Every finding on record at Maple City Rehabilitation and Nursing Center

Based on interviews and record reviews, the facility failed to ensure medical records were complete and readily accessible for three of five residents reviewed (Residents #2, #4 and #5). Specifically, the facility could not readily access medical records maintained in its prior electronic medical record system prior to May 2023 due to transition to a new electronic medical record program for Residents #2, #4, and #5. In addition, the facility could not provide the preadmission screening information for Resident #4. The findings include:The facility policy titled Retention of Medical Records last reviewed January 2026, included the facility must maintain entire resident records that are complete, accurately documented, and systematically organized.Resident #2 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (a progressive brain disorder that affects memory, thinking and behavior), aphasia (language disorder that affects someone's ability to speak and understand what others say), and adult failure to thrive (multifactorial state of decline). Resident #4 was admitted to the facility on [DATE] with diagnoses including cerebral palsy (a group of conditions that affect movement, balance, and posture), quadriplegia (paralysis that affects all four limbs and the torso), and epilepsy (repeated seizures). Resident #5 was admitted to the facility on [DATE] with diagnoses including schizophrenia (mental condition that affects how people think, feel, and behave), intellectual disabilities and adult failure to thrive. Review of medical records for Residents #2, #4, and #5 revealed that medical records prior to May 2023, which would have been accessed in the facility's previously used electronic medical record, were not readily available for review. In addition, the facility was unable to provide Resident #4's Preadmission Screening and Resident Review form (a federally mandated evaluation for all individuals seeking admission to a Medicaid-certified nursing facility) for the resident's 05/26/2016 admission. During an interview on 07/30/2026 at 8:25 AM, the Medical Records/Central Supplies clerk stated that the facility transitioned from Matrix (an electronic medical record system) to Point Click Care (an electronic medical record program) a year or a year and a half ago and they had not been able to access Matrix since the transition. The Medical Records/Central Supplies clerk stated that they were unable to locate information on Resident #4's Preadmission Screening and Resident Review.During an interview on 07/30/2026 at 8:30 AM, the Administrator stated that the facility no longer had access to Matrix and medical records prior to May 2023 were not accessible. During an interview on 07/30/2026 at 8:45 AM, the Assistant Director of Nursing stated they were not aware that they could no longer access Matrix until yesterday (07/29/2026). During an interview on 07/30/2026 at 9:30 AM, the Attending Physician stated that previous medical records could be important if necessary to see why a resident was on a medication or to find out more about their past medical history. The Attending Physician stated that archiving medical records is helpful for any physician. 10 New York Codes Rules and Regulations 415.22(c)(1)-(4), (f)(4)

Based on observations, interviews, and record review conducted during the Recertification Survey from 08/18/2024 to 08/23/2024, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for two (Resident #59 and #71) of two residents reviewed. Specifically, Resident #59 was readmitted from the hospital on 08/06/2024 following surgical treatment of an abscess (a painful, swollen lump filled with pus) and did not have a follow up evaluation as ordered in a timely manner. Resident #71, who had a contracture (a shortening of muscles, tendons, skin, and nearby soft tissues that prevent normal joint movement which is often painful) of the left hand did not have a care plan in place that included measurable goals, interventions, or monitoring which resulted in multiple pressure ulcers and a decrease in range of motion. This resulted in actual harm to Resident #71 that was not Immediate Jeopardy and is evidenced by the following: 1. Resident #71 had diagnoses that included a stroke and hemiparesis (weakness or the inability to move on one side of the body). The Minimum Data Set Resident Assessment, dated 05/31/2024, documented the resident was cognitively intact, had a functional limitation in range of motion in one upper extremity and one lower extremity, and did not have any pressure ulcers. The facility policy Contracture Management Program, dated January 2024, documented the facility will engage residents as appropriate in contracture management interventions to improve, maintain, and prevent deterioration of the mobility of joints, flexion, and extension of extremities. Relevant care plans will be initiated that address resident risks and actual impairments and interventions to address. The facility policy Resident Mobility and Range of Motion, dated January 2024, documented residents with limited range of motion will receive treatment, services, and equipment to increase and/or prevent further decrease in range of motion. The resident care plan will be developed by the interdisciplinary team based on the comprehensive assessment, will be revised as needed, and will include specific interventions, exercises, and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion. Interventions may include therapies, the provision of necessary equipment, and/or exercises and will be based on professional standards of practice and be consistent with state laws and practice acts. Review of an Occupational Therapy Discharge Summary, dated 10/11/2023, the Director of Therapy documented Resident #71 had a contracture to their left hand and their splint (a device used to treat a contracture that provides support, improves range of motion, prevents pain and impairment to skin integrity) was missing, a new one was ordered, and the resident would continue therapy treatment once the splint arrived. The facility was unable to provide evidence Resident #71 received a splint or any occupational therapy services since 09/28/2023. There was no documented evidence Occupational Therapy readmitted Resident #71 to resume therapy services. Review of the current Comprehensive Care Plan and Kardex (a care plan used by Certified Nursing Assistants to provide daily care) did not include information related to Resident #71's contracture to their left hand or interventions and monitoring for the contracture to prevent complications. Review of a progress note, dated 08/18/2024 at 8:37 PM, included Registered Nurse Supervisor #1 documented Resident #71 had three new pressure ulcers on their left hand due to the contracture. Two of the wounds were a stage two (partial thickness tissue loss as a shallow open ulcer) pressure ulcers, with the larger wound measuring three centimeters by one centimeter and one wound was considered an unstageable (full thickness tissue loss and wound base covered with dead tissue) pressure ulcer. The medical provider was notified, and verbal orders obtained for wound treatments and a follow-up with the facility wound care doctor. During observations on 08/18/2024 at 8:38 PM and 08/19/2024 10:42 AM, Resident #71's left hand was contracted and had open wounds of the left palm. There was no splint or dressing to the hand. During an interview at that time, Resident #71 stated the contracture had been there for a while, and they were not receiving any interventions or therapy for the contracture despite asking for therapy for two months. Review of a medical progress note, dated 08/18/2024, following a telemedicine visit Nurse Practitioner #2 documented the resident was being seen for multiple wounds to the left-hand contracture. Nurse Practitioner #2 ordered bacitracin (antibiotic ointment to help prevent infection) daily for three days and a wound consultant on 08/19/2024. There was no documented evidence a wound consult was ordered or completed. Review of a progress note, dated 08/19/2024 at 8:15 AM, the Director of Nursing documented Resident #71 had increased resistance to range of motion of their left hand, altered skin integrity, and an occupational therapy evaluation had been requested. Review of a physician's order, dated 08/19/2024, included to cleanse the left palm wound with normal saline, apply a thin layer of bacitracin, and cover with a dry dressing daily until 08/22/2024. The orders did not include orders for therapy services, or a follow-up visit with the wound doctor. During additional observations on 08/20/2024 at 10:18 AM and again at 2:29 PM, Resident #71 did not have a dressing covering the wounds to their left hand or any splint in place. Review of the August 2024 Treatment Administration Record revealed the left-hand wound treatment was signed off as completed on 08/19/2024 and 08/20/2024. During observations on 08/21/2024 at 1:05 PM, Occupational Therapist #1 was assessing Resident #71's left hand in the resident's room. There was no dressing in place to the left hand. During an immediate interview, Occupational Therapist #1 stated the resident had a contracture to their left-hand that required therapy. Review of an Occupational Therapy evaluation and assessment notes, dated 08/21/2024 and 08/22/2024, revealed the resident was being evaluated for increased pain that limited movement, decreased range of motion, decreased strength, and the need for splinting and passive range of motion, and that occupational therapy services were warranted. During an interview on 08/22/2024 at 9:37 AM, Certified Nursing Assistant #3 stated Resident #71 had a left-hand contracture for at least nine months and was unable to move their hand. Certified Nursing Assistant #3 stated Resident #71 had verbalized they wanted therapy to help with their left hand, but had not received any therapy during that time that they knew of. During an interview on 08/22/2024 at 2:04 PM, Occupational Therapist #1 stated Resident #71 was a high risk for contractures due to having a stroke and was surprised that Resident #71 did not have any interventions in place for contractures. The Occupational therapy department should have followed up and obtained a splint for Resident #71 based on the previous discharge summary, and was surprised it had been so long since occupational therapy had seen the resident. Occupational Therapist #1 stated Resident #71's left hand wounds were most likely caused by pressure from the contracture and the lack of interventions in place to keep the contracture from worsening and to protect the skin from breakdown. During an interview on 08/22/2024 at 4:15 PM, Physician #1 stated Resident #71 had contractures on the left side of their body, including the left hand, most likely a result of paralysis after their stroke. Physician #1 stated they would expect Resident #71 to be receiving interventions for the contracture including therapy services, range of motion exercises, and a device in their hand to help prevent skin breakdown. Physician #1 stated not receiving interventions for the contracture or therapy services could have led to the development of the pressure ulcers in Resident #71's hand. During an interview on 8/22/2024 at 5:25 PM, the Director of Nursing stated Resident #71 should have a care plan for the hand contracture that included interventions to prevent worsening of the contracture and prevent the development of a pressure ulcer. The Director of Nursing stated therapy should have been involved with the resident between their discharge on 09/28/2023 and the development of the pressure ulcers on 08/18/2024 and involved in quarterly assessments and care planning, but there was not a process in place for those evaluations. The Director of Nursing stated without a care plan with interventions for the contracture and the lack of involvement from occupational therapy, it most likely is what caused Resident #71 to develop pressure ulcers in the left hand. 2. Resident #59 had diagnoses that included hemiplegia (partial or complete paralysis on one side of the body), protein-calorie malnutrition, and an abscess (a painful, swollen lump filled with pus) of the buttock. The Minimum Data Set Resident Assessment, dated 05/08/2024, documented the resident was cognitively intact. Review of the Comprehensive Care Plan, dated 08/12/2024, revealed Resident #59 had a surgical incision to the right buttock. Interventions included to apply treatment per the physician's order, weekly documentation of the wound, and referral to appropriate medical specialists as needed for evaluation and treatment. Review of a nursing progress note, dated 07/30/2024 at 5:35 AM, Registered Nurse #1 documented Resident #59 had requested to see a nurse and reported having a boil on the back of their right hip. The wound was assessed and found to be inflamed with signs of infection, and the resident was transferred to the hospital. Review of a hospital History and Physical, dated 07/30/2024 at 4:17 PM, revealed Resident #59 had gluteal (buttocks region) abscess and a Computed Tomography (CT) scan noted a fluid collection that was suggestive of an abscess. A hospital Discharge Summary and After Visit Summary, dated 08/6/2024, included Resident #59 was seen by surgical services while hospitalized and underwent an Incision and Debridement (I&D) surgical procedure on 07/31/2024 and wound closure on 08/02/2024, was being discharged on [DATE], and had a post-operative appointment scheduled with General Surgery on 08/13/2024. Review of a Readmission Note, dated 08/06/2024 at 3:13 PM, the Assistant Director of Nursing documented Resident #59 was readmitted to the facility. Review of physician's orders, dated 08/08/2024, included to cleanse the right buttock surgical wound with sterile water or normal saline, place a normal saline soaked gauze to the open area, apply skin prep (liquid skin protectant) to the peri-wound (surrounding skin), and cover with a silicone foam bordered dressing daily. An order, dated 08/06/2024, included an appointment scheduled for 08/13/2024 at 10:00 AM with the hospital general surgeon. During observations on 08/22/2024 at 11:47 AM, the wound was approximately three to four inches long. The lower portion of the wound incision closed with three sutures and the upper portion was a circular in shape open area. During an immediate interview, Registered Nurse #2 stated they would have the physician come look at the wound due to a possible dehiscence (the reopening of a surgical incision that had been stitched or stapled closed). Review of interdisciplinary progress notes from 08/06/2024 to 08/23/2024 did not include any documented evidence the Surgeon's office or any medical provider had evaluated the surgical wound following the resident's return to the facility. During an interview on 08/22/2024 at 2:43 PM, Registered Nurse Supervisor #2 stated they had spoken with the Director of Nursing who said Resident #59 was not being followed by a Wound Care Consultant because the resident was scheduled for a surgical follow-up appointment, but the appointment had been cancelled. Registered Nurse Supervisor #2 stated the facility's physician was assessing the resident's wound at that time. During an interview on 08/22/2024 at 4:59 PM, the Director of Nursing stated when Resident #59 returned to the facility from the hospital, a portion of the incision was not sutured closed (left open). The Director of Nursing stated residents were typically seen by the facility's Wound Care Consultant after surgical follow-up appointments. Resident #59's surgical appointment that had been scheduled for 08/13/2024 had to be changed to 09/12/2024 and Unit Clerk #1 (who schedules appointments) would know more about it. During an interview on 8/22/2024 at 5:53 PM, Licensed Practical Nurse Manager #1 stated Resident #59's surgical follow-up appointment had been rescheduled by Unit Clerk #1 but was not sure why. Licensed Practical Nurse Manager #1 stated the appointment should have been left as scheduled. The Wound Care Consultant had not been asked to see Resident #59 since their re-admission and the surgical follow-up appointment was now scheduled for 09/12/2024. During an interview on 08/23/2024 at 9:49 AM, Unit Clerk #1 stated their role involved setting up resident appointments and scheduling transportation. Resident #59 had an appointment scheduled for 08/13/2024 with the surgeon, but they had to reschedule it for transportation reasons. Unit Clerk #1 stated there were three residents scheduled for outside appointments on 08/13/2024, they could not get medical transport for all three residents, and Resident #59's appointment is now scheduled for 09/12/2024. Unit Clerk #1 stated they did send an email to Licensed Practical Nurse Manager #1 about Resident #59's appointment change but they had only been in their role for about two months and had not been told during training that someone (in leadership) should be notified if an appointment needed to be rescheduled or why. During interviews on 08/23/2024 at 02:17 PM and again at 04:41 PM, Physician #1 stated the facility used Wound Care Consultants (physicians) to assess residents with wounds and provide recommendations and as far as they knew, Resident #59 had not been seen by a Wound Care Consultant (following their surgery and readmission). Physician #1 stated follow-up appointments were important because the surgeon would recommend the treatment course, and they (facility staff) should be notified if an appointment was rescheduled or cancelled. Physician #1 stated rescheduling Resident #59's appointment could impact the resident due to a delay in treatment (not getting the surgeon's recommended treatment) and the resident could get an infection. Physician #1 said they observed Resident #59's wound on 08/22/2024 and the wound looked the same compared to their previous observation (no date provided), and they do not believe it had dehisced (the reopening of a surgical incision that had been stitched or stapled closed). During an interview on 08/23/2024 at 4:49 PM, the Director of Nursing stated Unit Clerk #1 was responsible for resident appointments and if an appointment needed to be rescheduled or cancelled, it should be discussed with the unit manager and notify the physician. The Director of Nursing did not know the why Resident #59's 08/13/2024 appointment had been rescheduled, and a special request for a Wound Care Consult had now been made since the surgical follow-up appointment had been rescheduled (for 09/12/2024). 10 NYCRR 415.12

Based on observations, interviews, and record review conducted during the Recertification Survey from 08/18/2024 to 08/23/2024, the facility did not allow a resident the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident for one (Resident #31) of five residents reviewed for accidents. Specifically, Resident #31's side rails that were used to increase their independence and mobility in bed were removed by the facility as considered being a restraint without an appropriate assessment resulting in a fall out of bed with injury. This resulted in actual harm to Resident #31 that was not Immediate Jeopardy and is evidenced by the following: The facility policy Use of Side Rails, last reviewed January 2024, documented side rails are considered a restraint when they are used to limit the resident's freedom of movement. Side rails are permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents. An assessment will be made to determine the resident's medical symptoms or to assist with mobility and transfers of residents. Resident #31 had diagnoses including a stroke with left hemiparesis (weakness on one side of body), chronic pain, and depression. The Minimum Data Set Resident Assessment, dated 06/06/2024, revealed the resident was cognitively intact and required substantial to maximum assistance to roll left and right. Review of the current Comprehensive Care Plan, dated as revised 06/21/2024, and current Kardex (used by Certified Nursing Assistants to direct daily care) documented Resident #31 required assistance with mobility related to limited mobility, weakness, and left hemiplegia. Interventions included, but not limited to, substantial to maximum assistance to roll left and right with two staff assistance. During an interview on 08/18/2024 at 8:05 PM, Resident #31 stated the facility staff removed their side rails that they had used for a long time to move around in bed because they (the facility) considered them a restraint. Resident #31 stated after the siderails were removed, they fell out of bed, and they continue to be afraid of falling again. In a facility Accident/Incident Report and Incident Summary, dated 06/17/2024, Licensed Practical Nurse #2 documented Resident #31 had an observed fall on 06/16/2024 resulting in a brain bleed. Recommended steps to prevent recurrence was a therapy evaluation. Review of the facility Fall Risk Assessment Evaluation, dated 06/18/2024, revealed that prior to Resident #31's fall from bed on 06/16/2024 the resident had no history of falls in the prior six months. In a medical progress note, dated 06/17/2024, Nurse Practitioner #1 documented Resident #31 rolled out of bed while receiving care and was hospitalized resulting in a subarachnoid hemorrhage (brain bleed). A Rehabilitation Referral, dated 06/18/2022 (identified by the Director of Nursing as misdated and should have been dated 06/18/2024), signed by the Registered Nurse Supervisor included a referral to therapy to assess for adaptive equipment and/or assistive device due to a fall. Review of Resident #31's medical record did not include any evidence a therapy evaluation had been completed following the resident's fall with injury, or that a side rail assessment had been completed to determine the safety of one or the use of one for increased independence in bed mobility. During an interview on 08/23/2024 at 9:26 AM, Certified Nursing Assistant #1 stated Resident #31 had told them they were upset that their siderails were removed as they only had the use of one arm, and they could grab the siderails with that arm and move around and assist the aides with bed mobility as before. During an interview on 08/23/2024 at 9:44 AM, Unit Clerk/Certified Nursing Assistant #1 stated they had been caring for Resident #31 for many years and they used to have side rails which they used to help themselves roll, in addition to assisting the staff with bed mobility and positioning. The Unit Clerk/Certified Nursing Assistant #1 stated Resident #31 had a fear of rolling out of bed and the side rails also gave the resident peace of mind. During an interview on 08/23/2024 at 10:20 AM, Maintenance Staff #1 stated they were told side rails were not allowed and to remove them all (all side rails in the facility), and they guessed it came from the prior Administrator. Maintenance Staff #1 said they remembered Resident #31 saying they were unable to turn in bed without the side rails. During a telephone interview on 08/23/2024 at 10:28 AM, the Director of Maintenance stated they were ordered by the prior Maintenance Director to pull the side rails approximately 6 to 12 months ago, but did not get any information as to why, stating we just followed the work order. During an interview on 08/23/2024 at 10:38 AM, the Director of Nursing stated side rails were removed throughout (the facility) to stay in line for a restraint free facility and they were not aware Resident #31 had side rails prior to them being taken off their bed. The Director of Nursing stated no other type of bar had been considered to their knowledge and did not know if any side rail audit (assessment) had been completed. The Director of Nursing stated the therapy referral was dated as 06/18/2022 but should have been dated 06/18/2024. It should not have prevented therapy from completing a referral as the referrals were discussed in morning report and therapy checks their referrals on a regular basis. During an interview on 08/23/2024 at 11:15 AM, Occupational Therapist #1 stated this facility did not allow any side rails for any reason because they say they are a restraint. Occupational Therapist #1 said that a side rail on Resident #31's bed would not limit their freedom of movement and would not be considered a restraint for this resident. Occupational Therapist #1 said Resident #31 would actually be a very good candidate for a side rail due to their hemiparesis on one side and a strong arm on the other (to pull themselves over and hang on) and increase their participation with self-positioning and bed mobility (rolling to the side). Occupational Therapist #1 stated they did not put this information in their last therapy discharge note because the facility did not allow any side rails for any resident, and they were told by the Director of Nursing that they had to make a recommendation on Resident #31's Discharge Summary for the resident to participate in rolling to the side using strength of whole body (versus a side rail), despite their affected left side that was unable to yank or pull. During an interview on 08/23/2024 at 12:25 PM, the Administrator stated side rails were not a restraint if they were used appropriately. During an interview on 08/23/2024 at 2:09 PM, Physician #1 stated if the therapy department had made the recommendation for a bed mobility device the resident should be able to have one. Physician #1 stated they knew this resident used to have a siderail for self-positioning but was no longer allowed to have one due to the facility not allowing side rails any longer. Physician #1 stated if a resident had a cerebral vascular accident (stroke), had lost use of one side of their body, and had a strong opposite arm, a side rail or another device that could be added to the bed would help prevent them from rolling out of bed and there would be a less chance to fall with a barrier there. 10 NYCRR 415.5(e)(1)

Based on interviews and record review conducted during the Recertification Survey from 08/18/2024 to 08/23/2024, for 24 (Residents #1, #5, #22, #25, #27, #28, #37, #49, #58, #59, #61, #69, #73, #76, #79, #82, #83, #84, #85, #100, #109, #110, #161, #311) of 24 residents, the facility did not ensure that the baseline care plan (care plan developed within 48 hours of admission that includes the minimum healthcare information necessary to properly care for the immediate needs of the resident) was completed within the required timeframe and that a summary of the baseline care plan was provided to the resident and/or their representative. Specifically, for Residents #73 and #82, the facility could not provide evidence that a baseline care plan was completed within 48 hours of the resident's admission. For Residents #1, #5, #22, #25, #27, #28, #37, #49, #58, #59, #61, #69, #76, #79, #83, #84, #85, #100, #109, #110, #161, and #311, the facility could not provide evidence that a summary of the baseline care plan was provided to the resident and/or resident representative. The findings included, but were not limited to, the following: Review of the facility policy Care Plans-Baseline, dated January 2024, included the baseline care plan would be developed for each resident within forty-eight (48) hours of admission and used until the facility staff could conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan. The resident and their representative would be provided a summary of the baseline care plan that included, but was not limited to, the initial goals of the resident, a summary of the resident's medications and dietary instructions, and any services and treatments to be administered by the facility. 1. Resident #73 had diagnoses that included dementia, depression, and hypertension (high blood pressure). The Minimum Data Set Resident Assessment, dated 06/07/2024, documented the resident had severely impaired cognition. Review of the electronic health record for Resident #73 did not include documented evidence that a baseline care plan had been completed and the facility was unable to provide additional evidence of its completion when requested. 2. Resident #82 had diagnoses that included a neurocognitive disorder with Lewy bodies (a form of progressive dementia), pseudobulbar affect (a nervous system disorder that causes involuntary laughing and crying), and depression. The Minimum Data Set Resident Assessment, dated 07/05/2024, documented the resident had severely impaired cognition. Review of the electronic health record for Resident #82 did not include documented evidence that a baseline care plan had been completed and the facility was unable to provide additional evidence of its completion when requested. 3. Resident #5 had diagnoses that included major depressive disorder, diastolic congestive heart failure (a long-term condition where the heart cannot pump blood well enough to give the body a normal blood supply), and hypertension (high blood pressure). The Minimum Data Set Resident Assessment, dated 07/10/2024, documented the resident was cognitively intact. Review of the electronic health record for Resident #5 did not include documented evidence that a summary of the baseline care plan was provided to the resident and/or their representative and the facility was unable to provide additional evidence that the summary had been provided when requested. 4. Resident #85 had diagnoses that included diabetes, epilepsy (a brain condition that causes recurring seizures), and schizophrenia (a mental disorder characterized by hallucinations and delusions). The Minimum Data Set Resident Assessment, dated 06/10/2024, documented the resident was cognitively intact. Review of the electronic health record for resident #85 did not include documented evidence that a summary of the baseline care plan was provided to the resident and/or their representative and the facility was unable to provide additional evidence that the summary had been provided when requested. During an interview on 08/22/2024 at 12:25 PM, the Social Worker stated baseline care plans were completed by nursing and social work was not involved in the process. The Social Worker stated they provided information to include in the baseline care plan, and if something stood out about a resident, they would add it to the care plan. During an interview on 08/23/2024 at 1:57 PM, the Administrator stated some residents' data was located in the electronic health record system that was previously used by the facility, however, when they looked in that system for the identified residents, they did not have a baseline care plan. During an interview on 08/23/2024 at 5:50 PM, with the Director of Nursing and Administrator, both stated they were not aware of any issues regarding the completion of baseline care plans or summaries being provided to the resident and/or resident representative. 10 NYCRR 415.11

Based on observations, interviews, and record review conducted during the Recertification Survey from 08/18/2024 to 08/23/2024, for one of one main kitchen, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, non-food contact surfaces were dirty, utensils and dishware were dirty, floors were dirty, there was missing grout between floor tiles, a reach-in cooler was dirty, and food items were not stored 6 inches above the floor. The findings are: Record review of the facility sanitization policy and procedure, dated 01/2024, listed 2. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners will be kept in good repair, 3. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions. Observations in the main kitchen on 08/18/2024 between 6:42 PM and 7:16 PM included the following: a) Several juice containers, butter, a can of soda, and three crates of milk containing 10 half-gallon containers were stored directly on the floor in the walk-in cooler. b) There was a bag of vegetables and a bag of zucchini slices on the floor in the walk-in freezer underneath the shelves. c) The upright reach-in cooler was heavily soiled with food on the bottom shelves (loose cut up lettuce), dried food debris on ledges, dried food residue on gaskets, and the outside had dried food debris. d) There was a large amount of food crumbs in both sides of the base of the stainless plate warmer unit. e) There were food crumbs in the drawers that contained large utensils (spoons, scoopers, spatulas, etc.) and one #6 scooper had dried food debris on it. During observations on 08/19/2024 at 9:12 AM and 08/20/2024 at 11:50 AM, the upright reach-in cooler remained dirty with food crumbs and debris in bottom of cooler, including water puddles of cloudy water with white floating debris in them. During observations on 08/20/2024 11:45 AM, the kitchen floors under the ovens, storage racks, dish machine, and food preparation area were dirty with food spillage, debris, and grime. There was soiled rag stuffed into a drain line under the preparation sink. Additionally, most of the dish room floor was missing grout and there was stagnant water with food debris in the grooves. During an interview on 08/20/2024 at 11:52 AM, the Acting Food Service Director/Registered Dietician stated the kitchen needed to be cleaner and a deep cleaning should take place at least weekly. The Acting Food Service Director/Registered Dietician also stated that the missing grout in the dish machine area has been an ongoing issue for years and they were not sure what the plan was to address it. The Acting Food Service Director/Registered Dietician stated that cleaning duties get divided up between different staff daily, and there were a lot of new people that were trying. The Acting Food Service Director/Registered Dietician also stated that hopefully when a new Food Service Director starts, we can get staff on board with training for cleaning and it will look like it used to. During an interview on 08/21/2024 at 4:00 PM, the Administrator stated the kitchen should be cleaner and needed be addressed. The Administrator also stated that they were in the middle of hiring a new Food Service Director as they had been without one for a month. 10 NYCRR: 415.14(h), 10 NYCRR: Subpart 14-1, 14-1.43(a), 14-1.95, 14-1.110(d), 14-1.170

Based on observations, interviews, and record review conducted during the Recertification Survey from 08/18/2024 to 08/23/2024, the facility did not ensure that all drugs and biologicals were properly stored in accordance with State and Federal Laws for two (Unit One Hall A and Unit Two Hall A) of two medication carts and one (Unit Two) of two medication rooms reviewed. Specifically, medication carts contained expired medications, insulin without an open or expiration date, and one bottle of eye drops without any resident identifiers. Additionally, the medication room contained expired medications. This is evidenced by but not limited to the following: The undated facility policy and procedure, Storage of Medications, included drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. During an observation on 08/21/24 at 4:45 PM, the Unit Two Hall A medication cart had four bottles of medications that were open and in use, including one bottle of fish oil that expired June 2024, one bottle of Vitamin C and one bottle of Vitamin D3 that expired July 2024, and one bottle of cetirizine hydrochloride (allergy medication) that had no expiration date printed on the bottle. Additionally, there was one Lantus (long-acting) insulin pen in use with no open or expiration date on it. During observations on 08/21/2024 at 5:02 PM, the Unit Two medication room had five bottles of expired medications including two bottles of bisacodyl (laxative) that expired February 2024, one bottle of fish oil that expired April 2024, one bottle of fish oil that expired June 2024, and one bottle of Vitamin C that expired July 2024. Additionally, the medication refrigerator had two boxes of bisacodyl suppositories that expired February 2024, nine doses of the influenza vaccine that expired 06/10/2024, and one open box of acetaminophen suppositories that expired June 2024. During an interview at that time, Licensed Practical Nurse Manager #1 stated no expired medications should be stored in either the medication carts or the medication room, and the expired medications should have been found during night shift audits that were completed by the nurses. During observations on 08/22/2024 at 12:52 PM, the Unit One Hall A medication cart had one bottle of artificial tears eye drops that had no resident identifiers and no open or expiration date, one vial of insulin lispro (short-acting) and one vial of insulin glargine (long-acting) that were in use and not labeled with an open or expiration date, one bottle of simethicone (used to treat gas and bloating) that expired June 2024, and a vial of insulin glargine that was in use and had expired on 08/01/2024. During an interview at that time, Licensed Practical Nurse #1 stated each resident-specific medication should have a label that included resident identifiers, and insulin and eye drops should be labeled with an open and expiration date. During an interview on 08/23/2024 at 4:49 PM, the Director of Nursing stated resident-specific medications should be labeled with resident identifiers, insulin and eye drops should be labeled with open and expiration dates, and no expired medications should be stored in medication carts, medication rooms, or medication refrigerators. The Director of Nursing stated audits were being completed monthly on the medication carts and included checks for expired medications, expiration dates on medications, and resident identifiers. The identified medications must have been missed during the audits. 10 NYCRR 415.18(e)(1-4)

Based on observations, interviews, and record review conducted during the Recertification Survey and complaint investigation (NY00345323) from 08/18/2024 to 08/23/2024, for two (first and second floors) of two resident-use floors, the facility did not ensure a safe, clean, comfortable, and homelike environment. Specifically, there were roof leaks, missing ceiling tiles, and resident care equipment was dirty. The findings are: Record review of a roof vendor work estimate, dated 07/19/2024, revealed: roof repairs on the Ballasted EPDM (ethylene propylene diene terpolymer; a durable synthetic roofing membrane) roof system as needed in the active leak location on the South side of the building. The notes section of this report listed: Although work will be performed per proper roofing practices and we will stand behind our work, no guarantees can be provided on repair work due to the condition of the existing roof systems. Record review of an undated email communication from the Environmental Services Director to Corporate documented: The roof has been leaking above the second-floor day room for around a year. We applied a sealant which stopped the leaks. Just recently the leaks started again we set a plan in place (that included) drainage tarps and cans to catch the rainwater or divert it to a can. Starting Monday, the 26th of August we will start the roof repair in house. Record review of email communication from the Environmental Services Director to Corporate dated 07/25/2024, documented: I sent a proposal on possible roof repair. As of right know we have the leak under control but need the roofing company to come in and fix it permanently. The email response from Corporate on 07/31/2024, documented We have had some success repairing roofs in house using the two application silicone products. Observations on 08/19/2024 at 9:40 AM and 08/21/2024 at 9:00 AM included an oxygen concentrator was in use in resident room [ROOM NUMBER]-B (first floor) and had liquid spills, a buildup of dust, and debris on all surfaces. Observations on 08/19/2024 at 1:27 PM and 08/21/2024 at 9:38 AM included the oxygen concentrator in resident room [ROOM NUMBER]-A (first floor) was in use and covered with dust. During an interview at this time, Resident #76 stated that once a week they use a tissue to clean the vent so the machine does not overheat, and staff do not clean the machine. Observations on 08/19/2024 at 10:37 AM included an approximately 8-feet by 8-feet wide drainage tarp was installed in the suspended ceiling of the second-floor day room with multiple missing ceiling tiles. The drainage was observed to be going into a 32-gallon garbage can adjacent to the door to the day room. During an interview at this time, the Environmental Services Director stated the roof has been leaking and coming into the building on the second floor and has been an issue for over a year. The Environmental Services Director also stated that corporate wants to add a rubber sealant on to the roof and maybe some roof drains. Observations on 08/19/2024 at 10:40 AM included two missing 2-feet by 4-feet ceiling tiles in the suspended ceiling of the storage closet off the second-floor day room. Two trash cans were observed to be on the floor collecting water dripping from the ceiling. During an interview at this time, the Environmental Services Director stated the ceiling tiles were left open until the roof could be fixed and was not sure when it would be fixed. Observations on 08/19/2024 at 10:43 AM included five missing ceiling tiles and an approximately 2-feet by 2-feet tarp installed in the suspended ceiling within the second-floor nourishment room/nurses charting room. The drainage was observed to be going into a trash can and four other trash cans were on the floor collecting water leaking from the ceiling. When interviewed on 8/19/2024 at 10:43 AM, the Environmental Services Director stated the whole area around the day room on the second floor has been an issue when it rains heavy, and the roof top mechanicals are installed on the roof over the day room area. Observations on 08/19/2024 at 10:46 AM included two sit to stand resident lifts (#44853 and #2658249) on the second floor with footrests that were rusty and covered in debris. During an interview at this time, the Environmental Service Director stated maintenance staff should clean and wipe down the lifts when doing their monthly electrical inspections, and the lift looked like it was missed and not cleaned. During an interview on 08/22/2024 at 11:09 AM, the Administrator stated that either Certified Nursing Assistants (CNA) or housekeeping should be cleaning the oxygen concentrators, and there is a policy, but the procedure is not clear at this point. 10 NYCRR: 415.29, 415.29(b), 415.29(i)(2), 415.29(j)(1)

Based on observations, interviews, and records review conducted during a Recertification Survey and complaint investigation (NY00345323) from 08/18/2024 to 08/23/2024, for one of one kitchen, the facility did not ensure there was an effective pest control program. Specifically, small brown flies and fruit flies were present and untreated. The findings are: The facility pest control policy dated 01/2024, documented the following: E. A complaint log will be maintained by the Maintenance Department. Whenever there is a complaint noted, a maintenance work order is to be sent to the Maintenance office. F. Monitoring of pest control is performed as part of the weekly environmental rounds conducted by Performance Improvement Committee designee, daily observations, and documentation by staff in the Maintenance/Engineering log located at all Nursing stations and Security Stations departmental rounds and preventative measures. Record review of the past three months of maintenance logs on units revealed no pest control concerns were noted by staff. Pest control vendor treatment records for the past three months documented the following: - On 05/13/2024, all drains in the main kitchen and kitchenettes were treated to cut down on the current and ongoing drain fly issue. - On 05/21/2024, all internal drains throughout the building were treated including the kitchen. - On 06/03/2024, all interior drains were treated to cut down on drain fly activity including the kitchen and two kitchenettes. - On 06/08/2024, treated the drains in the kitchen and the first floor as well as second floor kitchenette with an aerosol cleaner and all the drains to cut down and attempt to prevent on going drain fly activity. Also informed customer that the staff need to clean a little bit better in the kitchen to continuously help with the drain activity. - On 07/09/2024, treated all of the drains with a foam cleaner to continuously prevent and cut down on drain fly activity. Observations on 08/18/2024 at 6:34 PM included approximately 20 small, brown flies flying around flats of soda cans in the dry storage room within the main kitchen. Observations on 08/19/2024 at 3:47 PM and 8/20/24 at 11:52 AM included several small, brown flies in the dry storage room within the main kitchen. During an interview on 08/19/2024 at 3:47 PM, the Acting Food Service Director/Registered Dietician stated there were no current pest control issues they were aware of, and they believed the only preventative treatments were being done for ants. During an interview on 08/20/2024 at 11:30 AM, the Environmental Services Director stated they have not seen any flies and nothing was documented in maintenance logs that they saw. During an interview on 08/20/2024 at 11:52 AM, the Acting Food Service Director/Registered Dietician stated the kitchen was lacking in cleanliness and deep cleaning should take place at least weekly. During an interview on 08/21/2024 at 4:00 PM, the Administrator stated they were not aware of any pest control concerns. 10 NYCRR: 415.29(j)(5)

Based on observations, interviews, and record review conducted during the Recertification Survey from 08/19/2024 to 08/23/2024, for one (Resident #85) of three residents, the facility did not ensure residents who needed respiratory care were provided such care consistent with professional standards of practice. Specifically, Resident #85 was observed wearing oxygen via a nasal cannula (a device that delivers oxygen through a person's nose), did not have a physician order in place for oxygen use via a nasal cannula, and there was no documentation in the Medication Administration and Treatment Administration Records that reflected the use of oxygen via nasal cannula each shift. This is evidenced by the following: The facility policy Oxygen Administration. dated January 2024, included to verify and review a physician's order for oxygen administration. Resident #85 had diagnoses that included chronic obstructive pulmonary disease (COPD), obstructive sleep apnea (disorder in which breathing stops and starts repeatedly during sleep), and pneumonia. The Minimum Data Set Resident Assessment, dated 06/10/2024, revealed Resident #85 was cognitively intact and received continuous oxygen therapy. Review of the current Comprehensive Care Plan included Resident #85 used a continuous positive airway pressure (CPAP- a machine that delivers continuous air while a person is sleeping) and had shortness of breath when lying flat. Interventions included to provide oxygen per physician's orders and to maintain and change the oxygen tubing per protocol. Review of current physician's orders did not include the use of oxygen via nasal cannula. Review of a Provider Progress Note, dated 06/07/2024 at 2:34 PM, Physician #2 documented Resident #85 was admitted to acute care (hospital) for pneumonia and a chronic obstructive pulmonary disease exacerbation (symptoms become more severe) which required continuous oxygen supplementation. The assessment and plan included to continue around the clock oxygen requirements at baseline. Review of a Progress Note ,dated 08/16/2024 at 7:17 PM, Physician #1 documented Resident #85 had been on 3.5 liters per minute of oxygen via nasal cannula. They decreased the oxygen to 2.5 liters per minute, which Resident #85 said felt better. Review of the Medication Administration and Treatment Administration Records from 08/01/2024 to 08/23/2024 did not include documentation that reflected Resident #58 ' s use of oxygen via nasal cannula each shift. During observations on 08/22/2024 at 11:33 AM, Resident #85 was in their room, wearing a nasal cannula with oxygen set at 2.5 liters per minute. During an interview at that time, Resident #85 said they had worn oxygen for quite some time including since they had been readmitted to the facility from the hospital on 06/06/2024. Resident #85 said facility staff told them the oxygen was to be worn as needed and was recently sent out to an appointment without oxygen on. During observations on 08/23/2024 at 11:04 AM, Resident #85 was in their room wearing a nasal cannula with oxygen set at 2.5 liters per minute. During an interview at that time, Resident #85 said they were on oxygen all the time and facility staff never told them they did not require oxygen. During an interview on 08/23/2024 at 11:18 AM, Licensed Practical Nurse #3 said if a resident used oxygen, a physician's order was required, and nurses would ensure the resident's oxygen settings matched the order. Licensed Practical Nurse #3 said there was usually an order on the electronic Treatment Administration Record where the nurse could enter how much oxygen the resident was on per shift. During an interview on 08/23/2024 at 11:43 AM, Licensed Practical Nurse Manager #1 said Resident #85 was a resident on the unit that wore oxygen as needed. When the electronic medical record was reviewed at that time, Licensed Practical Nurse Manager #1 said there was no order for oxygen via nasal cannula in place for Resident #85. They said there should be an order for oxygen to include how much oxygen, how long it was to be worn (e.g., continuous, at bedtime, as needed, etc.), how it was provided (e.g., mask, nasal cannula, etc.), and nurses should document if the oxygen was on or not. Licensed Practical Nurse Manager #1 said it was possible that staff forgot to reorder oxygen for Resident #85 when they were readmitted from the hospital. During an interview on 08/23/2024 at 2:17 PM, Physician #1 said oxygen did require an order. They would tell the nurse how much oxygen the resident should receive, the nurse would enter the order in the electronic health record, and the physician would confirm the order. Physician #1 said they had decreased Resident #85's oxygen from three liters per minute to 2.5 liters per minute, and while the resident had sleep apnea and used oxygen at bedtime, they had not seen the resident wear oxygen during the day. During an interview on 08/23/2024 at 4:49 PM, the Director of Nursing said oxygen use did require a physician's order and did not know why there was not an order in place for Resident #85's oxygen via nasal cannula. The Director of Nursing said Resident #85 was supposed to use continuous positive airway pressure, but the resident did not wear it. The Director of Nursing said prior to their hospitalization , Resident #85 wore oxygen at night because they did not have a continuous positive airway pressure machine. 10 NYCRR 415.12(k)(6)

Based on observations, interviews and record review conducted during the Recertification Survey from 08/18/2024 to 08/23/2024, for one (Resident #59) of one resident reviewed for tube feedings (nutrition administered via a tube inserted directly into the stomach via the abdomen due to the residents' inability to consume food and drink by mouth), the facility did not provide appropriate treatment and services to prevent potential complications. Specifically, there was no documented evidence that Resident #59's total daily intake of tube feedings was being monitored to ensure their nutritional needs were being met, physician's orders regarding administration of the tube feedings while consuming food were unclear, and free water flushes and nutritional supplements were not administered as ordered by the physician. This is evidenced by the following: The facility policy Enteral Nutrition (method of supplying nutrition directly into the gastrointestinal tract), dated reviewed January 2024, included that the enteral nutrition would be ordered by the physician based on the recommendations by the dietician. The dietician, with input from the physician and nurse, would estimate calorie, protein, nutrient, and fluid needs; determine whether the resident's current intake is adequate to meet their nutritional needs; recommend special food formulations; and calculate fluids to be provided (beyond free fluids in formula). Additionally, the nurse would confirm that there were appropriate orders for oral (PO) intake or restrictions for nothing by mouth (NPO), as appropriate. 1. Resident #59 had diagnoses that included hemiplegia (partial or complete paralysis on one side of the body), protein-calorie malnutrition, and dysphagia (difficulty swallowing). The Minimum Data Set Assessment, dated 05/08/2024, included that the resident was cognitively intact, had a feeding tube and was on a mechanically altered diet. Review of the Comprehensive Care Plan included to administer tube feeding and water flushes per the dietician's recommendation(s) and physician's orders, and for the dietician to evaluate quarterly, and as needed, by monitoring caloric intake and estimated needs. Current physician orders included: a. Administer Jevity 1.5 (tube feed formula) via gastrostomy tube (G-tube-a tube that is surgically inserted through the stomach wall and into the stomach in which to administer nutrition) at a rate of 90 milliliters an hour to begin at 8:00 PM and disconnect at 12:00 PM with a total volume of 1440 milliliters infused daily. b. Administer 150 milliliters of water via gastrostomy tube every three hours, five times a day, for a total volume of 750 milliliters. c. Regular diet, ground texture and thin consistency - to take Resident #59 to the dining room for meals to eat under nursing supervision. (ordered 08/19/2024 for quality of life.) d. Juven (nutritional supplement) packet via gastrostomy tube three times a day. There was no order indicating if Resident #59's tube feedings should be stopped during meals. During observations on 08/21/2024 at 10:05 AM, Resident #59 was observed in their room, connected to their tube feeding pump infusing Jevity 1.5 at 90 millimeters an hour and a bag of water at 151 milliliters of water flushes every two hours (versus 150 milliliters every 3 hours as ordered). During observations on 08/22/2024 at 7:45 AM, Resident #59 was in the dining room and was disconnected from their tube feeding. During an interview at the time, Registered Nurse #2 said Resident #59 was disconnected from their tube feeding and would be reconnected after breakfast and a dressing change. At 9:05 AM, Resident #59 remained not connected to their tube feeding. At 11:45 AM, Resident #59 was connected to the tube feeding via the pump which was programmed to infuse the tube feeding at 90 milliliters of Jevity 1.5 every hour and the water was infusing at 150 milliliters every six hours (versus every three hours as ordered). During observations on 08/23/2024 at 10:38 AM and at 11:41 AM, Resident #59 was again disconnected from their tube feeding. Review of Medication Administration Records for 08/07/2024 to 08/23/2024 revealed documentation that Resident #59 ' s tube feeding was administered from 8:00 PM continuously to 12:00 PM and the water flushes were documented as administered 150 millimeters daily at 1:00 AM, 4:00 AM, 7:00 AM, 10:00 AM, and 10:00 PM, despite the observations of the tube feeding being off during the same time frame and the water flushes programmed incorrectly. The Juven nutritional supplement was not signed off as administered on 35 of 49 opportunities with reasons being documented as not available, not in stock, or not received from pharmacy. There was no documentation of the total volume of tube feeding actually administered each day (taking into consideration the observations of the tube feeding being off). There was no documented evidence that the medical team had been notified that the Juven nutritional supplement had been unavailable. During an interview on 08/23/2024 at 11:43 AM, Licensed Practical Nurse Manager #1 said the nurses who hang the tube feeding during the night should make sure the pump settings matched the physician orders. Licensed Practical Nurse Manager #1 said Resident #59's tube feeding order was to start at 8:00 PM and turn off in the morning with 90 milliliters an hour for 16 hours for a total volume of 1440 milliliters. Licensed Practical Nurse Manager #1 said the pump (with the set total volume of 1440 milliliters) should let the nurses know (by beeping) when 1440 milliliters had been administered. Licensed Practical Nurse Manager #1 stated there should be an order (if decided on by the dietician and the physician) to stop the tube feeding during meals, but did not believe there was one for Resident #59. Licensed Practical Nurse Manager #1 stated staff told them that Resident #59 wanted their tube feeding off during breakfast, so they disconnected it, and were not sure why it was off again except because it was lunchtime and the resident was eating. After review of the resident's Medication Administration Record with the surveyor, Licensed Practical Nurse Manager #1 said there were packets of Juven in the medication cart but if the nurses did not have it, they should notify pharmacy or dietary and call the medical team to get an order for something else, or hold the medication and document. During an interview on 08/23/2024 at 1:36 AM, Certified Dietician #1 said they document monthly on residents with tube feedings which includes the ordered tube feeding and (water) flushes. Certified Dietician #1 said they could not find the total amount of tube feeding that was actually administered, and if they did not have a documented amount of tube feeding given to compare to the total volume ordered, then they could not determine if the resident had received the ordered amount to meet their nutritional needs. Certified Dietician #1 said Resident #59 was receiving food strictly for pleasure and the tube feed was based on 100 percent of their nutritional needs. Certified Dietician #1 stated stopping the tube feeding during meals would require a physician's order. During an interview on 08/23/2024 at 2:17 PM, Physician #1 said the nurses are responsible for ensuring the resident received the total volume tube feeding as ordered. Physician #1 stated there would be an order to hold the tube feeding during meals (if that was intended). Physician #1 said the majority of Resident #59's nutrition is provided via the feeding tube and the food items provided (at meals) are for the resident's pleasure. Physician #1 said staff are taking Resident #59 to the dining room, where they are watched by the nurse during meals, but no one told them staff were stopping the tube feeding during meals. During an interview on 08/23/2024 at 4:49 PM, the Director of Nursing stated there should be a medical order to hold (disconnect) a tube feeding during a meal. The Director of Nursing stated the process for ensuring the resident received the tube feeding as ordered consisted of it being on the pump and completing the tube feeding once 1440 milliliters had been administered (as ordered). The Director of Nursing stated if a medication was not available, staff should notify Pharmacy and medical provider, and document this. 10 NYCRR 415.12(g)(2)

Based on observations, interviews, and record review conducted during the Recertification Survey and complaint investigations (NY00338206 and NY00337318) from 08/18/2024 to 08/23/2024, the facility did not ensure that appropriate treatment and services were provided to prevent urinary tract infections for a resident with an indwelling urinary catheter (tube inserted into the bladder to drain urine into a drainage bag) for one (Resident #25) of one resident reviewed. Specifically, Resident #25 had a history of urinary tract infections and was observed on multiple occasions with their urinary catheter drainage bag, catheter drainage port, and catheter tubing lying directly on the floor without a barrier, and with the drainage bag completely full of urine resulting in a backup of urine in the tubing. This is evidenced by the following: Resident #25 had diagnoses including [NAME] disease (a rare genetic disorder that affects the kidneys), neuromuscular dysfunction of the bladder (the bladder does not work properly causing an inability to urinate), and urinary tract infections. The Minimum Data Set Resident Assessment, dated 06/20/2024, documented the resident was cognitively intact, had an indwelling urinary catheter, had a urinary tract infection in the last 30 days, and that Resident #25 did not refuse care. The Comprehensive Care Plan and Kardex (care plan used by the Certified Nursing Assistants for daily care) included catheter care every shift, perineal (groin) care every shift, and monitor for signs and symptoms of a urinary tract infection. Hospital discharge summaries dated 01/17/2024, 06/17/2024, and 07/17/2024 documented Resident #25 was treated for a urinary tract infection. Treatment included replacing the urinary catheter that was dislodged from the bladder and intravenous (via a vein) antibiotics. Review of current physicians' orders revealed an order for catheter care every shift. During an observation on 08/18/2024 at 8:37 PM, Resident #25's foley drainage bag was completely full of urine resulting in a backup of urine in the tubing. During an interview at this time, Resident #25 stated they were experiencing abdominal pain. During observations on 08/20/2024 at 2:19 PM and 08/21/2024 at 9:34 AM and again at 3:52 PM, Resident #25's foley drainage bag, drainage spout, and tubing were laying on the floor with no protective barrier. During an interview on 08/22/2024 at 9:06 AM, Certified Nursing Assistant #3 stated they were responsible for performing catheter care each shift, draining the drainage bag, and making sure the drainage bag was not on the floor. They stated if they found the drainage bag on the floor, they would hang it back up off the floor. Certified Nursing Assistant #3 stated the Resident #25's foley drainage bag was frequently found on the floor and that the Kardex did not include instructions to keep the drainage bag off the floor. During an interview on 08/22/2024 at 3:53 PM, Licensed Practical Nurse #1 stated they are responsible for catheter care that included emptying the drainage bag. Licensed Practical Nurse #1 stated urinary catheter drainage bags should never be on the floor or be completely full of urine backing up the tubing. This is due to infection control, so the resident does not develop a urinary tract infection. Review of Resident #25's treatment administration records for 06/01/2024 through 08/22/2024 revealed that on 23 shifts the catheter care was not signed off as provided as ordered. During an interview on 08/22/2024 at 4:15 PM, Physician #1 stated the most common complication from a urinary catheter is a urinary tract infection. Physician #1 stated Resident #25 was at an increased risk for a urinary tract infection related to having a urinary catheter, and not emptying the drainage bag and having urine back up the tubing and letting the drainage bag touch the ground without a barrier all would increase that risk and potentially cause a urinary tract infection. During an interview on 08/23/2024 at 4:49 PM, the Director of Nursing stated documentation not signed off as completed could mean the care was not done. The Director of Nursing said urinary catheter drainage bags should be emptied at least every shift and before it is so full urine is backing up. Drainage bags should never be on the floor, and catheter care should be completed as ordered and at least every shift. The Director of Nursing stated catheter care, emptying the drainage bag, and keeping it off the floor are to prevent urinary tract infections. 10 NYCRR 415.12(d)(1)

Based on observations, interviews, and record reviews conducted during the Recertification Survey from 08/18/2024 to 08/23/2024, for one (Resident #16) of one resident, the facility did not ensure the resident received treatment and/or assistive devices to maintain hearing. Specifically, Resident #16 was hard of hearing, had a documented request to be seen for hearing aids, and the facility did not arrange for an audiology (hearing) evaluation. This is evidenced by the following: Resident #16 had diagnoses including diabetes, depression, and bilateral hearing loss. The Minimum Data Set Resident Assessment, dated 07/03/2024, included the resident was cognitively intact, was able to hear with minimal difficulty, and did not have hearing aids. During an interview on 08/19/2024 at 10:24 AM, Resident #16 stated when they were admitted , they were told the facility would help them get hearing aids. They were seen to get their ears cleaned and sent to a hearing specialist, but still had not been evaluated for hearing aids. Resident #16 stated their inability to hear affects them daily and makes them feel isolated because they cannot hear anything that is going on around them and cannot participate in most activities. Resident #16 stated they would purchase their own hearing aids if they could afford them, but was told the facility would help them. Review of the current Comprehensive Care Plan revealed the resident had a hearing deficit, hearing loss, and impacted cerumen (a condition that occurs when too much earwax builds up in the ear canal). Interventions included to refer to audiology for a hearing consult as ordered. Review of a Care Plan Meeting form, dated 05/24/2023, revealed after discussion with the resident's family they did not want the resident to have hearing aids. Review of a Care Plan Meeting form, dated 10/10/2023, revealed Resident #16 was hard of hearing which made it difficult to communicate with them at times. The resident would be seen by an otolaryngologist (ear, nose, and throat doctor) for possible hearing aids as they lost a pair due to not remembering to take them out or put them in. Review of a Care Plan Meeting form, dated 04/03/2025, revealed Resident #16 had reported to nursing they would like to get hearing aids. During an interview on 08/23/2024 at 12:57 PM, Medical Records Staff #1 stated they had previously worked as the Unit Clerk on Resident #16's unit and had received an order, around early April 2024, for Resident #16 to be seen by audiology for hearing aids. They stated they tried to speak to Resident #16 about making the appointment, but they were unable to hear them, so they contacted the appointed family member. Medical Records Staff #1 stated the family member said they were not going to pay for the resident to get new hearing aids because they had previously come up missing. Medical Records Staff #1 made the former Director of Nursing and former physician aware via email. During an interview on 08/23/2024 at 5:45 PM with the Administrator and Director of Nursing, the Administrator stated they were not aware Resident #16 wanted to be evaluated for hearing aids and they would have the Unit Clerk get a quote for hearing aids and present it to the resident. 10 NYCRR 415.12(a)(3)(b)(1-3)

Based on observations, interviews, and record review conducted during a Recertification Survey and complaint investigation (NY00338206) from 08/18/2024 through 08/23/2024, for one (Resident #5) of ten residents, the facility did not ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene. Specifically, Resident #5 was observed over several days with debris underneath their fingernails including while eating. This is evidenced by the following: The facility policy Care of Fingernails/Toenails, dated January 2024, documented that nail care included daily cleaning and regular trimming. The policy included to remove dirt from around and under each nail. Resident #5 had diagnoses that included muscle weakness, depression, and arthritis. The Minimum Data Set Resident Assessment, dated 07/10/2024, revealed Resident #5 was cognitively intact, had highly impaired vision, and required moderate assistance with personal hygiene. Review of the current Comprehensive Care Plan and Kardex (care plan used by Certified Nursing Assistants for daily care) included that Resident #5 was legally blind, required moderate assistance with personal hygiene, and maximal assistance with bathing. Review of the Care Plan Meeting form, dated 07/23/2024, revealed Resident #5 had a history of refusing to get out of bed and often refused linen changes. It did not include mention of nail care refusals. During observations on 08/19/2024 at 9:14 AM, Resident #5 had dark debris underneath all their fingernails. During observations on 08/21/2024 at 9:23 AM, Resident #5 continued with dark debris underneath multiple nails on both hands. During observations and interview on 08/22/2024 at 8:40 AM, Resident #5 was in bed with a bowl of cereal. Resident #5 had debris underneath fingernails on the left hand and was using the left hand to touch their cereal. During an interview at that time, Resident #5 said they use their hands to eat because they cannot see, and staff do not assist them with hand hygiene prior to meals. During an observation on 08/22/2024 at 12:25 PM, the resident had debris underneath multiple nails of their left hand. At 12:43 PM, Resident #5 was touching various food items on their lunch tray with their left hand. During an observation on 08/23/2024 at 10:42 AM, Resident #5 had debris underneath the multiple nails on both hands. Review of Interdisciplinary Progress Notes from 07/01/2024 to 08/23/2024 did not include documented evidence that Resident #5 was offered or refused nail care. Review of the Documentation Survey Report (used to track completion of resident care tasks) from 08/01/2024 to 08/23/2024 did not include documented evidence that Resident #5 was offered or refused nail care. During an interview on 08/23/2024 at 10:47 AM, Certified Nursing Assistant #5 said they assist residents with nail care and the Activities staff polish residents' nails. Certified Nursing Assistant #5 said there is a green bag of hand wipes that are used for residents (to perform hand hygiene) who had meals in the dining room, but they did not know if hand washing or a hand wipe were offered to residents who had meals in their rooms. Certified Nursing Assistant #5 said nail care should be provided when residents' nails were long or if dirty but this was not documented when provided. Certified Nursing Assistant #5 stated they had cared for Resident #5 for several days. The resident had impaired vision, so they told the resident where items on their plate were located. Certified Nursing Assistant #5 said they had not assisted Resident #5 with handwashing prior to breakfast that morning and the resident used their hands to eat. Certified Nursing Assistant #5 said they saw that Resident #5 had debris underneath their nails but had not provided nail care due to being rushed. During an interview on 08/23/2024 at 11:08 AM, Licensed Practical Nurse Manager #1 said on shower days, nails should be cleaned and trimmed if long or jagged. If debris was observed underneath a resident's fingernails, it should be cleaned at any time. If a resident refused nail care, the staff should notify the unit manager. When observed at that time, Licensed Practical Nurse Manager #1 said Resident #5's fingernails were dirty and they would clean them. During an interview on 08/23/2024 at 4:49 PM, the Director of Nursing said nail care was done as a part of the resident's shower, but unkempt (dirty) or sharp fingernails should be addressed even if it was not a resident's designated shower day. 10 NYCRR 415.12(a)(3)

Based on observations, interviews, and record review conducted during a Recertification Survey from 08/18/2024 to 08/23/2024, the facility did not ensure the nurse staffing information was posted daily and included the required information. Specifically, the facility did not post the accurate nurse staffing data on 08/18/2024, 08/20/2024, 08/21/2024 or 08/22/2024, as required per the regulations. This is evidenced by the following: During an observation on 08/18/2024 at 8:30 PM, the daily nurse staffing information was not visibly posted. During observations on 08/20/2024 at approximately 11:15 AM, 08/21/2024 at 10:29 AM, and 08/22/2024 at 9:04 AM, the posted daily nurse staffing information was dated 08/19/2024. During an interview on 08/21/2024 at 10:29 AM, Receptionist #1 stated Scheduler #1 was responsible for printing the daily nurse staffing information. Scheduler #1 was on vacation and no one else had printed the daily nurse staffing information. During an interview on 08/23/2024 at 9:41 AM, the Assistant Director of Nursing stated Scheduler #1 was responsible for posting the daily nurse staffing information. The Assistant Director of Nursing stated they were unsure of the process for the daily nursing staffing postings. During an interview on 08/23/2024 at 9:47 AM, the Director of Nursing stated Scheduler #1 worked Monday through Friday from 7:00 AM to 3:00 PM and would occasionally work on the weekends. The Director of Nursing stated they were responsible for posting the daily nurse staffing when Scheduler #1 was not working, and the nursing supervisors would be responsible for posting the information on off shifts. Scheduler #1 was unavailable for an interview during the survey. 10 NYCRR 415.13

Based on interviews and record review conducted during the Recertification Survey from 08/18/2024 to 08/23/2024, for six (#52, #312, #313, #314, #315, and #317) of seven residents reviewed, the facility did not provide the appropriate liability and appeal notices to Medicare beneficiaries at the termination of their Medicare coverage. Specifically, the facility did not provide a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to Residents #314 and #315 and did not provide a Notice of Medicare Non-Coverage (NOMNC) to Residents #52, #312, #313, #317, and/or their representatives informing them of their appeal rights and/or their liability for services. This is evidenced by but not limited to the following: The Centers for Medicare & Medicaid Services (CMS) Form Instructions for the Notice of Medicare Non-Coverage Form CMS-10123 documented the Notice of Medicare Non-Coverage must be delivered at least two calendar days before Medicare covered services end. The Centers for Medicare & Medicaid Services Form Instructions Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage documented Medicare requires Skilled Nursing Facilities to issue the Skilled Nursing Facility Advance Beneficiary Notice to original Medicare beneficiaries prior to providing care, that Medicare usually covers, but may not pay in this instance because the care was not medically reasonable and necessary or considered custodial. 1. Resident #52 was admitted to the facility on [DATE] under Medicare Part A services and discharged home on 08/13/2024. The Notice of Medicare Noncoverage was not provided to the resident and/or representative at least two calendar days before Medicare covered services ended. 2. Resident #312 was admitted to the facility on [DATE] and started Medicare Part A services on 05/01/2024 and discharged home on 06/27/2024. The Notice of Medicare Noncoverage was not provided to the resident and/or representative at least two calendar days before Medicare covered services ended. 3. Resident #314 was admitted to the facility on [DATE] and started Medicare Part A services on 02/01/2024 and ended services on 04/12/2024. The Skilled Nursing Facility Advance Beneficiary Notice was not provided to the resident and/or representative. Resident #314 remained in the facility receiving custodial care. 4. Resident #315 was admitted to the facility on [DATE] under Medicare Part A services and ended services on 03/05/2024. The Skilled Nursing Facility Advance Beneficiary Notice was not provided to the resident and/or representative. Resident #315 remained in the facility receiving custodial care. During an interview on 08/23/2024 at 3:25 PM, the Director of Admissions stated that residents receiving Medicare Part A services that required a Notice of Medicare Noncoverage were completed by the therapy department, and that the Director of Rehabilitation should be aware when a resident is discharged from therapy under Medicare Part A services to issue the Notice of Medicare Noncoverage and the Skilled Nursing Facility Advance Beneficiary Notice when applicable (resident remains in the facility under custodial care). The Director of Admissions stated that it was an oversight that some residents were not provided the Skilled Nursing Facility Advance Beneficiary Notice because the Director of Rehabilitation had thought those residents only required the Notice of Medicare Noncoverage. During an interview on 08/23/2024 at 3:36 PM, the Director of Rehabilitation stated they provide the Notice of Medicare Noncoverage at least 48 hours before a resident receiving Medicare Part A services ends, and they should provide the Skilled Nursing Facility Advance Beneficiary Notice (informing residents of their liability for services) if there were benefit days remaining and the resident remained in the facility. The Director of Rehabilitation stated that if the beneficiary (resident) intended to continue services and the facility believed the services may not be covered under Medicare, that it was the facility's responsibility to inform the beneficiary about potential non-coverage and the option to continue services with the beneficiary accepting financial liability for those services. 10 NYCRR 415.3

Based on interviews and record reviews conducted during the Abbreviated Survey, (complaint #NY00336027) and completed [DATE], it was determined that the facility could not ensure there were adequate number of personnel in the facility to provide basic life support, including cardiopulmonary resuscitation (CPR- emergency lifesaving procedure performed when the heart and/or lungs cease functioning). Specifically, the facility did not maintain an updated list of staff who were currently certified in cardiopulmonary resuscitation and could not provide evidence that a cardiopulmonary resuscitation certified staff member was in the facility at all times to provide basic life support when needed. This is evidenced by the following: Review of the facility-provided list of licensed nursing staff revealed no evidence that 5 of 32 licensed active nurses were currently certified in cardiopulmonary resuscitation. Review of the 'Punch Detail Reports' (timecards) for all licensed nursing staff from [DATE] to [DATE] revealed no evidence that a cardiopulmonary resuscitation certified nurse (or other staff member) had been in the facility on 7 of 14 night shifts. During an interview on [DATE] at 3:40 PM, the Director of Human Resources said the Nurse Educator kept track of staff cardiopulmonary resuscitation certifications. During an interview on [DATE] at 4:17 PM, Registered Nurse Supervisor #1 said they had been certified in cardiopulmonary resuscitation, but when reviewing their certification, they stated it had expired [DATE]. During an interview on [DATE] at 1:26 PM, the Assistant Director of Nursing provided a list of the facility's licensed nurses and identified the names of the nurses who the facility had evidence of current certification for cardiopulmonary resuscitation. The Assistant Director of Nursing said Human Resources and the Nurse Educator both were responsible for obtaining evidence of cardiopulmonary resuscitation certifications for all nurses. The Assistant Director of Nursing said they had been the Nurse Educator up until three weeks prior and had discussed with the previous Administrator getting someone to come in and provide cardiopulmonary resuscitation trainings for staff to keep their certifications current. The Assistant Director of Nursing could not answer why their inquiry was never acted upon. The Assistant Director of Nursing said in their previous role as the Nurse Educator they had not kept a list of staff that were certified in cardiopulmonary resuscitation which was an oversight, and that Human Resources was supposed to collect this information during the hiring process. During an interview on [DATE] at 1:51 PM, Licensed Practical Nurse #2 said they were trained in cardiopulmonary resuscitation during nursing school, but their certification had expired in [DATE]. Licensed Practical Nurse #2 said they notified the previous Nurse Educator (current Assistant Director of Nursing) and were told that they were waiting for someone to come into the facility and provide staff with the required training. Licensed Practical Nurse #2 said they had told the previous Director of Nursing, current Director of Nursing, and the current Assistant Director of Nursing that their certification had expired. During an interview on [DATE] at 2:00 PM, Licensed Practical Nurse #4 said they had undergone cardiopulmonary resuscitation training (in the past) but that their certification had expired. During an interview on [DATE] at 2:16 PM, the Director of Human Resources said they did not have a list of what certifications were needed for new employee hires and that they were not aware they needed to get cardiopulmonary resuscitation certifications for all nurses. During an interview on [DATE] at 2:28 PM, the Director of Nursing said they were not aware that cardiopulmonary resuscitation certifications were not being tracked. During a telephone interview on [DATE] at 11:36 AM, the current Administrator said Human Resources should maintain a list of cardiopulmonary resuscitation certified staff and that if a resident needed cardiopulmonary resuscitation, they would expect the nurses to initiate this. The Administrator said they were not aware that the certifications were not being maintained and that current nurses' certifications had expired, or that there had not been a certified nurse on every shift. 10 NYCRR 415.11(c)(3)(i)

Based on interviews and record review conducted during an Abbreviated Survey (NY00302380 and NY00321005) 8/3/23 to 10/3/23, the facility did not ensure the resident's right to be free from abuse for three (Residents #3, #4, and #5) of six residents reviewed for abuse. Specifically, staff reported potential abusive behavior towards all three residents by one staff member (Registered Nurse (RN) #1). This is evidenced by the following: The facility policy, Abuse Prohibition Program, dated January 2023, documented that all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, and/or theft/misappropriation of resident property are thoroughly investigated by facility management. Review of an undated Event Summary/Conclusion Report, signed by the RN/Regional Clinical Director, revealed that on 9/16/22 the Director of Nursing (DON) was made aware of a complaint by Resident #5 that RN #1 was inappropriate with them. During the course of the investigation two additional residents (Residents #3 and #4) appeared to also have been dealt with inappropriately. The Report included that on 9/16/22 the following occurred: - At approximately 5:05 AM Resident #5 told a Certified Nurse Assistant (CNA) that RN #1 forced their upper dentures out of their mouth, was very rough with them causing a skin tear to their arm and was so forceful (plugged their nose in an attempt to open their mouth) trying to force medications into their mouth that the plastic spoon broke and caused a bruise to their lip. When assessed by the DON, Resident #5 stated that they felt safe as long as RN #1 did not come back. - At approximately 5:45 AM Resident #4 was found with their room fan on and their blankets on the floor. Housekeeper #1 stated to the DON that RN #1 told them that Resident #4 punched them, so they removed the resident's covers and turned the fan on. The DON's assessment revealed no injuries at the time. - At approximately 5:50 AM Resident #3 put their call light on and told the CNAs who responded to keep the (swear word) away from me. Resident #3 stated RN #1 threw the TV remote at their head, and it hurt. The resident's bed linens were on the floor, the window was open and the TV remote was on the floor. The DON's assessment revealed no injuries at the time. 1. Resident #5 had diagnoses including Failure to Thrive, osteoporosis and dysphagia (difficulty swallowing). The Minimum Data Set (MDS) Assessment, dated 6/28/22, documented Resident #5 had moderately impaired cognition and no behaviors exhibited at that time. Resident #5's Comprehensive Care Plan documented that they had full upper and lower dentures and to encourage removal at bedtime to soak. Resident #5's September 2022 Medication Administration Record (MAR) documented medications were administered at 12:12 AM on 9/16/22 by RN #1. In an undated statement dated 9/16/23 and signed by the DON, Resident #5 stated that RN #1 held their nose so they would have to open their mouth and then ripped out their dentures. In a nursing progress note, dated 9/16/22 at 5:45 a.m. the DON documented that Resident #5 had a skin tear and bruising on their left wrist and a tiny cut on the inside of their cheek. 2. Resident #4 had diagnoses including Alzheimer's disease, dementia, and chronic pain. The MDS assessment dated [DATE] documented the resident had severely impaired cognition and no behaviors exhibited at that time. The September 2022 MAR documented that medications were administered to Resident #4 at 12:19 AM by RN #1. Resident #4 was unable to give an accurate statement of what occurred but did verbalize to the DON that if they saw RN #1, they would take (them) out. 3. Resident #3 was a [AGE] year-old male admitted to the facility 12/23/2021 with diagnoses that included a stroke and psychosis (a mental disorder characterized by a disconnection from reality). The MDS Assessment, dated 7/2/22 documented Resident #3 had severe impairment of cognitive function and verbal behaviors directed at others but no physical behaviors at that time. In an undated statement signed by the DON, Resident #3 stated that RN #1 forced them to take their medications so Resident #3 spit them out and then RN #1 threw the medications, the water, and their TV remote at them. Statements documented on 9/16/22 from involved staff members included the following: a. CNA #3 stated that RN #1 told them that Resident #4 was aggressive taking their medications, so they took their blanket and turned the fan on, that Resident #3 had spit their medications at them, but they got the resident to take them anyway and that they (RN #1) also told them (CNA #3) that they forced Resident #5 top teeth out by holding their arm down. b. Housekeeper #5 stated that RN #1 had told them Resident #4 had punched them in the stomach, so RN #1 ripped the resident's blankets off and turned the fan on and did not care. c. CNA #4 stated that when they went to give care and saw a skin tear on Resident #5's arm and a sore mouth, the resident told them that RN #1 touched them all over and put their fingers in their mouth and forced their dentures out. CNA #4 reported this to the DON. During an interview on 8/3/23 at 3:00 PM Housekeeper #5 stated they were working in housekeeping at that time and on 9/16/23 RN #1 told them that Resident #4 had hit them, so they ripped their blankets off and turned the fan on. When interviewed on 8/3/23 at 3:30 PM CNA #4 stated that on 9/16/22 the RN #1 told them that they had gotten spit on by the Resident #4, so they ripped their blankets off and turned the fan on. CNA #4 went to Resident #4's room, covered them up and turned off the fan. CNA #4 said that when answering Resident #5's call light, they noticed blood on the corner of the resident's mouth and a skin tear on the resident's forearm. Resident #5 told them RN #1 ripped their dentures out of their mouth, so they notified the DON. CNA #4 stated that when they heard Resident #3 yelling, they went into their room which was freezing and found their blankets were on the floor. Resident #3 told them that they had been sleeping when RN #1 shoved meds in their mouth, so they spit them out and then the nurse threw the remote and hit the resident in the forehead. During an interview on 8/4/23 at 6:47 AM the DON stated that they were contacted by several staff on 9/16/22 regarding reports several residents had made regarding RN #1. The DON said they came to the facility immediately, assessed and interviewed all the residents and removed RN #1 from the facility. During an interview on 10/3/23 at 3:20 PM RN/Regional Clinical Director stated that they were notified by the DON on 9/16/22 regarding staff reports of a nurse who was upsetting residents and acting strangely. The DON reported they immediately went to the facility, spoke with residents and staff and then removed the accused (RN #1) from the building. They concluded that abuse did occur and they had the accused arrested, the responsible parties notified and staff re-educated regarding abuse, protection of residents and advocating for them. Based on the following corrective actions it was determined through interviews and record review the facility implemented corrective actions to correct the non-compliance effective 9/16/22: Residents were assessed, first aid was rendered to Resident #5 and medical notified. Police department notified, and all responsible parties (family) were notified. Social Work department to follow up with all residents to ensure stability Staff education commenced regarding abuse, neglect and mistreatment and reporting. RN #1 removed, and agency notified of termination from the facility. 415.4 (b)(1)(i)

Based on observations, interviews, and record reviews conducted during the Recertification Survey and complaint investigation (#NY 839), completed on 6/10/22, it was determined that the facility did not ensure the resident's environment was free from accident hazards for one (Resident #32) of three residents reviewed. Specifically, Resident #32, who had severe impairment of cognitive function, was able to exit the facility unsupervised due to a door alarm failure. Additionally, the residents care plan was not revised following actual exit seeking behavior and an elopement. This was evidenced by the following: Resident #32 had diagnoses that included Alzheimer's disease, dementia, and a history of repeated falls. The Quarterly Minimum Data Set Assessment, dated 4/18/22, revealed that Resident #32 had severely impaired cognition, that wandering behavior occured daily, and that the resident was independent with ambulation and required supervision with ambulation both on the unit and off the unit. The 1/16/22 Comprehensive MDS Assessment documented that Resident #32 wandered less than daily but that wondering did not place the resident at significant risk of getting to a potentially dangerous place such as outside the facility. Review of the current CCP revealed that Resident #32 had safety awareness limitations, wandered and was at risk for elopement. Interventions included routine checks and observations, a wander guard and to observe for exit seeking behaviors. Review of the undated CNA Resident Profile revealed elopement precautions and a wander guard but no other interventions for CNAs to use regarding exit seeking behaviors. Review of the Behavioral Care Plan, dated 2/28/22, revealed that Resident #32 had impaired safety awareness and invaded the space of other residents placing themselves at risk for adverse resident interaction. The behavior plan did not include exit seeking behaviors and interventions. The 'Investigation Summary' dated 6/1/22, documented that Resident #32 exited the facility at 4:20 p.m., through the Unit B hallway emergency exit door and exited the building. Resident #32 was seen by a staff member in passing and was brought back into the building unharmed. At the time the wander guard was in place. The emergency exit door did not alarm. The summary documented that the resident was outside due to a door that did not properly secure after the alarm had been sounded earlier in the day (by Resident #32 attempting to exit). The resident was out of site for 2 to 5 minutes due to a malfunction of the alarm system with no findings of care plan violation. A nursing progress note, dated 6/2/22, documented that a meeting was held to review the elopement and that Resident #32 would be offered diversional activities and the doors would be checked often. Review of the Biweekly door alarm check audit revealed that all doors including the door in question were checked for functionality monthly and signed off as checked once a month for past 3 months. There were no documented rechecks following the 6/1/22 elopement. During multiple daily observations from 6/7/22 through 6/10/22 day shift, Resident #32 was observed wandering throughout Unit B including behind the nurse's station going through the desk (gate present but not closed), attempting to open a medication cart, and touching items on the cart including drinking cups, and on 6/9/22 at 1:45 p.m., at the Unit B hallway emergency exit door (the same door the resident eloped from on 6/1/22), shaking the handle attempting to exit. No staff were present at the time and the resident eventually gave up and walked away from the door. In an interview on 6/8/22 at 8:16 a.m., CNA #1 stated that they were not present the day Resident #32 eloped but that normally they would redirect any resident if they were observed to be attempting to leave the building. CNA #1 stated that Resident #32 wandered around the unit daily and staff try to redirect the resident but that when redirected the resident just goes in a different direction and is unable to be stopped. In an interview on 6/8/22 at 1:05 p.m., the Director of Environmental Services (DES) stated they were notified (on 6/1/22) that Resident #32 had been pushing on the Unit B hallway exit door and tripped the alarm. The DES stated that they had reset the door by using the panel by the nurse's station and that the door was closed and appeared in proper working order after the reset. The DES then stated that they were called back to the same exit door later in the day after Resident #32 eloped out of the building due to the door failing to alarm. The DES stated that the door did not alarm as it should have and that the door was examined to be in working order after another hard reset. The DES stated they did not have the door examined by the company following the failure to alarm. The DES stated audits are conducted on the doors once a month. During an interview on 6/8/22 at 2:31 p.m., the Unit Manager Registered Nurse stated they are responsible for revising care plans. The Unit Manager stated they did not make any revisions to Resident #32's care plan after the actual elopement. The Unit Manager stated this was Resident #32's first elopement. During an interview on 6/8/22 at 2:38 p.m., the Director of Nursing (DON) stated that they did not see any changes to Resident #32's care plan following the elopement. The DON stated that the Unit Managers are responsible for making care plan revisions and that they would have expected some revisions following an elopement. 415.12 (h)(2)

Based on observations, interviews and record review conducted during a Recertification Survey, completed on 6/10/22, it was determined that for one (Resident #36) of two residents reviewed the facility did not ensure that the resident received care consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable and that the resident received the necessary treatment to promote healing of a pressure ulcer, prevent infection and prevent new ulcers from developing. Specifically, Resident # 36 developed two pressure ulcers and the facility was unable to provide documented evidence that the resident's skin issues were evaluated and assessed by the medical team, did not do skin checks consistently per facility protocol, did not administer treatments as ordered by medical team for several days and did not notify the medical team of the missed treatments and did not revise the care plan following multiple skin issues. This is evidenced by the following: The facility policy Pressure Ulcer Precautions documented that all patients will have a Braden Score (skin assessment used to predict and prevent pressure ulcers) completed. If the Braden Score is 6-18 then high-risk pressure prevention precautions will be implemented. This included but not limited to assessing the skin daily, use skin protectant ointments, utilize high protein supplements, and pressure reduction devices on the bed and chair. The facility policy Weekly Skin Observations, dated January 2020, documented that the nurse will do a weekly head-to-toe skin observation and document as completed on the Treatment Administration Record (TAR) and additionally, document findings in the resident's electronic medical record (EMR). Resident # 36 was admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set assessment dated [DATE], documented that the resident was moderately impaired cognitively, required the extensive assistance of two staff for bed mobility, was at risk for developing pressure ulcers and had no current pressure ulcers. Preventative measures included pressure reducing devices for the bed and chair. The Braden Scale for Predicting Pressure Score Risk, dated 4/25/22, documented a score of 15 (indicating Resident #36 was at risk for pressure ulcers). In the nursing admission progress note dated 4/25/22, the Registered Nurse (RN)/ Clinical Leader (CL) documented a small scab below the right knee and no other skin issues. The Comprehensive Care Plan (CCP), dated 4/28/22, documented that Resident #36 was at risk for pressure ulcers and interventions included for the medical provider to evaluate as needed, preventative distribution surfaces per recommendations and follow preventative skin care measures. In a progress note, dated 5/10/22, the physician documented that Resident #36 was seen for a readmission from the hospital (5/7/22 to 5/9/22) for respiratory failure and a urine infection. Under skin assessment the provider documented warm and dry. There was no documentation related to any skin breakdown. Interdisciplinary progress notes documented the following: a. On 5/11/22, Licensed Practical Nurse (LPN) #1, documented observation of an open area to Resident #36's left buttock area. Selan (?) was applied, and the skin team (consisting of a RN and a LPN) was notified. b. On 5/14/22, the Dietician documented that Liquacel (a high protein supplement to assist with wound healing) was requested twice daily related to an open area on the buttocks. c. On 5/17/22 the LPN/Nurse Manager (NM) documented Resident #36's scrotum and peri area were macerated (skin breakdown) and Dermaseptin (a barrier cream used to treat and prevent minor skin irritations) was applied. d. On 5/19/22 and 5/28/22 RN #1 documented the resident's groin, bottom and penis were irritated. e. On 5/30/22 the LPN/NM documented that Resident #36 had an area measuring 4 centimeters (cm) by 4 cm on the right inner buttocks that was unstageable, covered in eschar (dead tissue) with surrounding redness (potential sign of infection). f. On 5/31/22 RN #2 documented that the interdisciplinary team reviewed Resident #36 due to an unstageable pressure ulcer to the right buttocks and a fluid filled blister on the right foot. Review of the first documented Wound Care Flow Sheet, dated 5/31/22 (20 days after the first observed open area), and signed by the LPN/NM revealed an unstageable pressure ulcer to the right gluteal fold/buttocks measuring 4 cm x 4 cm with 100% eschar in the wound bed. A ROHO mattress (specialty mattress used for pressure reduction) was ordered, directions to return the resident to bed after meals and turn and position frequently. Current treatment included to cleanse area with wound spray and cover wound with a dressing. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] a. On 5/17/22 Dermaseptine (a skin protection ointment) was first ordered to the scrotum and peri area. b. On 5/31/22, (first medical order to any open area) included to cleanse right inner buttocks area with wound spray, apply nickel size amount Santyl (ointment used to debride dead tissue to promote healing) and cover with a dressing daily and apply skin prep to left heel twice daily. The order did not include the right foot heel blister. c. On 6/6/31 to apply skin prep to the right heel twice daily. d. On 6/7/22 Liquacel 30 milliliters twice daily. The May 2022 Treatment Administration Record (TAR) included an entry for weekly skin observations once a day on Saturdays with documentation that was signed as not completed on 5/7/22 (resident not available due to hospitalization from [DATE] to 5/9/22) or on 5/14/22 (due to no shower given) and as completed on 5/21/22 and 5/28/22. The May TAR included skin prep to left heel ulcer twice a day beginning 5/31/22. There were no nursing progress notes regarding a skin check on 5/9/22 (return from hospital) or following the missed skin check on 5/14/22. There was no documentation in the EMR related to any observations/skin issues seen with the skin checks (including the open area on the buttocks or the heels) as signed off as completed on 5/21/22 and 5/28/22. The June 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The June 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation of wound care on 6/9/22 at 1:50 p.m. Resident #36 was transferred to the bed by two staff using with a stand lift. The open area to the right inner buttocks was the size of a nickel with white/tan slough (dead tissue) covering the wound base. The edges were white and peeling. There was a second area near the pressure ulcer the shape of a quarter moon about 2.5 cm long that appeared scabbed over. Wound care was completed as ordered. When interviewed on 6/9/22 at 10:37 a.m. the RN/CL stated they, in conjunction with the LPN/NM, are responsible for revising the CCP and they would expect the CCP to be updated when a resident developed a pressure ulcer. When interviewed on 6/9/22 at 1:27 p.m. the LPN/NM stated did they did not assess pressure ulcers, the RN did. The LPN/NM stated they had documented the note of Resident #36's unstageable pressure ulcer (5/31/22) but that it was not within their scope of practice to assess them. The LPN/NM stated they would document what they saw, notify the skin team, ensure staff turned and repositioned the resident and that medical was made aware through the team health folder. The LPN/NM stated any changes in a resident's skin should be reported to them or an RN and that weekly skin checks should be completed weekly on the resident's shower day and documented in the medical record under observations. After reviewing the medical record and team health notes the LPN/NM stated they could not provide evidence that the medical team had assessed the pressure ulcers or had any involvement in the treatment plan (until 5/31/22). The LPN/NM stated there was no evidence that the CCP had been revised to reflect the current skin needs of the resident. When interviewed on 6/10/22 at 9:44 a.m. the Director of Nursing (DON) stated the medical provider should be notified of skin issues and an assessment done by both medical and the Dietician. The DON said that supplements would have to be ordered and that nursing should discuss all the needs with the medical team. The DON stated weekly skin checks are to be completed on shower days and observations documented in the EMR. The DON stated they have some glitches with these issues that need to be improved on. The DON added that any changes to a resident's skin status should be updated in the CCP. An attempt was made to speak with Resident #36's medical provider however phone call was not returned prior to the survey exit. 10NYCRR 415.12(c)(12)

Based on observations, interview and record review conducted during a Recertification Survey completed on 6/10/22, it was determined that for one (Resident #43) of five residents reviewed, the facility did not ensure that a comprehensive person-centered care plan was developed and implemented to address the resident's medical, physical, mental, and psychosocial needs. Specifically, Resident #43's Comprehensive Care Plan (CCP) was not individualized with goals and interventions to address use of [CONDITION(S)] medications. This is evidenced by: Resident #43 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set Assessment, dated 5/12/22, documented that Resident #43 had active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the CCP, dated 5/26/22, included a goal of fewer behavioral episodes through the use of multiple interventions that included following a behavioral care plan, offering support and reassurance as needed and provide medications as ordered. The Behavioral Care Plan dated 1/12/22, documented Resident #43's behaviors such as physical and verbal aggression and anger with multiple recommended interventions. In a medical progress note dated 4/22/22, the Nurse Practitioner documented that Resident #43 was on three [CONDITION(S)] medications which included [MEDICATION(S)] (mood stabilizer) 125 milligrams (mg) twice daily (BID), [MEDICATION(S)] (antipsychotic) 0.25mg daily (QD), and [MEDICATION(S)] (antidepressant) 50mg QD. Review of a Social Work progress note dated 5/16/22, revealed that Resident #43 completed a tele psych session due to the resident's continued restlessness, agitation and aggression at times when redirection was attempted following wandering. The Psychiatrist recommended increasing [MEDICATION(S)] to 125mg three times a day and [MEDICATION(S)] to 0.25mg BID. Additional recommendations included behavioral tracking for two weeks, and to monitor for excessive drowsiness, falls and impaired motor abilities. Review of the current medical orders revealed that the Psychiatrist's recommended medication changes were ordered. Neither the CCP or the Behavioral Care Plan included the use of multiple [CONDITION(S)] medications (including recent increase), goals, and/or monitoring for side effects. Multiple observations on 6/8/22 during the day shift identified Resident #43 self-propelling in a wheelchair down the hallways, sitting in the hallway or being wheeled by staff. No behaviors were observed. During an interview on 6/10/22 at 9:05 a.m., the Director of Nursing (DON) stated that Social Work is responsible for adding [CONDITION(S)] mediations to the CCP. The DON stated that CCPs that were last updated on 5/19/22 and 5/26/22 but did not address [CONDITION(S)] medication use. 415.11(c)(1)

Based on observations, staff interviews, and record reviews, it was determined that for 16 of 98 residents reviewed for Advance Directives (Cardiopulmonary Resuscitation, CPR or Do Not Resuscitate, DNR), the facility failed to provide each resident with the necessary care and services to maintain the highest practicable physical well-being. Specifically, the facility failed to have systems in place to ensure that each resident would receive necessary care for the Advance Directives of their choice. Resident #83, did not have a documented Advance Directive, should have received CPR per facility policy, and did not receive CPR when found without a pulse. The color coded identification bracelets (white/CPR, blue/DNR) worn by residents/and or attached to resident equipment, failed to accurately represent each resident's Advance Directives (Residents #3, #14, #16, #22, #28, #29, #34, #39, #42, #64, #66, #68, #82, #102, and #104). The colored dot (blue/DNR) on the transfer status care posted at the head of the bed failed to accurately represent the residents' Advance Directives (Residents #3, #52, #82, #102, and #104). Resident #79's Medical Orders for Life Sustaining Treatment (MOLST) and physician orders did not match. This resulted in no actual harm with potential for serious harm that is IMMEDIATE JEOPARDY TO RESIDENT HEALTH AND SAFETY AND SUBSTANDARD QUALITY OF CARE. The Immediate Jeopardy was removed prior to exit on [DATE]. This is evidenced by, but not limited to, the following: Review of the facility's policy, "CPR/DNR,"revised [DATE], revealed that staff are expected to ensure residents have the opportunity to make a choice about Advance Directives and to make this information readily available to all staff by use of color coded identification bracelets (blue/DNR). In the event that a resident is found with the absence of a heart beat and respirations, the person finding the resident immediately notifies the nurse. The phrase to summon for assistance is "Code CPR." The nurse will then go immediately to the resident. Personnel will perform CPR and Automatic External Defibrillator (AED) usage as trained by recognized agency guidelines. 1. Resident #83 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the hospital transfer form, dated [DATE], revealed that the resident was being transferred to the nursing facility for rehabilitation services, that her mental condition had been clear, and that there was no DNR or Health Care Proxy (HCP). In a progress note, dated [DATE] at 2:30 p.m., Licensed Practical Nurse (LPN) #1 documented that the resident had been found unresponsive with no blood pressure or pulse. The resident's legs and feet were mottled (blue/purple colored). There was no reference to Advance Directives or actions taken documented in the progress notes. While being interviewed on [DATE] at 1:49 p.m. and 3:25 p.m., the Director of Nursing (DON) reviewed the medical record and said that she was unable to locate any Advance Directives. The DON explained that if a resident does not have Advance Directives in place, they are considered a full code. The DON said that CPR should have been started for this resident. When interviewed on [DATE] at 2:25 p.m. and [DATE] at 12:00 p.m., LPN #1 stated that the resident was gasping for air, so she was getting air. Also, the resident had no pulse, which means CPR should have been started. LPN #1 reported that she did not think about getting the AED from the emergency cart, which was down the hall. LPN #1 said the ambulance used the AED to find the resident's pulse. In an interview on [DATE] at 10:35 a.m., the Administrator said that he was not aware that this resident was found without a pulse and did not receive CPR. 2. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Assessment, dated [DATE], revealed that the resident's cognitive skills for daily decision making were severely impaired. During an observation on [DATE] at 8:30 a.m. with the Registered Nurse/Unit Manager (RN/UM), the resident was wearing a blue identification bracelet on her wrist. A white card posted at the head of her bed included a blue dot. The RN/UM stated that a blue identification bracelet and a blue dot posted at the head of the resident's bed on the transfer status card indicated that the resident had a DNR status. Review of the Medical Record revealed that the resident did not have a MOLST and did not have a physician's order for DNR. In an interview on [DATE] at 10:10 a.m., the RN/UM explained that the Social Worker (SW) is responsible for initiating the discussion about Advance Directives and filling out the MOLST. Nursing is responsible for getting the physician's order if the resident wishes for DNR status and for applying the correct identification bracelet on the resident. The RN/UM stated that the resident's identification bracelet and code status [REDACTED]. When interviewed on [DATE] at 10:35 a.m., the LPN charge nurse stated that Resident #3 does not have a MOLST form and/or a physician's order for DNR and is considered a full code until a decision is made. The LPN charge nurse stated that she is responsible for checking the residents' wristbands to make sure they correctly identify the resident's wishes. She said that she usually does this once a week but does not document that it has been done. The LPN charge nurse said that she did check wristbands on [DATE] and did not know why she missed this resident. 3. Resident #79 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's MOLST, dated [DATE] and last reviewed [DATE], included to provide CPR. The current physician orders were for DNR. On [DATE] multiple staff members were interviewed regarding how to identify a resident's code status and how to react if a resident is found unresponsive. These include, but are not limited to, the following statements: a. At 3:25 p.m., the DON said that if a resident has no Advance Directive orders they are considered a full code. Residents wear white identification bracelets if they are a full code and blue identification bracelets if they are DNR. She said that the identification bracelets could be located on the walker or wheelchair because some residents tend to pull them off their wrists. The DON said there should be no code status lists at the nursing station. Also, there will be a blue dot on a resident's transfer status card located by the bed when a resident is a DNR. b. At 3:40 p.m., LPN #1 said that she would check the identification bracelet for code status. A blue identification bracelet is a DNR, and a white identification bracelet is a full code. LPN #1 said if nothing was written (Advance Directive orders), the resident is a full code. c. At 3:44 p.m., the charge LPN explained that the blue identification bracelet is for DNR, and the white identification bracelet is for full code. Also, there is a blue dot on the transfer card above the bed for DNR and no dot if they are a full code. The full code list can also be checked. d. At 3:45 p.m., LPN #2 said that she would check the identification bracelet for code status. LPN #2 did not know what to do if there was no identification bracelet. Also, a dot at the head of the bed is for DNR status, and no dot is a full code. e. At 3:50 p.m., the RN Evening Supervisor said that if the resident is wearing a blue identification bracelet, CPR would be started; a white identification bracelet is a DNR. He said if there was no code status available, he would treat it as a full code. f. At 3:53 p.m., LPN #3 stated that the resident's identification bracelet is used to check for code status. LPN #3 explained that a blue identification bracelet indicates DNR, and if a resident does not have a code status, CPR would be started. When interviewed on [DATE] at 10:20 a.m., the DON said that it is her expectation that the staff look at the identification bracelets to determine code status. If staff is in the resident's room, they can look at the transfer status card. If nothing is present, staff should start CPR. The charge nurse on each unit checks the transfer status cards and identification bracelets for accuracy. She said she is not sure how often this is done. The DON said if the identification bracelet is not on the person, it could be on the resident's wheelchair or walker. She said that she was not aware of any inconsistencies with the identification bracelets and transfer status cards. The DON said that the facility's CPR policy and procedure, dated 2005, has not been updated or changed since that time. However, this policy does not address the system for checking the identification bracelets for accuracy. During an observation on [DATE] at 4:03 p.m., Resident #79 was wearing a white identification bracelet. When interviewed on [DATE] at 4:15 p.m., the RN charge nurse said that the DNR on the physician's orders was a mistake made by the pharmacy because this was not on the previous month's orders. The RN charge nurse said that the mistake should have been caught when the physician's orders were checked for accuracy. During an interview on [DATE] at 8:30 a.m., the Administrator said that he was not aware there was a problem with inconsistencies in the process to identify the resident's advance directive status. In an interview on [DATE] at 9:30 a.m., the covering physician stated that Advance Directives should be documented in the medical record within 24 hours of admission, especially if there are no determined wishes. When this is not done, he is very uncomfortable because he is called in the middle of the night to make decisions. On [DATE] at 3:30 p.m., the facility presented a letter alleging compliance to remove the immediacy related to Advance Directives. Actions taken include the following: a. On [DATE], the facility developed an in-service program, "Facility Policy Regarding Identification of Code Status," to be presented to all licensed staff and Social Workers. b. As of [DATE], 92 percent of staff members expected to perform CPR or involved in determining resident's code status had been in-serviced. All other facility staff will be in-serviced prior to working their next shift. c. On [DATE], all resident medical records were reviewed for Advanced Directives. Once verified, all residents were observed to ensure they were wearing the accurate identifiers. Discrepancies were immediately corrected. Identification bracelets attached to equipment were removed. d. On [DATE] and [DATE], visual checks of code identifiers were completed and were accurate. Identification bracelets will be checked for accuracy daily. e. The Social Worker was made responsible for following up with residents/representatives to confirm that the Advance Directive wishes at the time are current. Based on observations, staff interviews, and record review, the survey team verified that the Immediate Jeopardy had been removed prior to exit. a. Documentation on in-service records, dated from [DATE] through [DATE], show that 92 percent of licensed staff and Social Work staff had been educated regarding the facility's Advanced Directives policy and procedure. The facility planned to inservice all staff prior to starting their next shift. b. Interviews conducted from 3:30 p.m. to 4:50 p.m. on [DATE] with facility staff confirmed their understanding of determining code status. (10 NYCRR 415.12)

Based on observations, staff interviews, and record reviews, it was determined that the Administrator failed to ensure the facility was administered in an effective and efficient manner that would enable each resident to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Specifically, the facility's administration failed to have systems in place to ensure that each resident/designated representative have the opportunity to formulate their choice of Advance Directives (Cardiopulmonary Resuscitation, CPR, Do Not Resuscitate, DNR). The facility's administration failed to have systems in place for staff to readily identify resident Advance Directives in order to provide timely and appropriate care and services. The facility did not provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Additionally, the facility continues to have repeated deficiencies under F329. (Recertification Surveys of [DATE], [DATE], and 5/ ,[DATE]). This resulted in no actual harm with potential for serious harm that is IMMEDIATE JEOPARDY TO RESIDENT HEALTH AND SAFETY. The Immediate Jeopardy was removed on [DATE] prior to exit, and is evidenced by, but not limited to, the following: 1. F309, Quality of Care S/S=L The facility's administration failed to have systems in place to ensure that each resident's Advance Directives were readily identifiable in order to provide timely and appropriate care and services. Issues included Resident #83, who did not have documented Advance Directives, and was considered a full code. This resident was found without a pulse and did not receive CPR. The resident subsequently expired. Other observation of all facility residents determined that the facility's system in place for staff identification of residents' Advance Directives was faulty. Color coding used on identification bracelets/resident equipment (white/CPR, blue/DNR) and on the transfer status cards (blue dot/DNR, no dot/CPR) to alert staff to the residents' Advance Directives were not accurate. The Medical Orders for Life Sustaining Treatment (MOLST) and physician orders [REDACTED]. Fifteen residents residing in the facility did not have documented Advance Directives. During an interview on [DATE] at 10:20 a.m., the Director of Nursing (DON) stated that she was not aware of inconsistencies with the identification bracelets and transfer status cards. The DON reported that the facility's CPR policy and procedure, dated 2005, has not been updated or changed since that time. This policy does not include a plan to monitor the accuracy of the identification bracelets. The facility later provided a revised CPR policy, dated [DATE]. On [DATE] at 8:30 a.m., the Administrator said he was not aware that there was a problem with inconsistencies in the process to identify the residents' advance directive status and should have been. In an interview on [DATE] at 9:30 a.m., the covering physician stated that Advance Directives should be documented in the medical record within 24 hours of admission and need to be available for physicians to make appropriate care decisions. 2. F155, Formulation of Advance Directives, S/S=L The adminstration failed to ensure that there was a system in place to provide each resident/ designated representative with the opportunity to formulate an Advance Directive in a timely manner. When interviewed on [DATE] at 10:35 a.m., the Administrator said that he was not aware of the resident who was a full code and did not receive CPR. He said if he had known, he would have investigated and started a Quality Assurance review for Advance Directives. On [DATE] at 3:25 p.m. and on [DATE] at 3:55 p.m., the DON said that if a resident does not have documented Advance Directives, they are considered a full code. Also, the Social Worker is responsible for initiating conversations regarding Advance Directives with each resident/designated representative. The DON said the physician signs the MOLST but does not get involved otherwise in determining the Advance Directives. When interviewed [DATE] at 9:30 a.m., the covering physician stated that Advance Directives should be documented in the medical record within 24 hours of admission, especially if there are not determined wishes. When this is not done, he is very uncomfortable because he is called in the middle of the night to make decisions. 3. F250 Social Services S/S=F The facility did not provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The issues included the lack of discussion and coordination of Advance Directives. During an interview on [DATE] at 2:22 p.m., a Social Worker (SW) said if a resident did not have Advance Directives, the resident would receive CPR. The SW stated that there are no clear guidelines for who in the facility is responsible for initiating the discussion with a resident about their Advance Directive wishes. In an interview on [DATE] at 10:10 a.m., the Registered Nurse/Unit Manager explained that the SW is responsible for initiating the discussion regarding Advance Directives and for completing the Medical Orders for Life Sustaint Treatment (MOLST). During interviews on [DATE] at 3:25 p.m. and on [DATE] at 3:55 p.m., the Director of Nursing said that the SW is responsible for initiating conversations regarding Advance Directives. During interviews on [DATE] at 3:54 p.m. and on [DATE] at 8:59 a.m., a SW said she does not usually wait longer than a six month period to go back to a resident to revisit their Advance Directive wishes. The SW said she has an informational packet she reviews with the resident and/or designated representative upon admission, unless they did not want to review it at that time. She usually leaves the packet with the resident, suggests to talk about it with their designated representative, and tells them she will be back to discuss it. The SW said she did not always document this discussion. She said that she did not notify the physician that the Advance Directives were not in place for several residents. 4. F329, Unnecessary Medications has been repeated for three consecutive Recertification Surveys ([DATE], [DATE], and [DATE]). The facility had shown a repeated lack of compliance with ensuring that each resident's medication regimen remains free from unnecessary medications. Specifically, physician orders [REDACTED]. The medication was given multiple times in the presence of adverse side effects, and the physician was not notified of consistently low blood pressures. The facility continues with the same problem with the same cardiac medication. In an interview on [DATE] at 1:36 p.m, the DON stated that if a blood pressure medication is held for three days, the physician should be notified. (10 NYCRR 415.26)

Based on observations, staff interviews, and record reviews, it was determined during an Extended Survey that the facility failed to maintain a Quality Assessment and Assurance (QAA) Committee that readily and consistently identified and corrected deficiencies for 15 of 15 residents reviewed for formulation of Advance Directives (Residents #3, #24, #27, #33, #58, #65, #83, #85, #90, #93, #95, #105, #109, #110 and #121), for 16 of 98 residents reviewed for care and services related to Advance Directives (Residents #3, #14, #16, #22, #28, #29, #34, #39, #42, #52, #64, #66, #68, #82, #102 and #104), and for 14 of 14 residents reviewed for Social Services related to Advance Directives (Residents #3, #24, #27, #33, #58, #65, #83, #85, #90, #93, #95, #105, #109 and #110). Please refer to F155, F309 and F250. Additionally, 1 of 10 residents reviewed for unnecessary medications was not free of unnecessary medications. This tag, F329, was repeatedly cited for three consecutive Recertification Surveys. Please refer to F329. This resulted in no actual harm with the potential for serious harm that was IMMEDIATE JEOPARDY TO RESIDENT HEALTH AND SAFETY. The IMMEDIATE JEOPARDY was removed prior to exit on [DATE]. This is evidenced by the following: During an interview on [DATE] at 10:20 a.m., the Director of Nursing (DON) stated that she was not aware of inconsistencies with the identification bracelets and transfer status cards. The DON reported that the facility's Cardiopulmonary Resuscitation (CPR) policy and procedure is dated 2005 and has not been updated or changed since that time. Also, this policy does not include a plan to monitor the accuracy of the identification bracelets. The facility later provided a revised CPR policy, dated [DATE]. When interviewed on [DATE] at 1:00 p.m., the Assistant Director of Nursing said that she was aware that there was a problem with CPR not being performed for a resident. She said she was not sure if an investigation should be done and added that she is not aware of any discussion regarding this in QAA. When interviewed on [DATE] at 10:35 a.m., the Administrator said that he was not aware of the resident who was a full code and did not receive CPR. He said he should have been aware. He said if he had known, he would have investigated and started a Quality Assurance review for Advance Directives. On [DATE] at 8:30 a.m. and at 10:05 a.m., the Administrator said that he was not aware that there was a problem with inconsistencies in the process to identify residents' Advance Directive status and should have been. The Administrator said that he was not aware of the resident who did not receive CPR. He said if he had been aware of the issues, then he definitely would have monitored and made changes as needed. When interviewed on [DATE] at 9:30 a.m., the covering physician stated that Advance Directives should be documented in the medical record within 24 hours of admission, especially if there are no determined wishes. Also, when this is not done, he is very uncomfortable because he is called in the middle of the night to make decisions. During an interview on [DATE] at 1:36 p.m., the DON stated that Advance Directives have not been monitored as part of the QAA in the past year. Also, the Medical Director/physician does not get involved in the resident/designated representative's choice of Advance Directives unless he is asked to speak to them. At times the Social Worker has a completed MOLST and does not share this with others for several days. The physician has not been involved in developing new policies but will be expected to review and make recommendations for policy change in the future. The DON stated that the facility policies regarding Advance Directives and the systems for staff identification of Advance Directives will be reviewed and revised. The DON said that there were no active issues currently being reviewed by the QAA committee. F329 has been repeated for three consecutive Recertification Surveys ([DATE], [DATE] and ,[DATE] /11). The facility had shown a repeated lack of compliance with ensuring that each resident's medication regimen remains free from unnecessary medications. Specifically, physician orders [REDACTED]. The medication was given multiple times in the presence of adverse side effects, and the physician was not notified of consistently low blood pressures. The facility continues with the same problem with the same cardiac medication. In an interview on [DATE] at 1:36 p.m., the DON stated that if a blood pressure medication is held for three days, the physician should be notified. (10 NYCRR 415.27 9 (a-c))

Based on observations, staff interviews, and record reviews, it was determined that for 15 of 15 residents reviewed for Advance Directives (Cardiopulmonary Resuscitation, CPR, or Do Not Resuscitate, DNR), the facility failed to ensure that there was a system in place that provided each resident/designated representative with the opportunity to formulate an Advance Directive. Specifically, medical records for Residents #3, #24, #27, #33, #58, #65, #83, #85, #90, #93, #95, #105, #109, #110, and #121 lacked documentation to show that each resident's wishes regarding Advance Directives were discussed, initiated, and implemented. This resulted in no actual harm with the potential for serious harm that is IMMEDIATE JEOPARDY TO RESIDENT HEALTH AND SAFETY. The Immediate Jeopardy was removed prior to exit on [DATE]. This is evidenced by, but not limited to, the following: Review of the facility's policy, "CPR/DNR," revised [DATE], revealed that staff are expected to ensure residents have the opportunity to make a choice about Advance Directives. 1. Resident #83 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Documentation on the hospital transfer form, dated [DATE], shows that the resident's mental condition is always clear. The sections for DNR and Health Care Proxy (HCP) are both checked "No." The facility's admission history and physical examination [REDACTED]. In an integrated progress note, dated [DATE] at 2:30 p.m., nursing documented that the resident was unresponsive with no blood pressure or pulse. The resident's legs and feet were mottled (blue/purple in color). "Mouth opens gasping. Unable to obtain an oxygen saturation level. Oxygen applied at 2 liters, and the son was notified." Nursing did not address Advance Directives in this note. Record review also revealed that the resident expired on [DATE]. During an interview on [DATE] at 1:49 p.m., the Director of Nursing (DON) stated that she had not found Advance Directive orders for this resident. If no Advance Directive orders had been written, the resident is considered a full code. In an interview on [DATE] at 2:22 p.m., the Social Worker (SW) also said that if a resident does not have Advance Directives, they are considered a full code. The SW stated that there are no clear guidelines for who in the facility is responsible for initiating the discussion with a resident regarding their Advance Directive wishes. In an interview on [DATE] at 9:30 a.m., the covering physician stated that Advance Directives should be documented in the medical record within 24 hours of admission, especially if there are no determined wishes. When this is not done, he is very uncomfortable because he is called in the middle of the night to make decisions. 2. Resident #109 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. In an observation on [DATE] between 9:00 a.m. and 10:00 a.m., the resident was not wearing an identification bracelet (color coded to show Advance Directive preferences). There was a white identification bracelet (CPR) attached to the wheelchair that she was sitting in at that time. There was another resident's name on the bracelet. When interviewed on [DATE] between 9:00 a.m. and 10:00 a.m., the charge LPN said that the resident was sitting in the wrong wheelchair. After surveyor intervention, the SW progress note, dated [DATE], revealed that she had contacted the resident's HCP to discuss the Medical Orders for Life Sustaining Treatment (MOLST) form and Advance Directives. The HCP came into the facility and signed the MOLST for a DNR. When interviewed on [DATE] at 1:00 p.m., the Registered Nurse (RN) Unit Coordinator said that this resident was changed to a DNR that day. She provided the surveyor with a MOLST form that was signed by the HCP and the physician on [DATE]. There was also a signed physician order, dated [DATE], for DNR. 3. Resident #95 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. In an observation on [DATE] between 9:00 a.m. and 10:00 a.m., the resident was not wearing an identification bracelet. After surveyor intervention, the SW progress note, dated [DATE], revealed that when she contacted the resident's son, he said that the resident's desire was for DNR. A physician's orders [REDACTED]. On [DATE] at 3:30 p.m., the facility presented a letter alleging compliance to remove the immediacy related to Advance Directives. Actions taken include: a. The 15 residents identified without Advance Directive orders, or their designated representatives, were contacted to determine their wishes. The initial contact was documented in the medical record. The Social Worker will follow-up within seven days to finalize a decision. Until this decision is made, the resident's code status will be full code. Physician orders [REDACTED]. b. The Social Worker was made responsible for following up with residents/representatives to confirm that the Advance Directives wishes are current. Based on record review, the survey team verified that the Immediate Jeopardy had been removed prior to exit. Record review completed between 9:00 a.m. and 10:00 a.m. on [DATE] revealed that for 15 of 15 residents that had been identified without Advance Directive orders, staff had revisited the resident/and or designated representative regarding wishes for Advance Directives and had documented this information appropriately. (10 NYCRR 415.3(e)(1)(ii))