specifically, Nursing Staff documented completion of Range of Motion exercises on several occasions in the medical record when they were not being provided. This was evident for 1 of 2 residents reviewed for Limited Range of Motion (Resident #57) The finding is. Resident # 57 had [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had intact cognition. The MDS further documented the resident required total assistance with transfer and toilet use, and extensive assistance with bed mobility, dressing, and personal hygiene. The MDS also documented that resident had Range of Motion (ROM) impairment of the lower extremities. On 02/24/20 during the initial visit to the resident, the resident was observed in bed, alert and awake with intact memory. The resident reported that staff stopped performing bedside exercises with her for a while She further stated that two rehab staff used to come and give her exercises while in bed, but that is not happening again. When the resident was asked if she received hand and leg exercises from the CNA, she replied, no. The resident stated she does not want to get out of bed, but she needs exercise on her legs to prevent further contractures. The physician's orders [REDACTED]. Bed mobility exercises 6 times per week for 15 minutes. A review of Certified Nursing Assistant (CNA) Documentation History Detail, dated from 12/18/19 to 2/26/19 documented the following: Nursing Rehab AROM/PROM. The CNA record also documented that the AROM/PROM exercises were provided and resident well tolerated. On 02/26/20 at 10:53 AM, an interview was conducted with CNA #4. She stated she has been taking care of the resident for over a year now. She stated that she does not perform ROM on the resident because, a while back, the resident began refusing ROM. She stated that resident has been refusing ROM for a long time. She acknowledged that the documentation on the C.N.A accountability was incorrect, and it was an error. 415.22(a)(1,2)

Based on record reviews and interviews conducted during the recertification survey, the facility did not ensure that the Minimum Data Set 3.0 (MDS) assessment accurately reflected the resident's current medical status. Specifically, a resident who had been on [MEDICAL TREATMENT] 3 times per week since 07/18/19 was not coded as a [MEDICAL TREATMENT] resident. This was evident for 1 of 38 sampled residents (Resident # 115). The finding is: Resident #115 had [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] did not identify that the resident was receiving [MEDICAL TREATMENT]. Section O (Special Treatments, procedures, and programs), item J was left bank. The physician's orders [REDACTED]. The Comprehensive Care Plan for Renal Function/End Stage [MEDICAL CONDITION] dated 7/18/19 documented that the resident is on [MEDICAL TREATMENT] 3 times per week. On 02/25/20 at 12:17 PM, an interview conducted with the Registered Nurse (RN # 6) who completed the MDS. She stated that maybe that section of the MDS was overlooked. When she completes the assessment, she reviews the medical record from the last review date and the previous MDS for changes. She stated that the [MEDICAL TREATMENT] was not captured. It was an oversight. 415.11 (b)

Based on observation, record review, and staff interviews conducted during the re-certification survey, the facility did not ensure a resident with limited range of motion received treatment and services to increase and/or to prevent further decrease in range of motion. Specifically, a resident with physician's orders [REDACTED]. This was evident for 1 of 2 residents reviewed for Limited Range of Motion (Resident #57). The finding is: The facility policy and procedure titled Specific protocols and Guidelines for performing Range of Motion (ROM) dated 2/2019 documented that the Active Range of Motion exercise (AROM) is conducted by staff giving directions, cues, and/or demonstration to residents. The Passive Range of Motion (PROM) exercise is performed by staff moving resident extremities as tolerated. The policy also documented that the Physical or Occupational therapists should be consulted for instructions/clarification on movements not described in the policy guidelines. Resident # 57 had [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had intact cognition. The MDS further documented the resident required total assistance with transfer and toilet use, and extensive assistance with bed mobility, dressing, and personal hygiene. The MDS also documented that resident had Range of Motion (ROM) impairment of the lower extremities. On 02/24/20 at 10:56 AM, during the initial visit to the resident, the resident was observed in bed, alert and awake with intact memory. The resident reported that staff had stopped performing bedside exercises. She stated that she is no longer receiving exercise on her extremities. She further stated that two rehab staff used to come and give her exercises while in bed, but that is not happening again. The resident was asked if she received hand and leg exercises from the Certified Nursing Assistant (C.NA), she replied, no. The resident stated she does not want to get out of bed, but she needs exercise on her extremities to prevent contractures. The physician's orders [REDACTED]. Bed mobility exercises 6 times per week for 15 minutes. A review of Certified Nursing Assistant (CNA) Documentation History Detail, dated from 12/18/19 to 2/26/19 documented the following: Nursing Rehab AROM/PROM. The CNA record also documented that the AROM/PROM exercises were provided and resident well tolerated. On 02/26/20 at 10:53 AM, an interview was conducted with CNA #4. She stated she has been taking care of the resident for over a year now. She stated that she does not perform ROM on the resident because, a while back, the resident began refusing ROM. The resident will only allow her to rub her lower legs with lotion. She further stated that the resident preferred the rehab staff to assist her with ROM exercises. CNA #4 stated she never informed the charge nurse that the resident was refusing ROM exercises. On 02/26/20 at 11:19 AM, an interview was conducted with the Director of Rehab, who stated that the resident was discharged to nursing rehab a while ago. He also stated that after residents is discharged from rehab, a notice is sent to the nursing, indicating that the resident needs nursing rehab services. In-service will also be provided to the CNAs on how to perform ROM exercises on residents. The rehab director stated the resident refused to transfer out of bed to wheelchair in order to be able to receive additional rehab services. The resident preferred to do the exercises in bed. As a result, we had to discharge the resident from our program to nursing rehab. He stated that the nursing staff were made aware through the weekly meeting. On 02/27/20 at 11:18 AM, an interview was conducted with the Charge Nurse (RN #3) who stated that she was not aware the resident refused ROM services. When she was asked about the protocol for nursing rehab for residents with contractures and limited range of motion exercises, she was unable to explain. She stated that she is a new nurse on the unit. 02/27/20 at 11:32 AM, an interview was conducted with RN #4, a supervisor. She stated that she was responsible for ensuring residents with nursing rehab receive services. She also described nursing rehab protocol as follows: Once a resident has completed their rehab services, the rehab staff will notify her if there is a need to continue nursing rehab. The rehab director will create an order and in-service the C.N.A. on what to do. The charge nurse is responsible for ensuring that the orders for ROM exercises are carried out. 415.12(e)(2)

Based on observations, record review, and interviews during the recertification survey the facility did not ensure that a resident received necessary services to prevent new ulcers from developing. Specifically, a resident with a physician's orders [REDACTED]. This was evident for 1 of 3 residents reviewed for Pressure Ulcer/Injury out of a total sample of 41 residents (Resident #39). The finding is: Resident #39 is severely cognitively impaired with a [DIAGNOSES REDACTED]. The resident's most recent Quarterly Minimum Data Set 3.0 ((MDS) dated [DATE] documented the resident had no unhealed PUs, and the resident is at risk for developing PUs. On 11/15/18 at 9:10 AM and 11/16/18 at 9:38 AM, Resident # 39 was observed sleeping in bed. On both occasions, there were no heel lifts or heel booties observed on the resident's feet or in the resident's room. On 11/19/18 at 3:07 PM the charge nurse for the unit, Registered Nurse (RN) #1, was present when SA observed that there were no heel lift devices present in the resident's room or personal closet. The Pressure Ulcer Comprehensive Care Plan (CCP) dated 8/14/18 documented Resident #39 has a potential for alteration in skin integrity as the result of having a history of PUs on bilateral heels. The right heel PU was resolved on 5/29/18 and the left heel PU was resolved on 8/14/18. Interventions included assessing resident, identifying risk factors using the Braden Scale, initiating protocol for PU treatment upon identification of PU, skin care daily, and skin checks every shift. The Impaired Skin Integrity CCP initiated 2/6/14 and most recently updated on 11/8/18 documented the resident was at high risk for skin breakdown due to impaired mobility, incontinence, and fragile skin. Interventions included administering medications and treatments as ordered, Certified Nursing Assistant (CNA) evaluation of skin condition daily, and completion of the Braden Scale. A Nursing Note dated 8/14/18 documented the resident's left heel PU had healed. The resident had very fragile skin and the heel lift order was to be continued. The Physicians Orders, renewed on 11/1/18, documented that the resident is to have bilateral heel lifts when in bed. This order was originated on 3/6/18. The Braden Scale initiated on 11/7/18 documented the resident as having a score of 13 indicating that the resident is at moderate risk for PU development. The resident's risk factors include very limited sensory perception, occasionally moistness, being chairfast, having very limited mobility, and friction and shearing. A review of the resident's Medication Administration Record [REDACTED]. An interview was conducted with the resident's CNA, CNA #1, on 11/19/18 at 11:58 AM. CNA #1 has worked for the facility for 8 months and with resident #39 for approximately 2 months. The resident requires total assistance with all activities of daily living. She usually takes the resident out of bed later in the morning, and the resident usually does not go back to bed throughout the day unless she has an accident or bowel movement. CNA #1 was aware the resident has a wedge cushion for positioning while in bed, but she was not aware of any other devices or equipment ordered for resident while she is in bed. CNA #1 is also unaware of the resident having any skin conditions or history of PUs. The resident is provided with lotion every day and periguard to the feet, sacrum, and groin area as preventative measures to ensure that her skin remains in good condition. The CNA is made aware of all devices and equipment orders for the resident by looking at her chart on the computer and by looking at what devices are currently present in her room. If the CNA notices that a device has been ordered for the resident but is not in her room, CNA #1 will let the nurse know. CNA #1 is aware of what heel booties are but was unsure of what would be considered heel lifts. On 11/19/18 at 2:54 PM, an interview was conducted with the charge nurse for the unit, RN #1. She has worked in the facility and on the resident's unit for approximately 8 months. RN #1 is aware that Resident #39 had a PU on her heel but states that it was healed. The resident continues to have a pressure relieving mattress. She had a physician's orders [REDACTED]. Upon checking the resident's chart and reviewing the current physician's orders [REDACTED].#1, heel lifts are made of foam and have circular cutouts so that when it is placed under the resident's heels, there is less pressure on the area while sleeping. The CNA is responsible for putting the heel lift in place for the resident. The charge nurse at night should do a visual check to ensure that devices are in place. RN #1 stated that she was not aware of whether the heel lifts and/or booties were documented on any type of accountability or treatment record. The physician's orders [REDACTED]. After observing that there were no heel lifts in the resident's room, the RN stated that she would contact the Rehabilitation (Rehab) Department to obtain a new device. An interview was conducted with the Director of Rehabilitation (DOR) on 11/20/18 at 10:27 AM. The DOR stated that the wound care nurse will recommend that a pressure relieving device, such as heel lifts, are needed for a resident. The wound care nurse will then secure an order from the Medical Doctor (MD), fill out an interim communication sheet and collaborate with the rehab department to ensure that the device is distributed. The Rehab Department will clarify the order to ensure that the device has been issued but does not complete an actual Rehab Assessment. Heel lifts are actually heel booties, which are cushioned individual booties that cover the entire foot and heel area and that are held in place with a Velcro strap. The facility does not have a separate device identified as heel lifts and does not utilize a foam device with heel impressions in them. The CNA accountability record is utilized to ensure that devices are in place. Part of the facility's Quality Assurance and Performance Improvement (QAPI) plan is that the Rehab Department checks the physician's monthly orders on a regular basis and ensures that the device that is ordered for the resident is in place and being utilized. The Rehab Department is not responsible for monitoring the presence and usage of heel lifts. On 11/20/18 at 12:04 PM, an interview was conducted with RN/Wound Care Nurse, RN #2. RN #2 has worked in the facility for approximately 6 years. Any pressure relieving devices ordered for a resident (heel booties/lifts) are documented on the CNA Documentation Record; and, the CNAs are the primary staff that are responsible for tracking the devices and ensuring that they are in place. The CNA would be the one to report any missing devices to the charge nurse. As of right now, there is no formal log or schedule for audits/spot-checks of pressure relieving devices. Spot-checks for pressure relieving devices are done sporadically, and there is no set schedule. Most of the time, the charge nurses on the unit are responsible for conducting spot-checks. 415.12(c)1

Based on observation, records reviewed, and interviews conducted during the refortification survey, the facility did not ensure that the residents who were assessed for elopement risk were adequately supervised. Specifically, Resident #33 was not provided with wander guard according to the physician order. In addition, there was no proper documentation by the Certified Nursing Assistant (CNA) in the resident's CNA documentation Record indicating that the resident's wander guard is in place and being monitored by staff to prevent accident, unsafe wandering and/or elopement. This was evident for 1 of 2 residents reviewed for accident/elopement risk out of a Sample of 41 residents. The Findings are: The facility's policy and procedure for Prevention of Elopement and Unsafe Wandering dated 6/2018 documented: Once determined as at risk for elopement, the resident' at risk for elopement status is reflected on the resident's clinical record. i.e. progress notes. MD/NP will be notified and an order for [REDACTED]. The Policy further stated that the CNA instructions is updated to reflect the placement of Watchmate; The CNA checks the placement of the Watchmate every shift, if found missing, it must be reported to the nurse using the stop and watch form and must be replaced immediately. The Resident Accountability form/Census is completed by the CNA each shift. Resident #33 is [AGE] years old admitted to the facility on [DATE]. Active [DIAGNOSES REDACTED]. On 11/14/18 at 10:20 AM, and 11:17 AM, the State Surveyor observed Resident #33 wandering around the floor and toward the exit door, and at 11:19 AM, towards the elevator doors. The resident appeared confused and was unable to engage in conversation with the State Surveyor. There was no wander guard observed either on the ankles or wrists. There was no staff monitoring resident at this time 1 staff was observed in the day room and other staff were observed providing care for residents in their rooms. On 11/15/18 from 11:211 AM to 11:31 AM the resident was also observed wandering in the elevator and on the unit unsupervised with no wander guard in place. On 11/16/18 at 10:30 AM Resident was observed wandering in the hall-way - unsupervised, noted with wet pant. No wander guard observed on the resident. The Quarterly Minimum Data Set (MDS) - Version 3.0, dated 08/16/2018 documented that the resident cognitive status is moderately impaired, on antipsychotic medication. The MDS also indicated that resident is occasionally incontinent of bowel and bladder. The MDS further indicated that the resident requires supervision for Bed mobility, transfer, walk in room/corridor, Locomotion on/off unit, and eating, and is extensive assistance of 1 staff for dressing, toilet use, personal hygiene, and bathing. No wandering behavior documented on MDS. The revised Comprehensive Care Plan (CCP) dated 12/27/2016 documented elopement as an identified risk as evidenced by resident observed wandering to another floor. Watchmate (wander guard) in place and functioning. The revised (CCP ) for elopement dated 05/03/2017 documented that resident's Elopement risk assessment score is 10. Watchmate intact. physician's orders [REDACTED]. The revised elopement care plan dated 08/04/2018 documented that resident is at risk for elopement, noted with behavior of wandering, and has Wander guard in place. Review of Nursing behavior/elopement monitoring notes between 11/01/2018 and 11/16/2018 documented that resident continues to wander and is being re-directed by staff. There is no documentation that resident's wander guard is checked. There is also no documentation that resident has ever been observed removing the wander guard. The revised elopement care dated 11/05/2018 documented that the resident is at risk for elopement, continue to wander in hallway, redirected as needed. There was no documentation that resident has wander guard in place. A review of the Resident CNA Documentation Records dated between 11/01/2018 and 11/16/2018 did not indicate that the resident's wander guard was checked for placement and functionality. There is no documentation that the wander guard was being monitored by CNA every shift. On 11/16/18 at 12:30 PM the CNA #3 was asked if resident had wander guard. CNA #3 checked both wrists and ankles. No wander guard was found. On 11/16/18 at 12:42 PM an interview was conducted with CNA #3. CNA #3 stated that sometimes resident removes the wander-guard, but could not recall the the last time the wander guard was observed on the resident. CNA stated that there is no place to document the wander-guard placement in the CNA accountability record, and that they just report to the nurse if the wander guard is not found on the resident. On 11/19/18 at 09:33 AM an interview was conducted with the Licensed Practical Nurse LPN #1. LPN #1 stated that the resident sometimes wander around to other floor and is always re-directed by the staff. LPN stated that Wander guard should be checked every shift by the CNA and to report to the charge nurse if not found on the resident. LPN further stated that the resident likes to take it off and hide it sometimes and also stated that the wander guard monitoring is documented in the CNA accountability record every shift. On 11/19/18 at 12:35 PM an interview was conducted with the social worker SW #5. SW stated that the resident is always seen in the nursing station and is constantly monitored and re-directed if noted with inappropriate behavior like putting on dirty cloth or putting on shoes incorrectly. SW also stated that the resident follows direction most of the time, and that the resident was moved to a private room on the unit because he was not getting on with other residents on the previous unit where he was sharing a room. 415.12(h)(2)

Based on interviews and record review conducted during an abbreviated and partial extended survey (NY 421), the facility administration failed to ensure that the facility is operated in a manner in which basic life support, including Cardiopulmonary Resuscitation (CPR) is provided in a timely manner to a resident requiring such emergency care. In addition, the administration failed to have a system in place to distinguish [MEDICAL CONDITION] emergency from other types of emergencies. This was evident in 1 out of 20 residents sampled (Resident #1). Specifically, Resident #1 was observed unresponsive and not breathing on [DATE] at approximately 10:30AM. Approximately ,[DATE] minutes had passed before CPR was initiated and approximately 5 minutes before 911 was activated. This practice resulted in actual harm and the potential for serious harm to the health and safety of all residents in the facility that is Immediate Jeopardy. The findings are: Resident #1 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) dated [DATE] documented a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of 15 indicating an intact cognition (,[DATE] Severe Impairment, ,[DATE] Moderate Impairment, & ,[DATE] Cognitively Intact). The resident has a pacemaker implanted in the right upper chest. The resident had no Advance Directive or Health Care Proxy (HCP). The facility policy and procedure titled STAT (EMERGENCY) with a review date of ,[DATE] documented that if a resident is noted unresponsive, the staff who responds must check the resident's pulse/breathing and advance directive, if any (order and/or name band). A STAT code must be paged for a Full Code resident, initiate CPR if there is no pulse, and call 911. After the incident occurred, the facility developed a new policy on [DATE] changing STAT for Full Code to CODE BLUE. The Medical Director was interviewed on [DATE] at 12:30 PM and stated that he does not remember when was the last time he reviewed the policy and procedure on STAT/CPR. He was made aware that STAT was changed to CODE BLUE the day after it had been changed. He was not involved in formulating or reviewing of the new policy. The Director of Nursing Service (DNS) was interviewed on [DATE] at 3:20 PM and stated that on [DATE], Resident #1 returned from [MEDICAL TREATMENT] after 10:00AM and he was observed unresponsive and not breathing in the ambulette. The resident's code status was not immediately identified because the resident was not wearing a wrist band. She stated that the staff who initially responded to the STAT code arrived on the scene without any emergency equipment because they were confused. The staff was not aware that the STAT code was for a resident in [MEDICAL CONDITION]. The DNS explained that STAT code is used for both a regular emergency (i.e. falls) and for [MEDICAL CONDITION]. The Administrator was interviewed on [DATE] at 4:08PM and stated that he was not aware that there was a problem related to the [DATE] incident. The Director of Nursing Service (DNS) gave him a copy of a revised policy on CODE BLUE. The policy was revised to change STAT, used to identify Full Code resident, to CODE BLUE. The Administrator stated that the DNS explained that she made the change so it would be clearer for the staff to know the difference between a Full Code and other emergencies. The Administrator stated that he was not asked to review the policy before it was changed. Immediate Jeopardy was removed prior to survey exit of [DATE] based on the following corrective actions taken. The facility: -Implemented a new policy titled Policy and Procedure on Emergency Care for Full Code Residents / Code Blue. The policy documented that in the absence of physician order [REDACTED]. The policy also documented that when a resident has no DNR order and has no pulse or respirations or if the resident is in acute distress with labored breathing and faint pulse, the nurse will instruct a staff member to call CODE BLUE by announcing on overhead page CODE BLUE UNIT (Area) ____ three times. In instances when CODE BLUE is announced off unit i.e. lobby, the crash cart will be brought to the lobby. -A CODE BLUE drill guideline and audit tool were also developed by the facility on [DATE]. -Developed and implemented education associated with the Policy and Procedure on Emergency Care for Full Code Residents / Code Blue that was provided to staff of all discipline. The staff that are not in-serviced (i.e. per diem, on leave of absence, on vacation) will be given a copy of the policy via mail. Upon return to the facility, the staff will be in-serviced by the DNS/ADNS and or the Registered Nurse Supervisor prior to working on the unit. -Emergency equipment (AED, ambu bag, oxygen, cardiac board) was made available in the nursing office on the first floor. 415.26

Based on observation, staff interviews and record review conducted during an abbreviated and partial extended survey (NY 421), the facility failed to initiate Cardiopulmonary Resuscitation (CPR) in a timely manner to an unresponsive resident who had Full Code status with no Advance Directive in place. This was evident in 1 out of 20 residents sampled (Resident #1). Specifically, on [DATE] at approximately 10:30 AM, Resident #1 was observed unresponsive in the ambulette after arriving from [MEDICAL TREATMENT] appointment. The staff responded without any emergency equipment. Approximately ,[DATE] minutes had passed before CPR was initiated and approximately five minutes before 911 was activated. This practice resulted in actual harm and the potential for serious harm to the health and safety of all residents in the facility that is Immediate Jeopardy and Substandard Quality of Care. The findings are: The facility policy and procedure titled STAT (EMERGENCY) with a review date of ,[DATE] documented that if a resident is noted unresponsive, the staff who responds must check the resident's pulse/breathing and advance directive, if any (order and/or name band). A STAT code must be paged for a Full Code resident, initiate CPR if there is no pulse, and call 911. After the incident occurred, the facility developed a new policy on [DATE] changing the code for [MEDICAL CONDITION] from STAT to CODE BLUE. Resident #1 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) dated [DATE] documented a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of 15 indicating an intact cognition (,[DATE] Severe Impairment, ,[DATE] Moderate Impairment, & ,[DATE] Cognitively Intact). The resident had a pacemaker implanted in the right upper chest. The resident had no Advance Directive or Health Care Proxy (HCP). The resident had a [MEDICAL TREATMENT] schedule 3 times a week on Tuesdays, Thursdays, and Saturdays. On [DATE] at 11:02AM, surveillance camera was reviewed with the Administrator. The time stamped in the camera's live feed was 11:08AM (actual time was 11:02 AM, the camera was six minutes fast) At 10:36 AM (actual time 10:30 AM) - Certified Nursing Assistant #1 (CNA #1) was waiting outside At 10:37 AM (actual time 10:31 AM) - CNA #1 walked towards the street/ambulette At 10:38 AM (actual time 10:32 AM) - CNA #1 went inside the building At 10:39 AM (actual time 10:33 AM) - escort and Registered Nurse Supervisor (RNS) went outside the building towards the ambulette At 10:40 AM (actual time 10:34 AM) - RNS went back inside the building At 10:42 AM (actual time 10:36 AM) - Ambulette driver and CNA #1 wheeled Resident #1 inside the building At 10:42 AM (actual time 10:36 AM) - Ambulette driver and CNA #1 wheeled Resident #1 to the dining room, staff observed coming into the lobby At 10:43 AM (actual time 10:37 AM) - RN #1 and Director of Nursing Service (DNS) wheeled Resident #1 out of the dining room towards the elevator. After that the resident was no longer visible on camera. At 10:45 AM (actual time 10:39 AM) - The Nurse Practitioner (NP) was observed walking towards the elevator At 10:49 AM (actual time 10:43 AM) - Emergency Medical Service (EMS) was onsite At 11:00 AM (actual time 10:54 AM) - EMS left the facility A Comprehensive Care Plan (CCP) on Advance Directive dated [DATE] documented that Resident #1 had no Advance Directive or Health Care Proxy (HCP) in place. A nurse's note dated [DATE] at 7:28 AM that was written by Registered Nurse #1 (RN #1) documented that Resident #1 went out to [MEDICAL TREATMENT] with an escort at 5:45 AM. A nurse's note dated [DATE] at 5:34 PM, written by the RNS, documented that CNA #1 came to the first floor and informed her that Resident #1 was in the ambulette (in front of the nursing home) and that the escort reported that something was wrong, Resident #1 needed help. The RNS went to check Resident #1 and observed him to be unresponsive to verbal and tactile stimuli. There was no chest movement observed. The resident's eyes were open and he had a palpable carotid pulse. The resident had no Advance Directive in place. A STAT code was called and at 10:33 AM, the NP was able to assess the resident. There was no spontaneous movement present, no audible breath sound, no palpable carotid pulse and CPR was performed. At 10:40 AM, 911 arrived in the facility. As per EMS, resident will be sent to the hospital. Resident #1 was transferred to the Hospital at 11:06 AM. The Prehospital Care Summary Report by the Fire Department New York (FDNY) dated [DATE] documented that 911 received a call from the facility at 10:38 (AM), FDNY arrived at 10:44, made contact with the Resident #1 at 10:45. Resident #1 was on the floor in supine position and CPR was in progress. Assessment revealed that Resident #1 was apneic (suspension of breathing), pale, with cold and moist skin, both eyes were not reactive. No blood pressure, no pulse, no respiration. CPR continued, Automated External Defibrillator (AED) applied, an oropharyngeal airway (OPA) inserted, assisted ventilation by Bag Valve Mask (BVM). Another ambulance arrived on the scene and provided Advance Live Support interventions. They left the facility with the resident at 11:06 AM and the resident was pronounced dead in Emergency Department (ED). Resident #1's Escort was interviewed on [DATE] at 2:15 PM and stated that when the ambulette arrived at the facility from [MEDICAL TREATMENT], Resident #1 was not responding and she asked CNA #1 who was standing in front of the facility to call for help. RNS came to the ambulette and checked the resident. The RNS instructed them to take the resident out of the ambulette and bring him into the lobby. CNA #1 was interviewed on [DATE] at 11:34 AM and stated that on [DATE] she was standing outside of the facility when she observed the ambulette pulled up in front of the building sometime after 10:00 AM. CNA #1 went to the ambulette and observed Resident #1 in the wheelchair in the back of the ambulette, he looked as though he was dozing off. The escort who was with Resident #1 tried to wake him up, but he was not responding. She stated that she ran inside the building and called the RNS. The RNS checked on Resident #1 and told them to bring Resident #1 inside the building. CNA #1 helped in wheeling Resident #1 to the first-floor dining room as instructed by RN #1, who was in the lobby when they entered the facility. CNA #1 stated that she left the facility after wheeling the resident to the dining room. The RNS was interviewed on [DATE] and [DATE] and stated that on [DATE] at approximately 10:30 AM, CNA #1 told her that there was something wrong with Resident #1 who was in an ambulette outside the facility. The RNS stated that she went to the ambulette and observed Resident #1 unresponsive, no chest movement, his carotid pulse felt weak, and he was not breathing. The RNS stated that Resident #1 had a weak carotid pulse because he had a pacemaker. She stated that she instructed the ambulette driver and the escort to take Resident #1 out of the ambulette and bring him to the lobby. Resident #1 had no wrist band so she had to go to the nursing office to ascertain the resident's code status in the computer, once she found out that the resident was Full Code, she asked the Assistant Director of Nursing (ADNS) to page STAT while she called 911. She stated that it took her approximately two minutes from the time she assessed the resident in the ambulette to the time she was able to figure out Resident #1's code status. The RNS stated that she was CPR certified. RN #1 was interviewed on [DATE] at 11:15 AM and stated that she was the charge nurse on the 2nd floor on [DATE] where Resident #1 resided. She stated that she received a phone call from the RNS stating that Resident #1 was unresponsive and that she was not told that it was a STAT so she only brought a sphygmomanometer (a machine used to measure blood pressure) and a glucometer (a machine used to measure blood sugar level) because Resident #1 was diabetic. When she arrived in the lobby, she observed Resident #1 in the wheelchair slumped over to one side. The resident had a weak carotid pulse and was not breathing. She added that he had the pulse because of his pacemaker. She was unable to take his blood pressure because of how Resident #1 was positioned in the wheelchair. She stated that she wanted to take Resident #1 to the 2nd floor because he was not breathing and there was no emergency equipment in the first-floor nursing office. RN #1 and the DNS put Resident #1 into the elevator to take him to the 2nd floor but instead the elevator went to the basement and back to the first floor. She stated that while the elevator was heading back up from the basement she heard a STAT paged overhead. The elevator door opened at the lobby, they took the resident off the elevator, placed him on the floor, and the NP started CPR. RN #1 stated that she was CPR certified. The NP was interviewed on [DATE] at 12:15 PM and stated that on [DATE] she heard a STAT paged overhead and she called the front desk to inquire about the STAT. She was informed that it was for Resident #1. She reported to the lobby and observed a group of staff standing by Resident #1. She explained that Resident #1 was in the wheelchair slumped over to one side and that he was unresponsive. She assessed the resident with no heartbeat, he was not breathing, and he had a thready pulse that was barely palpable. She further stated that Resident #1 needed CPR so they placed him on the floor and she started compressions. LPN #1 arrived on the scene and started telling staff to get the ambu bag (a self-inflating bag used to provide ventilation on patients who are not breathing or not breathing adequately), mask, and AED while she continued compressions. LPN #1 was interviewed on [DATE] at 1:07 PM and stated that on [DATE] he heard a STAT paged overhead and he went to the lobby where he observed the NP assessing Resident #1. He noted that there was no ambu bag or any other equipment at the scene so he started telling the staff to get the emergency equipment. He stated that the NP initiated CPR. The AED arrived and when it was applied to Resident #1, it verified that CPR was necessary. LPN #1 stated that he was CPR certified. The Rehab Director was interviewed on [DATE] and [DATE] and stated that on [DATE] at approximately 10:00 AM, she was in the conference room on the main floor when she heard a STAT paged. She responded to the lobby and observed RN #1 with Resident #1 who was slumped over in his wheelchair. She stated that RN #1 and the DNS wheeled Resident #1 onto the elevator to take him upstairs. However, the arrow on the elevator light was pointing downwards, she held the elevator door open asking them if they had the override key to direct the elevator straight to the 2nd floor. She stated that she felt someone pushed her hand off the elevator door and the door closed. She observed the elevator door open and the resident was wheeled out of the elevator, placed on the floor, and the NP who was in the lobby started CPR. The Rehab Director stated that in case a resident needed CPR they do not have emergency equipment in rehab department. They would wait for nursing to identify the resident's code status and, if appropriate nursing would initiate CPR. She stated they are allied health and they do not participate in an emergency like CPR. She stated that she was CPR certified. The Assistant Director of Nursing Service (ADNS) was interviewed on [DATE] at 11:43 AM and stated that on [DATE] the RNS came and told her to call STAT because Resident #1 was unresponsive. She called STAT to the lobby twice and stayed in the nursing office and prepared the paper work to transfer Resident #1 to the Hospital. She stated that DNR residents have a yellow dot on the wrist band and a yellow dot next to their name in the electronic medical record (EMR). The ADNS stated that when a resident is found unresponsive, the staff should check the resident's pulse, identify the resident's code status, and if full code start CPR right away and call 911. The ADNS further stated that it is better to check the code status in the chart because sometimes wristbands are not updated. The Administrator was interviewed on [DATE] at 4:08 PM and stated that he was not aware that there was a problem related to the [DATE] incident. He stated that he heard a STAT paged on [DATE] and when he went to the lobby he observed CPR in progress. The Receptionist was interviewed on [DATE] at 9:46 AM and stated that she was at the front desk when the ambulette arrived at about 10:32AM. The escort came and said that Resident #1 does not look good. The RNS went to check on Resident #1 and when she came back in she heard the RNS say he is not well I am calling 911. She stated that the escort, the ambulette driver, and CNA #1 brought the resident inside the building. She heard RN #1 tell them to bring the resident into the dining room. The receptionist stated that she announced STAT overhead and the nurses came to the lobby. She added that she observed Resident #1 being pushed onto the elevator, and then he was brought back to the lobby. CNA #3 was interviewed on [DATE] at 11:50 AM and stated that she does not know how to determine a resident's code status. She also stated that she forgot the code for [MEDICAL CONDITION] and that Code Blue is for allergy. LPN #3 was interviewed on [DATE] at 12:00 PM and stated that residents with Do Not Resuscitate (DNR) status have a yellow chart and a yellow dot on the wrist band. However, she was not sure of the code for [MEDICAL CONDITION]. LPN #4 was interviewed on [DATE] at 3:04 PM and stated that she could not remember what to look for on the wrist band to determine a resident's code status. CNA #4 was interviewed on [DATE] at 7:432 AM and stated that she does not know the color of the dot on the wrist band for DNR residents. The Medical Director was interviewed on [DATE] at 12:30 PM and stated that the Administrator informed him on [DATE] that Resident #1 was unresponsive in the ambulette, The Medical Director stated that the resident had a pulse because of the pacemaker and that the staff should have used a stethoscope to check the resident's heartbeat. He stated that I think the delay in initiating CPR was when the staff tried to take the resident upstairs. The DNS was interviewed on [DATE] at 3:20 PM and stated that on [DATE], Resident #1 returned from [MEDICAL TREATMENT] after 10:00AM and he was observed unresponsive in the ambulette. The RNS went to the ambulette and assessed Resident #1 who was unresponsive and not breathing. Resident #1 was not wearing a wrist band and the RNS had to go to the nursing office to find out the resident's code status. She stated that she was in the nursing office when RNS came in to check the resident's code status. She went out to the lobby and noted that RN #1 was in the lobby with Resident #1. RN #1 decided to take Resident #1 to the 2nd floor as there was no emergency equipment in the first floor (lobby level) nursing office. All emergency equipment is kept on the units. She stated that she accompanied RN #1 on the elevator with Resident #1 who was slumped over to one side in the wheelchair. She further stated that the elevator went down to the basement and then back up to the first floor where staff were waiting for the resident. The DNS stated that she did not hear a STAT Code announced and that she did not perform any assessment on Resident #1. The elevator stopped off on the first floor, the resident was taken off the elevator and was laid on the floor. The NP assessed Resident #1 and stated that he needed CPR, which she initiated. She stated that the staff who initially responded to the STAT code arrived on the scene without any emergency equipment because they were confused. The staff was not aware that the STAT code was for a resident in [MEDICAL CONDITION]. The DNS explained that STAT code is used for both a regular emergency (i.e. falls) and for [MEDICAL CONDITION]. Immediate Jeopardy was removed prior to survey exit of [DATE] based on the following corrective actions taken. The facility: -Implemented a new policy titled Policy and Procedure on Emergency Care for Full Code Residents / Code Blue. The policy documented that in the absence of physician order [REDACTED]. The policy also documented that when a resident has no DNR order and has no pulse or respirations or if the resident is in acute distress with labored breathing and faint pulse, the nurse will instruct a staff member to call CODE BLUE by announcing on overhead page CODE BLUE UNIT (Area) ____ three times. In instances when CODE BLUE is announced off unit i.e. lobby, the crash cart will be brought to the lobby. -A CODE BLUE drill guideline and audit tool were also developed by the facility on [DATE]. -Developed and implemented education associated with the Policy and Procedure on Emergency Care for Full Code Residents / Code Blue that was provided to staff of all discipline. The staff that are not in-serviced (i.e. per diem, on leave of absence, on vacation) will be given a copy of the policy via mail. Upon return to the facility, the staff will be in-serviced by the DNS/ADNS and or the Registered Nurse Supervisor prior to working on the unit. -Emergency equipment (AED, ambu bag, oxygen, cardiac board) was made available in the nursing office on the first floor. 415.3(e)(2)(iii)

Based on interview and record review, the facility failed to ensure that a resident (#2) with ongoing poor appetite was provided the necessary services to ensure adequate fluid intake to prevent dehydration and maintain health. Susbsequently, the resident required hospitalization for the treatment of [REDACTED]. Additionally, a resident (#1) with a history of dehydration was not provided with adequate monitoring and evaluation of her fluid intake to prevent the potential recurrence of dehydration. This was evident for 2 of 10 residents (#1 and #2) reviewed for dehydration which resulted in actual harm for resident (#2) that is not immediate jeopardy and no actual harm for resident (#1) with potential for more than minimal harm that is not immediate jeopardy. The findings include: 1. Resident #2, who was initially admitted to the facility on [DATE], has [DIAGNOSES REDACTED]. The Minimum Data Set, an assessment tool, dated 4/10/10 revealed that the resident has short term memory loss, no impairment with long term memory, is moderately impaired for decision making and has difficulty swallowing and eating. The resident's Comprehensive Plan of Care addressing dehydration and fluid management dated 3/19/10 and and updated on 3/31/10 noted that the resident was at risk for dehydration. The hydration goals included: the resident will not exhibit signs and symptoms of dehydration as evidenced by blood urea nitrogen and blood urea nitrogen/creatinine ratio within normal limits for 90 days; and the resident will have intake of greater than 75% of fluids served with meals and in between meals for 90 days. The interventions to achieve those goals included encourage consumption of fluids greater than 75% with and in between meal, monitor fluid intake, monitor weights and labs, check labs on a routine basis, and monitor intake and output as needed. A review of the meal consumption record ( a document used to record food intake at meal times) revealed that the resident's food intake at meal times from 4/1/10 to 5/4/10 varied from zero to 100 percent. Specifically, the resident's food intake included 15 meal refusals, 25% of meals 29 times, 50% of meals 31 times, 75% of meals 10 times and 100% of meals 4 times. According to nursing notes dated 5/04/10 the resident was transferred to a local hospital on that day due to Failure to Thrive (FTT). The hospital record showed that the resident's [DIAGNOSES REDACTED]. The resident was hydrated intravenously and returned to the nursing home on 5/06/10. On 5/6/10 the Physician's telephone readmission orders [REDACTED]. The results of blood drawn on 5/10/10 was reported to the Physician on that day. The report showed that the resident's blood urea nitrogen level (BUN, used to determine hydration and/or renal status) was 47 (reference range: 6 -24) and glomerular filtration rate (GFR, used to determine kidney function) was 47 (normal is greater than 59). The Physician signed the undated report indicating that these results would be further monitored. A review of the medical record revealed no further monitoring as planned by the physician. According to the monthly meal consumption record from 5/07/10 - 5/09/10 the resident refused all but one of his meals. There was no documented evidence of planned interventions to offer and monitor supplemental fluids between meals during this period of time. The readmission nutritional assessment completed by a certified dietitian on 5/10/10 noted that the resident was consuming less than 25 percent of his meal despite ongoing counseling and the offering of meal alternatives. The goals reflected in this evaluation included the resident maintaining and/or achieving good hydration status. The planned interventions recorded in this note included monitoring routine labs, encouraging intake of sufficient fluids, Ensure Plus 8 oz three times daily with medication pass and 4 oz juice with the 2 PM and 8 PM nourishments. According to standards of nutritional practice for fluid daily fluid requirement , the resident's minimum estimated fluid requirement at that time was 1270 cc daily based on his body weight of 112 lbs. On 5/10/10 the Physician also saw the resident. The physician's orders [REDACTED]. Another order was written by the Physician on 5/11/10 for 4 oz milkshake with lunch and supper. Further review of the meal consumption record (to include nourishment) for the month of May 2010 revealed that from 5/10/10 to 5/19/10 the resident refused all his meals excluding three. He consumed only 25 percent of these three meals. The amount of fluids consumed was not recorded/monitored. (The meal consumption records do not make a distinction between fluids and solids.) The meal consumption record also revealed that the resident refused all of his 2 PM and 8PM nourishments (which included 4 oz juice) during the period of 5/10/10 - 5/19/10, excluding two. Only 25 percent of these two nourishments was consumed. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. According to the data recorded, the resident consumed in cubic centimeters (cc) a combined total of Ensure and milkshake as follows from 5/11/10 to 5/19/10: 5/11 - 840 5/12 - 840 5/13 - 720 5/14 - 800 5/15 - 720 5/16 - 960 5/17 - 480 5/18 - 840 5/19 - 480 These amounts provided an average daily intake of 742 cc of supplements for the 9 days. Of this amount only 80 percent or 594 cc was actually liquid (the rest was solids). This amount was 676 cc less than the resident's assessed minimum daily requirement of 1270 cc. During this period of time (5/10/10 - 5/19/10) there is no documentation that the resident's total daily fluid intake and urinary output was monitored or assessed. The 24-hour report, which is reviewed daily by the facility's clinical and administrative staff did make reference to the resident's ongoing poor appetite/intake, but none specific to the adequacy of his daily fluid intake. This was noted on 5/7/10 to 5/13,/10, and 5/17/10 to 5/18/10. There is no documented evidence that during period of 5/6/10 to 5/20/10 any member of the ITT assessed the adequacy of the resident's daily fluid intake by comparing actual intake to assessed daily requirement. There is no documented evidence that the ITT considered alternate source of hydration when it was evident that the resident was not showing any improvement in the consumption of his meals. Further review of nursing notes revealed that on 5/16/10 the resident began to experience loose bowel movements on the night shift and that the resident reported to a family member on the telephone "I'M MISERABLE." This note did not reflect an assessment of the resident's hydration status by the nursing staff . According to the 24-hour report, the resident also had two additional loose bowel movements on the evening shift of 5/10/10. The Physician was informed about the loose stool on 5/16/10 via the MD Communication Book. The Physician visited the resident on that day and wrote an order for [REDACTED]. hydration status and the impact that loose stools would have on the resident's condition. On 5/18/10, a nursing note written at 2:00 PM stated that the resident was weak in appearance and had mild agitation when encouraged to eat. On 5/20/10 at 10:00AM a nurse documented the following: "Resident awake & responsive (with) confusion. On bed (with) lethargy & weak in appearance, refused Ensure 8 oz & water." This information was reported to the Physician who gave an order to transfer the resident to a local hospital due to FTT and poor oral intake. The 5/20/10 hospital admission [DIAGNOSES REDACTED]. The hospital lab report dated 5/20/10 showed the following results: BUN - 108, sodium - 159 (reference range 135 - 150), and creatinine - 2.7 (reference range 0.5 - 1.3). The resident was hydrated intravenously and returned to the facility with a gastrostomy tube (a tube inserted directly into the stomach for feeding.) A subsequent lab report obtained by the facility and dated 6/21/10 showed that the resident was maintaining his sodium, creatinine and GFR within normal limits. The resident's BUN level was 36, which is consistent with his baseline BUN level obtained at the time of admission in March 2010. A review of the undated facility's policy on the "Prevention & treatment of [REDACTED]. The resident's clinical record revealed no evidence of any consideration by the Physician to implement intravenous fluids. Nor was there any documented evidence of any communication between the Physician, nursing staff and/or the dietary staff regarding the need for intravenous fluids. The "Prevention & treatment of [REDACTED]. No specific plan was found in the clinical record to show that the ITT put other measures in place to improve the resident's oral fluid intake after the resident demonstrated no improvement in his intake at meal times subsequent to revision of his care plan 5/11/10. On 8/24/10 in the morning the Clinical Dietitian and Corporate Dietitian were interviewed about the lack of ongoing assessment of the adequacy of the resident's daily fluid intake and communication between the dietary staff and the physician. Both dietitians stated that they were recently employed by the facility and were not involved in the care of the resident prior to his 5/20/10 hospitalization . However, the Corporate Dietitian did state that a specific plan involving the offering of fluids with greater frequency than was in place should have been developed, implemented and monitored. The Physician was interviewed on 8/24/10 in the morning and 8/25/10 in the afternoon. These interviews revealed that there should have been better communication between the dietary and medical staff. The Physician also stated that he did communicate the need for intravenous fluids and tube feeding with the family. The Physician did not recall the specific dates that this was done. As noted above, in a review of the record, no initial and ongoing communication is documented in the resident's clinical record (which includes the physician, nursing and dietary progress notes) regarding the need for intravenous fluids and the implications of the refusal of such fluids in light of the ongoing poor fluid intake. In summary, the resident experienced harm related to the following: - Prompt measures were not taken to supplement the resident's poor fluid intake orally and/or intravenously. - No follow-up monitoring of the 5/10/10 abnormal lab data used to assess hydration status and renal function was performed until after the resident was hosptalized on [DATE]. -No ongoing assessment of the adequacy of the resident's total daily fluid intake to determine if the resident was meeting his daily fluid needs. -There was no evidence of an integrated approach by the ITT to address the ongoing poor fluid intake of the resident such, as communication between the dietary and medical staff, after the resident demonstrated no improvement in his intake at meal times. 2. Resident #1 has [DIAGNOSES REDACTED]. According to the 6/9/10 Minimum Data Set assessment, the resident requires limited assistance of one person to eat. Doctor's Progress Notes and hospital records from May through August, 2010 revealed that the resident was hospitalized multiple times during that period due to [MEDICAL CONDITION], altered mental status, weakness and behavior changes including agitation, refusal of medications and decreased appetite and intake of food and fluids. Many potential causative factors were noted but the source of the resident's behavior changes was not determined. Laboratory report of 7/14/10 showed that the resident's BUN level (Blood Urea Nitrogen) was noted to be 32 on 7/14/10, higher than her previous BUN level of 18 of 5/19/19 and indicative of insufficient fluids. There is no evidence in the clinical record that the resident's plan of care was revised to address that elevated BUN. The resident was hospitalized from [DATE] - 7/22/10 with an admitting [DIAGNOSES REDACTED]. The resident was re-hydrated with IV fluids at that time resulting in a BUN of 12 on 7/23/10. According to the Dehydration section of the Comprehensive Care Plan (CCP), most currently reviewed and revised on 7/27/10, the Clinical Dietitian (CD) identified the resident's daily fluid requirement to be 1190 - 1360cc. Interventions to ensure adequate hydration included encouragement to consume greater than 75% of the fluids served with meals and in between meals, to monitor fluid intake and check lab values on a routine basis and provide 240 cc of fluids every shift. A physician's orders [REDACTED].) Progress notes written by the Physician and nursing staff on 8/3/10 revealed that on that date the resident was noted to be drowsy and unresponsive to verbal stimuli. She was sent to the emergency room of a local hospital on [DATE] for evaluation. The hospital record of this visit stated that the resident was given intravenous fluids, after which she was alert. The surveyor reviewed the resident's clinical record for evidence of monitoring or calculation of the amount of fluids taken by the resident per day and for evaluation of the resident's daily fluid intake in order to assess for adequacy in an accurate and timely manner. A part of this review included a review of the resident's meal consumption, documented in the CNA (Certified Nurse Aide) Accountability Records, from 7/1/10 through 8/25/10. The resident's average intake during that period of time was 50 - 75% for breakfast, 50% for lunch and 50% for dinner. Additionally, her average intake of between meal nourishments was 50% at 2:00PM and 25 - 50% at bedtime. However, there was no differentiation between food and fluids consumed, i.e. the amount of fluids consumed was not noted. Additionally, there was no assessment of the adequacy of the resident's actual daily fluid intake reflected on the review sections of the care plan or in progress notes by the physician, nurses and dietary staff. The provision of the 240cc of fluids per shift, as ordered since 7/27/10, was noted on the resident's Medication Administration Records (MARs). Review of the MARs from 7/27/10 - 8/18/10 revealed no evidence that the resident received fluids on the night shift (12:00AM - 8:00AM) and that she consumed an average of 200cc during the day and evening shifts. Additionally, review of the MARs from 8/19/10 - 8/25/10 further revealed that offering the 240cc per shift was not done during that period of time. The CD was interviewed at 11:25AM on 8/25/10 to determine how she monitored the adequacy of the resident's fluid intake and hydration status. The CD stated that she did not refer to the meal consumption records or MARs. She stated that she observed some meals and that the unit nurse would tell her in the morning meeting if the resident's intake was poor. The CD also stated that she relied on laboratory results to determine the resident's hydration status. There was no evidence in the resident's physician's orders [REDACTED]. Record review revealed that lab tests were not done between 7/23/10 following rehydration in the hospital and 8/3/10 after the resident was again rehydrated and evaluated in the hospital. Additionally, lab tests were not done since 8/3/10. 415.12(j)