Every finding on record at Massapequa Center Rehabilitation & Nursing

Based on observations, record review, and interviews during the Recertification Survey initiated on 12/3/2024 and completed on 12/11/2024, the facility did not ensure that each resident who is unable to carry out activities of daily living received the necessary services to maintain grooming, personal, and oral hygiene. This was identified for one (Resident #146) of two residents reviewed for Activities of Daily Living. Specifically, Resident #146 was observed with long and yellow fingernails on their contracted right hand on multiple occasions. The finding is: The facility's policy and procedure titled Activities of Daily Livings (ADLs) last reviewed 1/2024 documented that residents who are unable to carry out Activities of Daily Living independently will receive the necessary services including but not limited to hygiene such as bathing, dressing, grooming and oral care. Resident #146 was admitted with diagnoses including Hemiplegia and Hemiparesis on the Right Dominant Side, Cerebral Infarction, and Type 2 Diabetes Mellitus. The Admission Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 10, indicating the resident had moderately impaired cognition. The Minimum Data Set assessment documented functional limitations in the range of motion on one side of the upper and lower extremity. The resident required moderate assistance for personal hygiene tasks. A Comprehensive Care Plan titled Activity of Daily Living (ADL) dated 9/18/2024 documented Resident #146 had a self-care deficit and potential decline in Activity of Daily Living function due to muscle weakness and/or muscle wasting and atrophy (muscle weakness). Resident #146 required moderate assistance for general hygiene. The Nursing Instructions for Certified Nursing Assistants, as of 12/9/2024, documented that Resident #146 had Hemiplegia (paralysis) on the right side and required moderate assistance for general hygiene. The instructions included skin checks and care every day at all shifts. A review of nursing progress notes from 11/1/2024 to 12/3/2024 revealed no documentation that Resident #146 refused to have their fingernails trimmed. During an initial tour conducted on 12/3/2024 at 10:51 AM, Resident #146 was observed in their room lying in bed. Resident #146 was alert and able to provide appropriate answers when asked. Resident #146 stated that they suffered right-side paralysis from a Stroke for a long time and had made limited progress in regaining function. Resident #146 stated they required assistance from staff for most of their daily needs. Resident #146 was observed reaching under their blanket with their left hand to lift their right hand. Resident #146's right hand was contracted into a fist and the fingernails on the right hand (all) digits were long and yellow. Resident #146's left-hand fingernails were trimmed. Resident #146 stated they would like their nails trimmed but could not do so on their own. During a follow-up observation on 12/3/2024 at 2:46 PM, Resident #146's right-hand fingernails remained long, yellow, and untrimmed. Resident #146 stated they received their morning care and ate lunch. Resident #146 stated staff has not offered to trim their nails and that they (Resident #146) would not refuse to have their nails trimmed. During an observation and interview on 12/3/2024 at 2:50 PM, Certified Nursing Assistant #3 stated they were the assigned aide to the resident this shift; however, they were not regularly assigned to Resident #146. Certified Nursing Assistant #3 stated they did not notice the resident's long nails until after the lunch meal. Certified Nursing Assistant #3 stated they left Resident #146's room about 10 minutes ago and were on their way to get a nail clipper. Certified Nursing Assistant #3 stated they should ask a nurse to see if it was appropriate for them (Certified Nursing Assistant #3) to cut the resident's nails. During an observation and interview on 12/3/2024 at 2:59 PM, Licensed Practical Nurse #6 (unit nurse) Resident #146's right-hand fingernails were observed to be long and yellow. Licensed Practical Nurse #6 stated Certified Nursing Assistant should check the resident's hands and report to the nurse if the nails were long and required trimming. Licensed Practical Nurse #6 stated if the resident has a diagnosis of Diabetes, then a nurse must trim the nails but the Certified Nursing Assistant could file the nails to prevent any skin breakdown. Resident #146's nails should have been cut as overgrown nails on the resident's contracted right hand could cut into their skin causing skin tears. During an interview on 12/4/2024 at 3:41 PM, Certified Nursing Assistant #7, who was the resident's regularly assigned Certified Nursing Assistant, stated they noticed Resident #146's nails getting long about a week ago. Certified Nursing Assistant #7 stated they encouraged Resident #146 to cut their nails but Resident #146 was nervous about getting their nails trimmed. Certified Nursing Assistant #7 stated they reported the refusal to a nurse; however, they could not recall the name of the nurse. Certified Nursing Assistant #7 stated they did not follow up and did not cut the resident's fingernails. During an interview on 12/10/2024 at 9:38 AM, the Director of Nursing Services stated Certified Nursing Assistant who provided care to the resident should look at the resident's skin and check their fingernails. The Director of Nursing Services stated Certified Nursing Assistants should report to the nurse if the resident's nails are long. The Director of Nursing Services stated that Certified Nursing Assistant could trim nails for non-diabetic residents but a nurse must trim the nails for residents with Diabetes diagnosis. The Director of Nursing Services stated overgrown nails with contracted hands could lead to possible skin breakdown. 10 NYCRR 415.12(a)(3)

Based on observations, record review, and staff interviews during the Recertification Survey initiated on 12/3/2024 and completed on 12/11/2024, the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice. This was identified for one (Resident #120) of two residents reviewed for Skin Conditions and for one (Resident #93) of one resident reviewed for Communication-Sensory. Specifically, 1) Resident #120 was observed with a dressing on the left side of the forehead on 12/3/2024 and 12/5/2024; however, there was no physician's order for any assessment treatment for the left side of the forehead lesion. Additionally, the facility did not initiate a care plan for the left side of the forehead lesion. 2) Resident #93 had Physician's Orders to receive an antibiotic eye drop indefinitely until seen again by their Retinal Surgeon and the resident did not receive dosages of their eye drops from 11/19/2024 through 11/25/2024. The finding is: 1) The facility's undated policy and procedure titled Skin Care Protocol documented that the Nurse will initiate an analysis, to identify risk factors, contributing factors, and source of the impaired skin. It may include but is not limited to a review of the medical record, medications, nutritional status, functional and self-care status, present plan of care for prevention of skin impairment, and staff statements. Notify the attending Physician upon identification or change in skin condition. Orders will be obtained for treatment specific to the wound for cleaning, treatment, dressing, and frequency. The Certified Nursing Assistant is responsible for monitoring the resident's skin during care and reporting any changes in skin integrity immediately to the Nurse in charge. Resident # 120 was admitted with diagnoses including Pulmonary Embolism, Atrial Fibrillation, and Disorder of the Skin and Subcutaneous Tissue. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #120 had intact cognition. The Minimum Data Set (MDS) assessment documented Resident # 120 had a skin condition that included open lesions other than ulcers, rashes, and cuts. A Progress Note dated 10/18/2024 documented the Nurse Practitioner had seen Resident #120 to evaluate the left-side forehead lesion that had gotten bigger and changed color. The nurses reported Resident #120 scratched the area (left-sided forehead lesion) with their nails at times. A Dermatology consult for biopsy was recommended but Resident #120's family member refused and requested that Resident #120 be treated by the facility as best as possible. Bacitracin (topical antibiotic) ointment was ordered twice a day for one week for the left side forehead lesion. A Physician order dated 10/18/2024 documented Bacitracin (topical antibiotic) ointment to the left side forehead lesion, twice a day for one week. The order was completed on 10/25/2024 and was not revised. Resident #120's medical record review revealed no care plan for Resident #120's lesion on the left forehead. Resident #120 was observed lying in bed on 12/3/2024 at 10:25 AM with a small band-aid on the left side of the forehead. An irregular, red-scabbed area was sticking out of the band-aid. During a second observation on 12/5/2024 at 9:04 AM, Resident #120 was lying in bed. A small band-aid was observed on Resident #120's left side of the forehead. The band-aid appeared loose and soiled. A scabbed area was sticking out of the band-aid. During an interview on 12/5/2024 at 10:42 AM, Certified Nursing Assistant #2 stated at times Resident #120 scratched the lesion on the left forehead, which made the area bleed. Certified Nursing Assistant #2 stated they reported the bleeding skin lesion to the nurses numerous times and the nurses applied dressing to cover the area. During an interview on 12/5/2024 at 10:54 AM, Licensed Practical Nurse #4 (Charge Nurse) stated when Certified Nursing Assistants reported that Resident #120's left forehead lesion was bleeding, a dressing was applied to the area. Licensed Practical Nurse #4 stated there are times when Bacitracin ointment was applied. Licensed Practical Nurse #4 stated the Nurse Practitioners were aware of the treatment. Licensed Practical Nurse #4 stated because the lesion was chronic, they used their Nursing judgment and applied treatment to the left forehead when the lesion was open and bleeding. During an interview on 12/5/2024 at 11:02 AM, Nurse Practitioner #2 stated the growth on Resident #120's forehead was chronic. Nurse Practitioner #2 stated the nurses updated them (Nurse Practitioner #2) about the lesion, but they (Nurse Practitioner #2) did not order a treatment because the lesion was chronic. During an interview on 12/9/2024 at 3:00 PM, Physician #3 stated Resident #120's forehead was chronic and the resident's family did not want further workup or consultations. Physician #3 stated they did not know Resident #120 had a behavior of scratching the lesion. During an interview on 12/10/2024 at 9:00 AM, the Director of Nursing Services stated a physician order is needed for all treatments. The Director of Nursing Services stated that Nurses cannot just use their judgment to apply treatments. The Director of Nursing Services stated a care plan for the chronic left-sided forehead lesion should have been in place with goals and interventions. 17732 2) The Consultation Policy and Procedure last reviewed in January 2024 documented residents will be evaluated by a Consultant as ordered by the Primary Medical Doctor (PMD). The Primary Medical Doctor will review the Consultant's recommendations and follow up accordingly. Resident #93 had diagnoses that included Status Post Corneal Repair and Hypertension. The Admission 5 Day Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognitive skills for daily decision-making. The Minimum Data Set documented the resident wore corrective lenses and the resident was able to see under adequate light. The Physician's Order dated 10/25/2024 documented for the resident to have an Optometry Consult. The Physician's Order dated 10/25/2024 documented for the resident to receive Polytrim eye drops (a prescription antibiotic for certain eye infections caused by bacteria) by ophthalmic (eye) route - place 1 drop to left eye 4 times daily for Unspecified Infectious Disease. This order was discontinued on 11/4/2024. The Physician's Order dated 10/26/2024 documented for the resident to wear a patch to their left eye for status post corneal repair. The Physician's Order dated 10/31/2024 documented the resident to go to an Eye Institute for a follow-up appointment on 11/4/2024. The Nursing Progress Note dated 11/4/2024 documented the resident returned from their eye appointment and recommendations included continuing the Polytrim eye drops 4 times per day and following up with the Eye Institute in one month. The Ophthalmology Report of Consultation 11/4/2024 documented as one of the recommendations for the resident to continue Polytrim eye drops four times daily. The Physician's Order dated 11/4/2024 for the resident to receive Polytrim eye drops by ophthalmic route for 7 days, place one drop to the left eye 4 times daily for Unspecified Infectious Disease. This order was discontinued on 11/11/2024. The Nursing Progress Note dated 11/12/2024 written by Registered Nurse #1 documented that Registered Nurse #1 spoke with the resident's (eye) Surgeon and the resident was to continue the Polytrim eye drops by ophthalmic route for 7 days. Place 1 drop to the left eye 4 times daily as per the Ophthalmology Medical Doctor (MD) with no stop date. The resident was to continue to receive the medication until further notice. The Physician's Order dated 11/12/2024 entered into the resident's Electronic Medical Record by Registered Nurse #1 documented Polytrim eye drops by ophthalmic (eye) route for 7 days place 1 drop to left eye 4 X [times] daily As per Ophth. M.D No stop date. Pt. [resident] to continue to receive medication until further Notice. This order was discontinued on 11/19/2024. A review of the resident's November 2024 Medication Administration Record revealed that the resident did not receive the Polytrim eye drops from the 11/19/2024 4:00 PM dose to the 11/25/2024 1:00 PM dose. The Physician's Order dated 11/25/2024 (last renewed on 12/4/2024), entered into the Electronic Medical Record by Licensed Practical Nurse #1, documented for the resident to receive Polytrim eye drops by ophthalmic (eye) route - place 1 drop to left eye 4 times daily for prophylactic measures. During an interview on 12/6/2024 at 9:40 AM, Registered Nurse #1 stated they should not have put a stop date for the Polytrim eye drop order when they entered the order into the Electronic Medical Record on 11/12/2024. Registered Nurse #1 stated that was an error because they knew the resident's eye drops needed to continue until they saw their eye doctor again. During an interview on 12/6/2024 at 10:00 AM, Licensed Practical Nurse #1 stated they realized the resident's Polytrim eye drops had stopped when the resident told them (Licensed Practical Nurse #1) on 11/25/2024 that they (Resident #93) had not received their eye drops on 11/24/2024. Licensed Practical Nurse #1 stated that they called the resident's representative, who had taken the resident to her Ophthalmology appointment on 11/4/2024, and the representative told them that the Ophthalmologist did not want to stop the Polytrim eye drops. Licensed Practical Nurse #1 stated that Registered Nurse #1 had called the resident's Ophthalmologist on 11/12/2024 to clarify the order and was told that the resident's Polytrim eye drops should continue until they were seen by the eye doctor again. Licensed Practical Nurse #1 stated that was why they got a new Physician's Order for the resident's eye drops to start again on 11/25/2024. During an interview on 12/6/2024 at 11:15 AM, the Optometrist who works with the resident's Corneal Specialist stated that the resident was being seen at the Eye Institute for a perforated ulcer of their left eye. The Optometrist stated that the resident's visit on 11/4/2024 was a follow-up to examine the bandage contact lens placed in the resident's left eye to seal the perforation in the resident's cornea. The Optometrist stated that it was important for the resident to receive the Polytrim eye drops until their next visit to the Eye Institute because the drops were an antibiotic given to avoid infection with the bandage contact lens on the resident's left eye. The Optometrist stated that the resident had a very severe infection, possibly herpetic, and could have lost their eye. During an interview on 12/10/2024 at 9:50 AM, the Director of Nursing Services stated Registered Nurse #1 accidentally put the Physician's Order for the Polytrim eye drops into the resident's Electronic Medical Record on 11/12/2024 with a stop date. 10 NYCRR 415.12

Based on observation, record review, and staff interviews during the Recertification Survey initiated on 12/3/2024 and completed on 12/11/2024, the facility did not ensure that drugs and biologicals were stored in a locked compartment. This was identified for one (Resident #46) of one resident reviewed for Accident Hazards. Specifically, Resident #46 was observed with a Calcitonin (Salmon) spray bottle on their overbed table and there was no staff in the vicinity. Additionally, Resident #46 was not assessed to self-administer their medication. The finding is: The facility's policy and procedure titled, Medication Storage, last revised on 1/2024, documented that medications must be stored in accordance with the manufacturer's specifications and secured in locked storage areas in compliance with State and Federal requirements and accepted professional standards of practice. Storage areas may include, but are not limited to, drawers, cabinets, medication rooms, refrigerators, and carts. Resident #46 was admitted with Diagnoses including Legal Blindness, Osteoporosis, and Myelodysplastic Syndrome (a group of disorders caused by blood cells that are poorly formed or do not work properly). The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13, which indicated Resident #46 had intact cognition. The Minimum Data Set (MDS) assessment documented Resident #46 had an active diagnosis of Osteoporosis and severely impaired vision. The physician's order dated 10/3/2024 and last renewed on 11/18/2024 documented to administer Calcitonin (Salmon) Spray 200 units per actuation (mouthpiece). One spray by nasal route daily in one nostril, rotating nostrils every day for age-related Osteoporosis. The medical record review revealed no care plan for the use of Calcitonin spray for age-related osteoporosis. During an observation on 12/3/2024 at 10:28 AM, a Calcitonin spray bottle was lying flat on Resident #46's overbed table. Resident #46 was in bed and there was no staff in the vicinity. During an interview on 12/3/2024 at 11:00 AM, Licensed Practical Nurse #3 (Medication Nurse) stated they administered the Calcitonin nasal spray to Resident #46 at 9:00 AM today. Licensed Practical Nurse #3 stated they must have forgotten to take and place the nasal spray in the medication cart. Licensed Practical Nurse #3 stated that Resident #46 cannot self-administer any medications. Licensed Practical Nurse # 3 stated they should not have left the nasal spray unattended in the resident's room. During an interview on 12/3/2024 at 11:15 AM, Licensed Practical Nurse #4 (Charge Nurse) stated Licensed Practical Nurse #3 should have taken the Calcitonin spray after administering the medication to Resident #46. Licensed Practical Nurse #4 stated that Resident #46 cannot self-administer any medications and all the nurses in the unit were aware that there should not be any medications left with Resident #46. During an interview on 12/9/2024 at 10:39 AM, Pharmacist #1 stated due to sedimentation, it is recommended the Calcitonin spray bottle should be kept in an upright position during storage and shaken before use. During an interview on 12/10/2024 at 8:58 AM, the Director of Nursing Services stated that the medication nurse should not have left the medication with the resident. The Director of Nursing Services stated that all medications should be kept in the medication carts unless the resident had an order for self-administration. The Director of Nursing Services stated that their expectation is for the Nurses to ensure that all medications are given and stored according to the facility's policy and procedure. 10NYCRR 415.18(e)(1-4)

Based on observation, record review, and interviews during the Recertification Survey initiated on 12/3/2024 and completed on 12/11/2024, the facility did not implement an ongoing infection prevention and control program to prevent, recognize, and control the onset and spread of infection to the extent possible. This was identified for one (Resident #14) of two residents reviewed for Skin Conditions. Specifically, there was no documented evidence that Resident #14, with a diagnosis of a chronic infected wound on the right hip, was placed on Enhance Barrier Precautions as per the facility's policy. The finding is: The facility's policy and procedure titled Enhanced Barrier Precaution, dated 4/1/2024 documented the facility will implement Enhanced Barrier Precaution to include any resident with chronic wounds (e.g. pressure injuries, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers) regardless of Multidrug Resistant Organisms colonization or infection status. Resident #46 was admitted with diagnoses of an Open Wound of the Right Hip, Infection due to Internal Right Hip Prosthesis, and Cellulitis. The Admission Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 15, which indicated Resident #14 had intact cognition. The assessment documented that Resident #14 had a Multidrug-Resistant Organism, Wound Infection, and Infection due to an Internal Right Hip Prosthetic. The resident had a surgical wound that required wound care and received antibiotics on admission. The Comprehensive Care Plan titled Skin Integrity - Surgical Right Hip, dated 9/6/2024 documented the resident had chronic infected prosthetic hardware with an open area along the scar line. Resident #14 was hospitalized from 10/1/2024 to 10/8/2024 for a non-healing wound to the right hip. Interventions included but were not limited to the surgical incision site treatment per the Physician's order. Maintain precautions as per the physician's order; maintain single room isolation; wear Personal Protective Equipment (PPE); and monitor for signs and symptoms of infection. A physician's order dated 10/8/2024 documented Contact Precautions. The order was discontinued on 11/15/2024 due to the Contact Precautions no longer being necessary. The Comprehensive Care Plan titled Infection - Chronic Cellulitis of Right Hip, dated 10/8/2024 documented interventions that included but were not limited to administering medications and changing the dressing to [the surgical site] per physician orders. During an observation on 12/3/2024 at 10:13 AM, there was no signage observed indicating Resident #14 was placed on Enhanced Barrier Precautions. During an interview on 12/3/2024, immediately after the observation, Licensed Practical Nurse #5 stated residents on Enhanced Barrier Precautions should have an orange dot sticker placed next to their name by the door. Resident #14's name by the door did not have an orange dot sticker. During an observation on 12/4/2024 at 11:28 AM, Resident #14's name by the door did not have an orange dot, no Enhance Barrier Precaution sign was posted, and no Personal Protective Equipment cart was observed in front of Resident #14's room. During an interview on 12/6/2024 at 1:32 PM, the Wound Care Nurse stated Resident #14 has a chronic open surgical wound on their right hip. The Wound Care Nurse stated that Resident #14 received daily wound treatments. During an interview on 12/6/2024 at 1:57 PM, the Infection Preventionist stated residents with chronic wounds should be placed on Enhanced Barrier Precautions. The Infection Preventionist stated Resident #14 had a chronic wound and they did not know why the resident was not placed on Enhanced Barrier Precaution. A review of the physician's orders on 12/6/2024 from 11/15/2024 to 12/5/2024 revealed no orders for Enhanced Barrier Precautions for Resident #14. A physician's order dated 12/6/2024 documented Enhanced Barrier Precautions due to a chronic wound. A review of the Comprehensive Care Plan on 12/6/2024 from 11/15/2024 to 12/5/2024 revealed no care plan for Enhanced Barrier Precautions for Resident #14. The Comprehensive Care Plan titled Enhanced Barrier Precaution dated 12/6/2024 documented the resident was placed on Enhance Barrier Precaution due to a chronic wound. Interventions included but were not limited to maintaining Enhanced Barrier Precautions during high-contact resident care activities. During an additional interview on 12/6/2024 at 3:17 PM, the Infection Preventionist stated they were responsible for tracking residents requiring Enhanced Barrier Precaution and other levels of isolation/precaution. The Infection Preventionist stated Resident #14 should have been placed on Enhanced Barrier Precautions because of an existing chronic wound, and it was an oversight. During an interview on 12/10/2024 at 9:38 AM, the Director of Nursing Services stated residents who had chronic wounds should be placed on Enhanced Barrier Precautions following Center for Disease Control and Prevention guidelines. The Director of Nursing Services stated that the Infection Preventionist is responsible for monitoring and ensuring residents are placed on appropriate precautions to prevent transmission of infections. 10 NYCRR 415.19(a) (1-3)

Based on observations, record review and staff interviews conducted during the Abbreviated survey (NY 076) on 09/14/2022, the facility did not maintain an effective pest control program. Specifically, there was evidence of fruit flies in the kitchen during the investigation and the facility's pest control treatment logs revealed there was ongoing conducive conditions for flies in the kitchen and in the basement near the kitchen, verbal reports of flies in the kitchen, and no access to the facility's complaint records for pest control purposes. The findings are: During a tour of the facility's main kitchen that is located in the basement on 09/14/2022 between 2:45pm and 3:10pm, live fruit flies were seen by the three-compartment sink area, near the dishwasher and near the pot drying area. Additionally, brown stained ceiling tiles were noted in the hallway near the kitchen entrance. During a record review of the facility's pest control service inspection reports on 09/14/2022 at 3:40pm, the following was noted: A review of the facility's pest control service inspection report dated 09/08/2022 indicated verbal reports of flies in the kitchen. Treated verbal reports. Recommend better sanitation practices in the kitchen hallways. A review of the facility's pest control service inspection report dated 08/11/2022 documented observed fruit fly activity at the kitchen hallways. Observed water damage at drop ceiling. Recommended fixing to prevent conducive condition. A review of the facility's pest control service inspection report dated 07/28/2022 recommended better sanitation practices in the basement. A review of the facility's pest control service inspection report dated 07/14/2022 indicated no access to kitchen logbook and to dietary office. Staff did not have keys. In concurrent interviews on 09/14/2022 at 2:50pm and 3:50pm, the Food Service Director stated that they started working at the facility approximately two weeks prior and had noticed the fly issue since then. They brought the fly concern to the attention of the Housekeeping Director and was told to reach out to the pest control company. They further stated that the fly issue was worse before and was now getting better. The Director of Engineering was interviewed on 09/14/2022 at 3:05pm, who stated that the stained tiles in the hallway near the kitchen was a result of condensation from the cooling system and that the tiles would be replaced. 415.29(j)(5)

Based on record reviews and staff and resident interviews during the abbreviated survey (#NY 076) conducted on 09/27/2022 the facility did not ensure that residents were free of significant medication errors (Resident #2). This was evident for one of three residents reviewed for pain. Specifically, Resident #2 did not receive five doses of [MEDICATION(S)] 50 milligrams (mg) give 2 (two) tablets to equal 100 mg by mouth three times a day for pain as prescribed by the Physician. The finding is: Resident #2 was admitted to the facility on [DATE] with the following medical Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident had intact cognition. The MDS also documented that Resident #2 had Occasional pain and that opioids were administered. The facility policy titled, Unavailable Medication Policy, effective date 08/29/2022, documented the following: In the event that a medication is unavailable for any reason, the facility shall act promptly to notify the appropriate practitioners for orders to be followed and the pharmacy to obtain medications in accordance with the updated orders. Review of the Comprehensive Care Plan (CCP) dated 12/29/2021 titled potential for pain as evidenced by: Resident #2 verbalization of pain or discomfort related to range of motion limitations and medical conditions of spinal stenosis and [CONDITION(S)]. Interventions included: administer pain medications as ordered, evaluate effectiveness of pain medication and monitor frequency/duration of pain. A review of the physicians' orders, dated 08/11/2022, documented: [MEDICATION(S)] 50 mg give 2 (two) tablets to equal 100 mg by mouth three times a day for pain. A review of Resident#2's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] o 09/01/2022 at 12:00 PM- comment: out of room/off unit o 09/02/2022 at 12:00 PM- comment out of room/off unit o 09/16/2022 at 12:00 PM- comment: out of room/off unit o 09/17/2022 at 12:00 PM - comment: awaiting delivery o 09/17/2022 at 6:00 PM- comment: awaiting delivery A review of the pharmacy report titled transactions by patient: dated 09/01/2022 thru 09/27/2022 documented all the medications removed from the Pyxis (a medication machine to store narcotics and other controlled medications) for Resident #2. The report revealed that [MEDICATION(S)] was not dispensed from the Pyxis on 09/16/2022 or 09/17/2022 for Resident #2. Resident #2 was interviewed on 09/27/2022 at 1:41 PM. Resident #2 stated that they have pain with movement of both of their (Resident#2's) knees. Resident #2 also stated that the pain is constant when they are ambulating or standing. An interview was held with the Licensed Practical Nurse #1 (LPN #1) on 09/27/2022 at 2:10 PM. LPN#1 stated that Resident #2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #1 reviewed the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #2. LPN#1 stated the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #1 stated they did not look for Resident #2; and that the 12:00 PM dose of [MEDICATION(S)] was not administered. LPN#1 could not explain why they did not look for Resident #2 to administer the medication. An interviewed was held with the Assistant Director of Nursing (ADNS), on 09/27/2022 at 4:17 PM. The ADNS stated the policy documented that when a residents medication supply was exhausted the nurse should use the Pyxis or call the physician for an alternate. The ADNS stated a medication should be administered per the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Interviewed Director of Nursing Services (DNS), on 09/27/2022 at 5:41 PM. The DNS reviewed the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The DNS stated that Resident #2 should have been reapproached and the [MEDICATION(S)] administered upon return to the unit. Additionally, the DNS stated that the physician was required to be notified of a missed medication and that [MEDICATION(S)] was available in the Pyxis. Interviewed Licensed Practical Nurse #3 (LPN #3) on 09/30/2022 at 2:45 PM. LPN#3 reviewed the MAR for Resident #2 and stated the [MEDICATION(S)] was not administered to Resident #2 on 09/17/2022 at 12:00 PM and 6:00 PM. LPN #3 stated they documented in the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN#3 stated that when a medication was not available the physician should be notified and that they could not recall if they notified the physician about the unavailability of the [MEDICATION(S)]. Interviewed Licensed Practical Nurse#4 (LPN #4), on 10/12/2022 at 11:37 AM. LPN #4 stated that Resident #2's [MEDICATION(S)] was not administered on 09/01/2022 at 12:00 PM or on 09/02/2022 at 12:00 PM. LPN#4 stated they documented in the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] #2 was off the unit, and they did not have time to look for Resident #2. LPN#4 stated they did not know the protocol for medication administration when a resident is off the unit and did not report to anyone that the [MEDICATION(S)] was not administered. 415.12

Based on observation, interviews and record review during the Recertification Survey completed on 05/04/2021, the facility did not ensure that each resident has the right to make choices about aspects of life that are significant to the resident. Specifically, one (Resident #548) of three sampled pooled residents, requested to take a nutritional supplement purchased by the resident. Resident #548 was not assessed by the facility staff to determine if the resident was a candidate to self-medicate. The findings are: The facility's Self Administration of Medication policy dated 11/01/2020 documented a resident may be allowed to self-administer medications if the team and the Primary Care Physician concurs the resident is capable of safe and effective self-administration. The policy documented to provide the opportunity to qualified residents that request to self-administer medications. Resident #548 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental status (BIMS) score of 15 indicating the resident's cognitive status was intact. The resident required supervision with set-up help for eating. The resident had no behaviors. The resident had functional Limitation in Range of Motion to one side of the lower extremities. Resident #548 was observed on 4/27/2021 at 11:58 AM in the resident's room sitting on the side of the bed. The resident stated that a choice was not given to the resident to self administer a nutritional supplement that the resident had ordered online. The Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order documented the resident has provided their own medication and the medication will be kept in the medication cart. The Registered Nurse Supervisor (RNS) #4 was interviewed on 4/29/2021 at 2:00 PM and stated the facility does not allow residents to take their own nutritional supplements. RNS #4 further stated the resident had communicated this concern to the Assistant Director of Nursing Services (ADNS). The ADNS, RNS #2, was interviewed on 5/3/2021 at 2:15 PM and stated residents cannot just order their own medications and take the medications or nutritional supplements without the physician's approval. When Resident #548 ordered the nutritional supplement, the staff took the nutritional supplement from the resident and explained that it would be kept on the medication cart until the Physician's approval. The resident was upset because of the facility policy. The Physician ordered the supplement to be kept on the cart. The ADNS stated that Resident #548 was not assessed to deternine if the resident could self administer the nutritional supplement. The Director of Nursing Services (DNS) was interviewed on 5/3/2021 at 11:45 AM and stated that residents are not allowed to self-medicate. The physician would not allow this resident to self-administer the nutritional supplement. The facility does not have a self-medication screening assessment to evaluate residents who want to self-medicate. 415.5 (b)(1-3)

Based on observation, record review, and interviews during the Recertification Survey completed on 5/4/2021, the facility did not ensure that all alleged violations of abuse were thoroughly investigated for 1 of 1 resident reviewed for Dignity. Specifically, the facility did not investigate an allegation of a Certified Nursing Assistant (CNA) attempting to photograph Resident #174 while disrobed. The finding is: The facility's Abuse, Neglect, and Mistreatment policy dated 1/5/2018 (revised on 1/2021) documented that the policy ensures that all patients will be treated with dignity, consideration, and respect at all times by employees. Any patient that reports fear or signs of abuse shall be evaluated by provider team as appropriate when a Patient verbalizes abuse, neglect or mistreatment. A full investigation of the incident will be done by the facility, immediately. When staff suspects that a patient is a possible victim of abuse, neglect, or mistreatment, the attending physician along with other relevant healthcare providers should be notified. Allegations against employees or other Healthcare Providers regarding patient abuse must be immediately escalated to the employee's supervisor. The supervisor must immediately informing the Administrator on Duty who must then immediately inform quality and nursing who will determine others who must be notified. The administrator on duty or a supervisor must immediately relieve the accused employee of responsibilities and either suspend pending investigation or place the employee on administrative leave pending the outcome of the investigation. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #174 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented that Resident #174 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The Behavior Care Plan (CCP) dated 4/26/2017 documented that Resident #174 exhibits confabulation and is easily agitated related to functional loss. Resident #174 gets easily aggravated with staff and confabulates stories. Resident #174 will [NAME] and puff and stare at aides in anger. Resident #174 accuses staff and saying things that staff has not said. Resident #174 gets angry very quickly. The care plan notes dated 2/5/2020 documented Resident #174 had accusatory behavior and alleged staff did not want to care for the resident. The [CONDITION(S)] Medication CCP dated 3/17/2017 documented that Resident #174 had Depression. The care plan note dated 11/26/20 documented Resident #174 was calm and cooperative with the plan of care. The nursing progress note dated 12/5/2020 at 11:10 AM, Licensed Practical Nurse (LPN) #5 documented that Resident #174 had a right groin open area and was seen by the Nurse Practitioner who ordered [MEDICATION(S)] (topical medication) twice a day. During the resident council meeting held on 4/27/2021 at 11:42 AM, Resident #174 stated that some CNAs would take their cell phones into the bathroom and bedroom area while providing resident care. Resident #174 expressed worry that there may be a person on the other end of the phone who will hear or see the resident they are providing care for. Resident #174 reported the concerns to the Registered Nurse (RN) Supervisor and the LPN. LPN #5 was interviewed on 5/4/2021 at 11:37 AM and stated that a few months ago CNA #9 attempted to use the cell phone to take a photo of Resident #174's groin area to show the LPN an abrasion in the skin folds. LPN #5 stated that CNA #9 was later fired but not for that reason. LPN #5 stated CNA #9 was given a verbal education on not using the phone in the care areas. LPN #5 stated that the RN Supervisor was made aware of the attempt to take a photo by CNA #9 but there was no investigation completed. LPN # 5 did not document the incident and thought the RN Supervisor would. Resident #174 was re-interviewed on 5/4/2021 at 12:55 PM and stated that on December 5th, 2020, a CNA (#9) was assisting the resident with cleaning the groin area while Resident #174 was seated on the toilet in the bathroom. While wiping the stomach folds over the groin, there was blood on the towel. The CNA (#9) then took out a cell phone and offered to take a photograph to show Resident #174 the wound. Resident #174 repeatedly told the CNA (#9) no and was shocked at the suggestion. Resident #174 stated that the CNA insisted and then offered to take a video. The CNA (#9) stated that it would be deleted afterwards. Resident #174 again said no and did not want any video or photo taken. Resident #174 stated that Resident #174 was not sure if any videos or photos were taken. Resident #174 felt horrible, nervous, and vulnerable. Resident #174 stated that immediately after the photo incident, Resident #174 informed LPN # 5. Resident #174 stated that the next day, the same CNA (#9) was assigned to Resident #174 again with an additional CNA. Resident #174 stated it did not make a difference in the experience because the original CNA (#9) insisted on handling Resident #174 without assistance and the other CNA was just standing there. Resident #174 stated that after that experience, Resident #174 requested that CNA (#9) not be assigned to the resident. Resident #174 thought the CNA (#9) was removed from the unit but on a 3pm-11 pm shift, the CNA once stood at the doorway and was glaring at Resident #174. Resident #174 felt fearful of the CNA (#9). The RN Supervisor was interviewed on 5/4/2021 at 2:02 PM and stated that the RN Supervisor works per diem for the unit. The RN Supervisor stated LPN #5 reported that Resident #174 did not like the way the assigned CNA #9 provided care. The RN Supervisor stated that LPN #5 did not inform the RN Supervisor of any attempt of CNA #9 taking a photograph of the resident while disrobed. The RN Supervisor reassigned CNA #9 for the rest of the shift. The incident was not documented . The RN Supervisor reported Resident #174's discomfort to the Assistant Director of Nursing Services (ADNS). The RN supervisor did not inform the next shift RN Supervisor. The RN Supervisor stated that they assumed that Resident #174 would inform the other staff members so that CNA #9 would not be assigned to Resident #174 again. The ADNS was interviewed on 5/4/2021 at 2:31 PM and stated that the ADNS did not investigate the allegation reported by the RN Supervisor and assumed that the RN Supervisor took care of it. The ADNS did not think a follow up investigation was necessary. The ADNS stated that if it was a bigger deal, Resident #174 would have reported it directly to the ADNS and Resident #174 did not make a formal grievance. The ADNS stated that Resident #174 is vocal about experiences and expected Resident #174 to directly report to the ADNS. The Director of Nursing Services (DNS) and the Administrator was interviewed concurrently on 5/4/2021 at 3:32 PM. The DNS stated that the RN Supervisor and the ADNS did not know about Resident #174's complaint regarding CNA #9 attempting to take photos and a video while disrobed in the bathroom. The DNS stated that Resident #174 is care planned for confabulation and generally reports that Resident #174 does not like the CNAs in general. Resident #174 has never made a complaint like this before and the DNS was not aware that Resident #174 had this specific concern about CNA #9. The Administrator stated that CNAs are not allowed to use the cell phone in resident rooms and it is not appropriate to take photos or videos of residents while providing care. The Administrator stated that LPN #5 should have documented the allegation made by Resident #174 and there should have been an investigation initiated. 415.4(b)(3)

Based on observation, interviews, and record review during the Recertification and Abbreviated Survey (NY 826) completed on 05/04/2021 the facility did not ensure each resident was given the appropriate treatment and services to maintain or improve their ability to carry out the Activities of Daily Living (ADLs). Specifically, Resident #61 had a Physical Therapy (PT) discharge assessment dated [DATE] that documented the resident could perform bed mobility tasks with minimum assistance with the use of side rails; however, the resident's half-side rails were discontinued on 2/24/2021 without an assessment to determine if the resident continued to require the use of half side rails to promote mobility. The finding is: The facility's policy and procedure titled Side Rails, dated January 2020, documented that it is the policy of the facility to ensure residents attain and maintain their highest practicable level of well being and be free from restraints and that the Registered Nurse (RN), based on assessment, will send a referral to the Rehab department to determine the residents' need for side rails as an enabler. Resident #61 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/11/2021 Quarterly Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS documented that the resident required extensive assistance of one person for bed mobility and extensive assistance of two persons for transfers. The admitting physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was discontinued on 2/24/2021 with the reason being no longer necessary. A Comprehensive Care Plan (CCP) effective 3/3/2020 titled, Side Rail Use-Non-Restraining had goals to the maintain current level of ADLs in the areas of bed mobility and transfer. There were no documented updates to the care plan. A nursing note dated 2/3/2021 documented the resident was referred to PT, and Occupational Therapy (OT) for changes in transfer status, bed mobility, dressing, and grooming. The resident had balance difficulty and decreased strength. An OT assessment dated [DATE] documented that the resident was referred to OT/PT by nursing for decline in ADLs and transfer status, requiring increased assistance from staff due to ill effects of Muscular Dystrophy (muscle weakness) and [CONDITION(S)] with associated muscle weakness. The resident was assessed by OT/PT and was placed on Restorative OT/PT services to maximize functional potential and safety with all areas of functional mobility and ADLs. A PT evaluation dated 2/3/2021 documented a long-term goal for rehab as follows: Patient will safely perform bed mobility tasks with minimum assist (Min (A)) with use of side rails for correct hand/foot placement, for task segmentation, and for proper sequencing in order to participate in edge of bed (EOB) activities. A quarterly Side-Rail assessment dated [DATE] documented that half side rails were needed for bed mobility and transfers and that the side rails would not restrict the resident's movement or exiting from bed. An Excel spreadsheet, dated 2/17/2021, provided by the Director of Rehab documented a list of residents' names who could have their siderails removed. Resident #61's name was on the list to have siderails removed. A PT discharge summary dated 2/18/2021 documented that the resident had achieved the goal of minimal assistance and will safely perform bed mobility tasks with use of side rails for correct hand/foot placement, for task segmentation and for proper sequencing in order to participate in edge of bed activities. On 4/26/2021 at 2:15 PM Resident #61's bed was observed. The resident was not present due to hospitalization on [DATE]. There were no side rails present on the bed. Certified Nursing Assistant (CNA #1) was interviewed on 4/28/2021 at 10:04 AM. CNA #1 stated when the side rails were removed from the bed the resident wanted them back because the resident was fearful about falling when turning in bed due to not having the siderails. CNA #1 stated the charge nurse was made aware. Licensed Practical Nurse (LPN #1), the charge nurse, was interviewed on 4/28/2021 at 10:07 AM and stated the nursing administration told her that the side rails were considered restraints. LPN #1 stated that the majority of side rails have been removed. LPN #1 further stated she was not aware of Resident #61's concerns related to the side rails. The Assistant Director of Nursing Services (ADNS) was interviewed on 4/30/2021 at 2:10 PM. The ADNS stated that a Registered Nurse (RN) completes the side rail assessment quarterly, but the decision is up to Rehab to make the final determination of whether a resident could benefit from side rails or if the side rails can be removed. The ADNS stated that Rehab generated a list of residents who did not require side rails. The Rehab Director was interviewed on 5/3/2021 at 2:46 PM and stated the removal of side rails throughout the facility was part of a Quality Assurance and Performance Improvement (QAPI) project because the perspective of the Director of Nursing Services (DNS) was that side rails were overused. The Rehab Director stated the rehab department was asked by nursing to assess side rail use. The Rehab Director stated rehab staff went around the facility, like an audit, to determine if residents could perform activities with or without side rails. The Rehab Director stated a list of names was generated of residents who could have side rails removed and the list was given to the maintenance department and the nursing department. The Rehab Director stated the list was generated on 2/17/2021 and stated that there was no documentation of these assessments. The Rehab Director stated that Resident #61 was on the list to have side rails removed. The Rehab Director reviewed the PT discharge assessment dated [DATE] that documented the resident required side rails for bed mobility. The DNS was interviewed on 5/4/2021 at 8:45 AM and stated that the removal of side rails was part of a QAPI project driven by the concern that there were too many side rails. The DNS stated that there were no documented assessments justifying the removal of side rails. The DNS stated emotional issues related to the removal of the side rails, such as the resident becoming fearful, were not assessed. The PT who completed the discharge summary on 2/18/2021 was interviewed on 5/4/2021 at 11:50 AM. The PT stated that Resident #61 met the rehab goal on 2/18/2021 and required the use of side rails to perform bed mobility. 415.12(a)(2)

Based on interviews and record reviews conducted during the Recertification Survey completed on 05/04/2021, the facility did not provide the necessary care and services to attain and maintain the resident's highest practicable well-being for one (Resident #550) of three residents reviewed for Quality of Care. Specifically, Resident #550 had a Pulmonary Consult dated 4/23/2021 that was not addressed by the attending physician in a timely manner. The findings is: Resident #550 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] documented the Brief Interview for Mental Status (BIMS) Score of 15 indicating the resident's cognitive status was intact. Review of nursing progress notes documented Resident #550 was seen by the Pulmonary Consultant on 4/23/2021 and documented the resident was noted with Shortness of Breath (SOB), Orthopnea (SOB while laying flat) and crackles likely due to [CONDITION(S)] (CHF). The resident will need to be aggressively treated with Diuretics (medication to help the body get rid of extra fluid). The recommendation was to start [MEDICATION(S)] (Diuretic) 40 Milligrams (mg) by mouth (po) daily (QD) and start [MEDICATION(S)] 2 puffs every 6 hours. The Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The attending Physician Note dated 4/25/2021 did not address the Pulmonologist recommendations made on 4/23/2021. The attending Physician was interviewed on 5/4/2021 at 12:23 PM and stated that the attending Physician was not aware of the Pulmonologist's recommendation until 4/27/2021. The attending Physician stated that the resident was seen by the attending Physician on 4/25/2021. The attending Physician was not aware that there was a Pulmonologist consult for review on 4/25/2021. On 4/27/2021 when the attending Physician became aware of the Pulmonologist's recommendation, [MEDICATION(S)] and [MEDICATION(S)] were then ordered. The attending Physician stated that the expectation was that the the attending Physician should have been notified of the Pulmonologist's recommendation after the resident was seen. The Pulmonologist was interviewed on 5/4/2021 at 11:30 AM and stated that the Pulmonologist examined Resident #550 and the resident required the recommended medications ([MEDICATION(S)] and [MEDICATION(S)]). The Pulmonologist further stated that the consult should have been addressed by the attending Physician within 1 to 2 days and that the 4 days wait was excessive. The Registered Nurse (RN) Supervisor #4 was interviewed on 5/4/2021 at 3:07 PM and stated that on 4/27/2021, the RN Supervisor noticed there was a Pulmonology consult completed for Resident #550 on 4/23/2021. The Pulmonologist normally provides a list of residents that are seen for consultation; however, the list was not provided to the Nursing supervisors or the Director of Nursing Services on 4/23/2021. When a consult list is provided, the RN Supervisor would review the consult and if there were any recommendations in the consult, the Physician would be notified for directions and orders. 415.12

Based on record review and staff interviews during the Recertification Survey completed on 05/04/2021, the facility did not ensure that the attending Physician must document in the resident's medical record that an irregularity identified by the Pharmacy consultant was reviewed and a rationale was documented for disagreement with the pharmacy consultant. This was identified for 1 (Resident #222) of 6 residents reviewed for unnecessary medications. Specifically, the Pharmacy Medication Regimen Review (MRR) documented a recommendation to stop the use of [MEDICATION(S)] ([MEDICATION(S)]) for Resident #222. The medical record lacked documented evidence of a Physician's rationale to address continued use of [MEDICATION(S)] for Resident #222. The finding is: Resident #222 was admitted with diagnoses that included Generalized Anxiety Disorder, Depression, and Agoraphobia (fear of open spaces) with panic disorder The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident's cognitive status was intact. The resident was taking antianxiety and antidepressant medications 7 of 7 days during the assessment look back period. The Physician orders dated 3/13/2021 documented [MEDICATION(S)] (Prozac) 40 Milligrams (mg) capsule- give 1 capsule (40 mg) by oral route once daily in the morning for Depression; [MEDICATION(S)] (Xanax) give 1 tablet (1 mg) by oral route every 8 hours; and [MEDICATION(S)] ([MEDICATION(S)]) 25 mg at bedtime. The Pharmacy MRR dated 4/14/2021 documented, Currently receiving [MEDICATION(S)] without a stop date. Long-term use is not recommended due to the high incidence of anticholinergic side effects. Please evaluate the continued need and add stop date x 1 week. The physician disagreed, did not sign the MRR, and did not document a rationale why the Physician disagreed with the Pharmacist's recommendation in the resident's medical record. The Physician was interviewed on 5/3/2021 at 12:53 PM and stated the Physician disagreed with the pharmacy consult to discontinue [MEDICATION(S)] because the resident has severe pruritus (itchiness). The Physician further stated he should have documented a rationale in the medical record to continue the use of [MEDICATION(S)] for Resident #222. 415.18(c)(2)

Based on observation, record review, and interviews during the Recertification Survey completed on 05/04/2021, the facility did not ensure that each resident remains free of [CONDITION(S)] drugs unless the medication is necessary. This was identified for 1 (Resident #498) of 6 residents reviewed for unnecessary medications. Specifically, Resident #498 with a diagnosis of Dementia was prescribed [MEDICATION(S)] (an antipsychotic medication) XR (extended release) for Agitation for behavior management. The finding is: The facility's policy, dated 9/4/2018 and revised on 10/2020, documented that residents displaying symptoms of a psychiatric disorder and/or behavioral symptoms shall have non-pharmacological interventions planned and carried out prior to psychiatric intervention. The manufacturer's safety information for [MEDICATION(S)] XR documented that elderly patients with dementia-related [CONDITION(S)] (having lost touch with reality due to confusion and memory loss) treated with this type of medicine are at an increased risk of death, compared to placebo (sugar pill). [MEDICATION(S)] XR is not approved for treating these patients. Resident #498 was admitted to the facility with diagnoses including Non-Alzheimer's Dementia, Anxiety Disorder, and Malnutrition. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #498 had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderately impaired cognition. The MDS documented that Resident #498 did not have indications of [CONDITION(S)] including hallucinations and delusions. The MDS also documented that Resident #498 did not have any behavioral symptoms, rejection of care, and wandering. Additionally, the MDS documented that Resident #498 received antianxiety medication for 6 of 7 days and antipsychotic medication 0 of the 7 days in the look back period. The physician's orders dated 4/6/2021 documented a request for a Psychiatrist Consultation. The Physician's orders dated 4/7/2021 documented [MEDICATION(S)] 5 Milligram (mg) give 1 tablet once daily in the evening for Unspecified Dementia with Behavioral Disturbance. Additionally, the physician's orders documented [MEDICATION(S)] 0.25 mg at 9:00 AM and 9:00 PM for Anxiety Disorder unspecified. The Physician's orders dated 4/15/2021 documented for the Registered Nurse (RN) Supervisor to check the wander guard every week on Sunday for placement and functionality. The Physician's orders dated 4/23/2021 documented Psychiatric consult to address Resident #498 being verbally aggressive toward staff, up all night accusing family member/staff of stealing from her, attempting to leave, and packing a suitcase multiple times. The Physician's order also documented [MEDICATION(S)] 25 mg give 1 tablet oral route 2 times per day without a diagnosis or indication for use. The Physician's orders dated 4/30/2021 documented Psychological Evaluation: reason: Emotional. The Physician's order also documented [MEDICATION(S)] 25 mg, give 1 tablet by oral route 2 times per day for agitation for behavior management. The Wandering/Elopement Risk Comprehensive Care Plan (CCP) dated 4/15/2021 documented Resident #498 had wandering, pacing and elopement behavior due to Dementia, Depression, Anxiety, and increased confusion. Interventions included placement of a roam alert bracelet and wander guard on the right ankle. The [CONDITION(S)] Medication CCP dated 4/16/2021 documented that Resident #498 takes antianxiety medication related to Dementia with behavior for the psychiatric disorder of Anxiety. Interventions included to administer medication per Physician's order, monitor for changes in behavior, functional status, side effects of medications, and the resident's response to medication. The Behavior CCP dated 4/23/2021 documented Resident #498 had verbal behavior symptoms, screaming at others, behaviors not directed towards others, verbal disruption, excessive agitation, and resistance to care. The resident had poor safety awareness, sundowning, motor restlessness, easily agitated and poor impulse control. The behaviors had mild-moderate intensity and the duration of behaviors varied. The behaviors were related to the medical condition of Dementia. Interventions included to assess behavior patterns for causative factors, develop/implement a behavior management plan created with the resident's input when able to participate, and provide psychiatric evaluation and treatment. The Care Plan Monitoring notes documented Resident #498 had behaviors of wandering on the unit, roaming in and out of resident's rooms, easily agitated, and resistant to care. Resident #498 was noted to be by the elevator doors stating that Resident #498 wanted to go home. Roam alert was in place to monitor safety, 1:1 provided, support and reassurance provided. The Certified Nursing Assistant Accountability Record (CNAAR) from 4/5/2021 to 4/30/2021 documented Resident #498 resisted care 16 of 25 days, displayed frequent crying/tearfulness 11 of 25 days, Yelling/Screaming 3 of 25 days, and Wandering 11 of 25 days. The progress note dated 4/23/2021 documented that Resident #498 was having behaviors, required 1:1 attention, did not sleep all night and was trying to get on the elevator repeatedly. Resident #498 was on [MEDICATION(S)] 0.25 mg twice a day and [MEDICATION(S)] 7.5 mg. A new order for [MEDICATION(S)] 25 mg twice a day was received, the [MEDICATION(S)] was discontinued, and a Psychiatric evaluation was pending. The Medical Progress Note dated 4/23/2021 documented that Resident #498 was awake, alert, very confused, responsive, and pleasant. The physician documented that Resident #498 had unstable behavior including anxiousness and was trying to leave as per the nurse. The physician documented that the treatment plan included to continue [MEDICATION(S)] 5 mg for Dementia with Behavior, to discontinue [MEDICATION(S)] and to start [MEDICATION(S)] 25 mg twice a day for unstable depression, and to continue using [MEDICATION(S)] 0.25 mg twice a day. The Psychiatric evaluation was pending. The Medication Administration Record for April 2021 documented that Resident #498 received [MEDICATION(S)] 25 mg two times per day from 4/23/2021 to 4/30/2021. The Psychological evaluation dated 4/30/2021 documented that Resident #498 had a primary psychological diagnosis of Adjustment Disorder with mixed disturbance of emotions and conduct. The current/past psychiatric diagnoses section of the evaluation documented that there was no known significant mental health or substance abuse history and the records indicated diagnoses of Dementia, altered mental status and anxiety. The mental status section of the evaluation indicated that Resident #498 had no psychotic symptoms. The psychologist documented that Resident #498 was able to converse fairly well, however the Resident's memory was poor and appeared to confabulate in an effort to conceal limitations. Resident #498 did not recall having been upset during a night last week which included yelling, packing personal items and attempting to elope from the facility. The 7:00 AM-3:00 PM Licensed Practical Nurse (LPN #4) on the Cedar Unit was interviewed on 4/30/2021 at 12:29 PM. LPN #4 stated that Resident #498 used to reside on the Cedar Unit. Resident #498 was pleasant but was very anxious about being in the facility due to unfamiliarity with the staff. LPN #4 stated at one point, Resident #498 would just pack the suitcase and roll down the hallway. LPN #4 stated that Resident #498 was never combative or challenging during care. The 3:00 PM- 11:00 PM LPN (#3) on the Dogwood Unit was interviewed on 4/30/21 at 3:58 PM. LPN #3 stated that Resident #498 is new to the Dogwood Unit and has lived there for about a week. Resident #498 is often sad and tearful. LPN #3 stated that the resident is always asking for family, can be confused about where she is and why she is here. Resident #498 has been responsive to the approach in care and is not combative or behaviorally challenging. The 11:00 PM-7:00 AM Certified Nursing Assistant (CNA #3) on the Cedar Unit was interviewed on 5/3/2021 at 2:29 PM. CNA #3 stated that Resident #498 used to live on the Cedar Unit and CNA #3 was assigned to provide care for the resident. Resident #498 cried a lot and wanted attention. If medication would not come to Resident #498 fast enough, Resident #498 would get angry and scream. Resident #498 did not have these behaviors every day. CNA #3 would talk to Resident #498 and offer tea when Resident #498 was upset. Resident #498 usually would calm down with the CNA #3's interventions. The 3:00 PM-11:00 PM CNA (#2) on the Cedar Unit was interviewed on 5/3/2021 at 2:49 PM. CNA #2 was assigned to provide care to the resident. Resident #498 was very depressed, always calling for a family member. Resident #498 liked to be talked to and was responsive to CNA #2's approach in care. Resident #498's behavior never escalated while CNA #2 provided care. The 3:00 PM-11:00 PM LPN (#2) on the Cedar Unit was interviewed on 5/3/21 at 3:34 PM. LPN #2 stated that she was the regular LPN on the Cedar Unit when Resident #498 resided there. LPN #2 stated that Resident #498 was constantly wandering and did not know what was going on. Resident #498 was often crying. Resident #498 liked to talk and would calm down when LPN #2 took the time to talk. The Physician was interviewed on 5/4/2021 at 10:07 AM. The Physician stated that Resident #498 did not receive a Psychiatric consultation to determine the appropriateness of the [CONDITION(S)] medications. The Physician stated that another order for a psychiatric consultation will be placed. The Physician stated that he knows of the manufacturer's warning against using [MEDICATION(S)] for Dementia. The Physician stated that Resident #498 was treated with [MEDICATION(S)] to address Depression and Agitation associated with Dementia despite the warning. The Physician stated that Resident #498 was noted to attempt to elope the facility and the Physician was concerned for Resident #498's safety. The Physician further stated that there were no other interventions available to prevent elopement and the medication would help restrict Resident #498's ability to elope from the facility. The Director of Nursing Services (DNS) was interviewed on 5/4/2021 at 5:09 PM. The DNS stated the facility's policy is to assess the resident and ensure that non-pharmacological interventions are attempted prior to introducing [CONDITION(S)] medications. The nursing staff should inform the attending physician that a referral for a Psychological or psychiatric consultation should be made in order to further assess the resident's clinical presentation. The DNS stated that the facility has been having a hard time getting Psychiatrists to visit the facility due to COVID-19. The DNS stated that professionally, she knows that the antipsychotic medication is not indicated for Dementia, but the physician makes the final determination of the medication regimen. 415.12(l)(2)(i)

Based on record review and staff interviews during the Recertification Survey completed on 5/04/2021, the facility did not ensure that outside professional services were furnished in a timely manner for one (Resident #222) of 6 residents reviewed for unnecessary medications. Specifically, Resident #222 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The finding is: Resident # 222 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set Assessment (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 that indicated the resident's cognitive status was intact. The Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The medical record lacked documented evidence that a Psychiatry consult was completed as of 4/29/2021. The Comprehensive Care Plan (CCP) dated 3/13/2021 for [CONDITION(S)] Drug Use documented the resident was on Antidepressants related to Depression. Interventions included to provide Psychiatric evaluation and treatment. The Physician was interviewed on 5/3/2021 at 12:53 PM , an order was placed for a Psychiatry consult on 3/13/2021. The Physician did not know why the Psychiatrist consult was not done until 4/29/2021. The Physician stated that the Psychiatrist consult should have been done sooner due to use of the [CONDITION(S)] medications and the resident's diagnoses. The Registered Nurse (RN) Supervisor #5 was interviewed on 5/4/2021 at 3:32 PM and stated RN #5 admitted Resident #222 and the Psychiatrist and other consults that were ordered by the Physician were were entered into the Electronic Medical Record system. It has been difficult getting consultants to come into facility. Resident #222 does have anxiety issues and the resident should have been seen sooner then 4/29/2021 by the Psychiatrist . The Director Nursing Services (DNS) was interviewed on 5/4/2021 at 5:45 PM and stated there was a problem scheduling Psychiatrists to come to the facility. The the resident should have been seen sooner once a consult was ordered. 415.26(e)(i-iv)

Based on record review and staff interviews during the Recertification Survey completed on 05/04/2021, the facility did not maintain accurate Electronic Medical Records (EMR) for one (Resident # 550) of 70 sampled resident records. Specifically, EMR system used by the facility erroneously deleted a consultation note that was written by the Pulmonologist consultant on 4/23/2021 when a correction update to the consult was made by the Pulmonologist on 4/28/2021. The finding is: Resident #550 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident's cognitive status was intact. Review of Nursing progress notes documented Resident #550 was seen by the Pulmonologist on 4/23/2021 with recommendations. The Pulmonologist note dated 04/28/2021 documented a correction to the 4/23/2021 note indicating that the medications recommended on 4/23/2021 by the Pulmonologist were non-urgent. The 04/28/2021entry by the Pulmonologist to update the 04/23/2021 note erroneously deleted the 4/23/2021 note from the EMR. The Director of Nursing Services (DNS) was interviewed on 05/14/2021 at 2:37 PM and stated that the 4/23/2021 note should not have been deleted and the EMR vendor will be contacted to correct the issue. The Administrator was interviewed on 5/4/2021 at 5:45 PM and stated that when a clinician is correcting the notes in the EMR it should not delete the previous entries and the EMR vendor will be made aware. 415.22(a)(1-4)

Based on record review and staff interviews during the recertification survey # NY 583, the facility did not ensure that a thorough investigation was conducted for one of three residents reviewed for Abuse. Specifically, Resident #1 was found with a reddened bruise to the face on January 4th, 2020. The facility did not obtain statements 72 hours prior to the incident to rule out abuse/neglect. Furthermore, statements revealed that resident # 1 had a bruise on January 3rd, 2020. There was no investigation to ascertain why the investigation and or Accident/Incident was not initiated earlier and reported to administration on January 3, 2020. The finding is: Resident # 1 was [AGE] years old admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) dated [DATE] documented the resident with BIMS 99 - indicating Resident was unable to complete the interview. The resident had a short-term memory problem and intact long-term memory. The resident required extensive assistance of 2 staff members for bed mobility and transfers, toilet use and bathing. Resident was non ambulatory. Resident was always incontinent of bowel and bladder. The progress notes documented: On 1/4/20- Approximately 930 AM, the Registered Nurse (RN) Supervisor documented -Called by unit nurse to assess bruise on right cheek of patient. Upon assessment, patient noted lying in bed with purplish red area to right cheek (shaped like a backward checkmark), with slightly diffused redness under right eye. Area measures 8 centimeters (cm) x 2 cm. No swelling or warmth noted at site. Skin intact, no active bleeding. Patient is on [MEDICATION(S)] daily, Denies pain and discomfort. Poor historian, reports I'm fine when asked about face. On 1/4/20 at 1035 AM, the Licensed Practical Nurse ( LPN) # 9 documented: Resident alert and verbal. Around 9:30 AM the Certified Nurse Assistant (CNA) called this writer in the room to look at the resident right cheek, which appeared to have a red bruise shaped like a backwards checkmark, no swelling noted. Unknown origin. Resident had no complaints of pain or discomfort. Incident report and statements was filled out. Supervisor came to assess the resident. The assigned Physician Assistant documented on 1/6/20 at 134 PM: Resident is [AGE] years old who was seen 1/6/2020 to follow up for R sided cheek swelling and discoloration x 3 days. Resident has minimal speech but when asked if he had a fall, he stated no, made his R hand into a fist, then put it to his right cheek. Resident then said bye, indicating he didn't want to speak about it anymore. Nursing manager informed of resident's actions. Resident on [MEDICATION(S)], not likely to be contributory. A Comprehensive Care Plan (CCP) dated 3/10/19 for Residents physical aggression, prevention of Abuse was in place. An Accident/ incident (A/I) investigation was initiated upon allegation of Abuse dated January 4th, 2020. Statements were received by staff. However, the facility failed to provide statements 72 hours prior to the incident when it was reported. The facility A/I documented they obtained statements 72 hours prior to the injury being found. The facility was unable to provide statements for staff that worked 72 hours prior to the incident. The facility documented they were unable to substantiate abuse had occurred. The investigation documented the resident was unable to identify the person who hit him. The facility also documented that they interviewed staff and obtained statements who took care of the resident from December 31st, 2019. This was not found in the investigation. The Resident's roommate who is alert and oriented was interviewed by the supervisor on duty. Roommate stated he heard noise like a thump and an aide told Resident not to do that. The Roommate did not hear Resident scream or yell- it sounded like Resident was hitting staff. The report concluded that the resident has a history of aggression towards staff and other residents. The resident has history of throwing himself on the floor and the resident has a tendency sleep leaning on his side rail in his bed, potentially causing redness bruise to the face accidentally. The investigation did not include statements from all staff that was in contact with the resident 72 hours prior to the incident. There were statements missing from RN Supervisors, LPNS and CNAS. An undated Policy and Procedure for abuse Prevention documented under investigation that all reports of resident abuse neglect and injuries of unknown origin are promptly and thoroughly investigated. The Administrator, Director of Nursing Service (DNS) or designee is to be informed of a suspected abuse regardless of the time of day or day in a week and the investigation begins at the knowledge of the suspected of abuse. The Administrator, DNS or designee investigates in accordance with the facility abuse investigation procedure, interview guidelines of privacy and confidentiality are followed as per abuse investigation procedures. A Policy and Procedure for Injuries of Unknown origin revised January 2020 documented that the name of witnesses and statements will be obtained 72 hours prior to the injury being found. Staff (#1-#10) assigned to the resident between 1/3/20 to 1/4/20 were interviewed between 8/13/20 to 8/17/20 at various time. Staff (CNAS and LPNS) interviews correlated with statement documentations provided in the investigation. Certified Nurse Assistant (CNA) # 1 interviewed on [DATE] at 2:30 PM and stated he notice a red area to the resident's face when he worked on January 4 2020 and reported it to the LPN. The CNA further stated that this resident used to rest his face against the side rail. The CNA also stated that the resident was difficult but worked well with CNA #1. LPN #2 was interviewed on 8/17/20 at 1:30 PM. She confirmed that the statement she submitted was what occurred. The statement documented the CNA called her into the room to look at the resident's right cheek which showed a red bruise. She stated there was nothing unusual that occurred prior to the finding. LPN #2 statement documented that the resident told her someone punched him in the face. Speech was unclear. The resident told her the incident happened during the 3:00 PM to 11:00 PM shift. The LPN stated she reported this to the supervisor and then incident report was initiated. LPN # 3 was interviewed on 8/17/20 at 2:45 PM. Her statement documented she went into the room to help the CNA on January 3rd, 2020 and remembered seeing some redness to the residents face. The LPN was asked about this statement and why was this not reported to her supervisor on January 3. She replied that she could not recall. She stated this should have been reported to the supervisor on January 3, 2020 and an investigation should have been initiated. CNA #4 was interviewed on 8/13/20 at 12:30 PM. CNA #4 stated he did not take care of the resident on the day of the incident but took care of him before on January 3rd 2020. The CNA stated that the resident was difficult and whenever care was provided to the resident, he made sure that the curtain between the resident is open so that the roommate witnesses the care provided to the resident. The CNA stated that there wasn't anything to report when he took care of the resident on January 3rd, 2020. CNA #5 was interviewed on 8/17/20 at 2:00 PM and stated she submitted her statement. She did not hear anything unusual when she was assigned to work with the resident on January 3rd 20 on the 3:00 PM today 11:00 PM shift. He provided statement to the facility. LPN # 6 was interviewed on 8/17/20 at 1:30 PM and stated she worked overnight the night January 3rd to the morning of January 4th. and did not notice any redness. CNA # 7 was interviewed on 8/17/20 at 130 PM and stated she worked overnight January 3rd to January 4th and does not recall the resident. She worked per diem and started working with the facility since November 2019. Stated she doesn't recall submitting any statements for the resident. NO statements by CNA # 7 was obtained by the facility. LPN # 8 was interviewed on 8/17/20 at 1:45 PM and stated she could not recall what occurred and further stated she provided a statement and recalled the resident being resistive to care at times. LPN # 9 was Interviewed on 8/17/20 at 3:45 PM and stated when she received report from the CNA that he had a reddened, area she initiated an investigation report. She further stated that the resident was quiet prior to the finding and she could not recall anything unusual before he was found with the reddened area to the face. LPN # 10 was interviewed on 8/13/20 at 3:45 PM and stated when the CNA found the resident with the reddened area and he initiated the accident /incident report. There was no negative behavior exhibited by the resident prior to the resident being found with the reddened area to the face. He could not recall if a statement was submitted. LPN # 10 sstatement was not found in the investigation. The resident's roommate was interviewed on 8/13/20 at 12:30 PM and stated he recalls the incident. He recalls the day before the resident was found with a bruise to the face. He stated the resident was giving staff a hard time. He stated the resident was rough with staff. The Director of Nursing (DNS) services was interviewed on 8/21/20 at 11 AM and stated she was not the DNS when the resident was found with this injury and stated per policy an injury of unknown origin, statements are to be collected 72 hours before the injury was found to rule out abuse and neglect. She also stated staff who found the injury on January 3, further investigation should have been initiated on that date and those statements should have been further investigated to determine why staff had not reported that on January 3, 2020. All staff hired are in serviced for abuse and neglect. 415.4(b)(l)(ii)

Based on observation, interviews, and record review during a COVID-19 Focused Infection Control Survey (NY 236) conducted on 8/13/20 to 8/14/20, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #8) of 8 Residents reviewed. Specifically, Certified Nursing Assistant (CNA) #3 provided direct care to Resident #8 on 8/10/20. CNA #3 tested positive for COVID-19 on 8/12/20. The facility did not identify Resident #8 as being exposed and did not place the resident on the transmission-based precautions. The findings were: The facility's policy titled Coronavirus Disease 2019 (COVID 19) Prevention and Detection updated 6/10/20 documented the facility will conduct regular surveillance of resident and employee infectious diseases and track any infection/illness. The Rapid [DIAGNOSES REDACTED] Cov 2 COVID-19 [MEDICATION NAME] result for CNA #3 dated 8/12/20 documented positive. Resident #8 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognitive status as severely impaired. The Admission/Discharge/Transfer (ADT) history documented Resident #8 was moved from Peach to Dogwood unit on 8/10/2020. The Certified Nurse's Aide Documentation History dated 8/10/20 documented CNA #3 provided care to Resident #8 including bathing, bed mobility, dressing, eating, personal hygiene, transfer, toilet use, and locomotion. The medical records for Resident #8 lacked documented evidence for Contact/Droplet precautions before and after exposure to CNA #3. On 8/14/20 at 4:32 PM the Director of Nursing Service (DNS) was interviewed with the Registered Nurse Infection Preventionist. The DNS stated CNA #3 worked on the Peach unit on 8/10/20 and was assigned to Resident #8. On 8/12/20, DNS was notified that CNA #3 was positive for COVID-19. The DNS stated that all residents on the Peach unit were placed on Contact and Droplet Precautions and were swabbed. The DNS stated that she was responsible for surveillance/contact tracing and did not identify Resident #8 as being exposed to CNA #3. In addition, she stated that the facility should have traced all residents who came in contact with CNA #3 in the last 72 hours and should have placed those residents on Contact and Droplet Precautions. The DNS stated that Resident #8 should have been tested for COVID-19 and placed on quarantine for 14 days. On 8/14/20 at 5:26 PM the Medical Director (MD) was interviewed via phone and stated Resident #8 should have been tested and placed on quarantine for 14 days. 10 NYCRR 415.19(a)(2)

Based on record review and interviews during the Complaint survey, the facility did not ensure sufficient nursing staff to provide the services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 of 8 nursing units. Specifically, Resident # 1 had intact cognition and was dependent on staff for Activities of Daily Living (ADL). The resident was not provided care according to his needs in a timely manner and was not gotten out of bed until 1:20 PM due to insufficient staff. The findings were: Resident # 1 was [AGE] years old with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented intact cognition for the resident. The resident required total dependence of 2 staff members for bed mobility and transfers. The Resident was non- ambulatory and was totally dependent on staff for dressing, personal hygiene, eating, and toilet use. There was 1 stage 4 pressure ulcer documented. On 4/13/19 at 1:20 PM, the Resident was observed in bed, lying on his right side. The resident was awake. There were no odors. The resident was in a single room. The Resident was interviewed and stated he has not been out of bed yet despite asking to get out of bed earlier in the shift. He further stated the staff did not provide his ADL care. The resident was hoping he was transferred out of bed to eat lunch. He was told the unit was short-staffed and staff could not get him out of bed earlier in the shift. He also stated that as of 1:20 PM, his [MEDICAL CONDITION] bag was not been emptied. The Facility assessment dated [DATE] did not include an assessment of the acuity of care and the number of staff required to care for the residents on each unit. The staffing assignments dated 4/13/19 was reviewed. On the Orchard unit, 1 Licensed Practical Nurse (LPN) was transferred to another unit (Dogwood) due to a call in. 1 Certified Nurse Assistant (CNA) called in without a replacement. The unit had 1LPN and 4 CNAs to care for 38 residents. The CNA was interviewed on 4/19/19 at 1:30 pm and stated she was not able to provide AM care (ADL care) to the resident as of 1:30 PM on that date. She stated she went in earlier that day to empty his Foley bag and told him that she could not transfer him out of bed earlier due to staffing. We are short. I can't give him AM care now (at 1:30 PM) because I have to feed another resident. After I feed my resident, I will give him (Resident #1) AM care, with a male CNA and then transfer him out of bed. The Registered Charge Nurse was interviewed on 4/19/19 at 1:35 PM and stated 2 CNAs had called in on the unit. The unit was supposed to have 5 CNA's. We were able to replace 1 CNA. The unit had 4 CNAs to care for 38 residents. One LPN on the unit also called in. We were not able to replace the nurse that called in. The LPN on the unit was assigned to administer medications and be an in-charge on the unit. The Director of Nursing Services (DNS) was interviewed on 4/19/19 at 3:15 PM and stated the ideal staffing for the unit should be 5 CNAs. Four CNAs could complete their assigned residents. The Resident should not have had to wait till after lunch to get out of bed, although sometimes it is the resident's choice not to get out of bed. We are constantly recruiting. We were not able to find a fifth CNA for that unit on 4/13/19. 415.13(a)(1)(i-iii)

Based on record reviews, observations and staff interviews during the recertification survey (Complaint # NY 75), the facility did not ensure that a system of records was maintained to account for all controlled drugs to prevent loss or diversion. This was evident for 1 of 3 resident's reviewed for pharmacy services. Specifically, Resident # 2 was administered Narcotic medications (MS Contin) without an accurate reconciliation of the narcotic record. The findings were: Resident #2 was admitted [DATE] with a [DIAGNOSES REDACTED]. The Minimum Data Set Assessment (MDS-an assessment tool) dated 9/4/18 documented the Brief Interview for Mental Status (BIMS) score as 15 indicating intact cognition. The MDS also documented that the resident rarely had mild pain and was on a pain regimen. The physician's orders [REDACTED]. 1 tablet (30 mg) by oral route every 12 hours. The Patient Controlled substance administration record (IPC) documented [MEDICATION NAME] mg ER was dispensed on 7/15/18 for 20 tablets. The last tablet in the blister pack was used on 7/25/18 at 9 pm. The Medication Administration Record [REDACTED]. A Narcotic Script Log for (MONTH) (YEAR) documented a triplicate dated 7/26/18 for MS Sulfate 30 mg for the resident. Another triplicate was logged on 7/29/18 for [MEDICATION NAME] tab, twice daily (bid). The facility lacked documented evidence of the IPC for the [MEDICATION NAME] packs from 7/26/18 through 7/30/18 at 10 AM for the resident. The MAR indicated [REDACTED]. The IPC dated 7/30/18 documented a blister pack of [MEDICATION NAME] mg, 10 tablets was received on 7/30/18. The first tablet of [MEDICATION NAME] mg was given at 10 pm on 7/30/18. The Licensed Practical Nurse # 1 (LPN) was interviewed on 4/16/19 at 5:19 PM and stated that she gave the resident his own medication on 4/26/18 at 10 PM. She recalled there was an order and she wouldn't give the medication without an order. It was possible the RN told her to give the resident his own medication and she would obtain the order. On 4/20/19 at 5:45 PM, LPN # 1, further stated she had not administered the [MEDICATION NAME] the resident on 7/28/18 and 7/29/18 because the medication was not available in the facility. She stated on 7/28/18 the resident was comfortable and did not require pain medication. On 7/29/18, the resident complained of pain. LPN #1 called the physician and obtained an order for [REDACTED].>The Director of Nursing Services (DNS) was interviewed on 4/15/19 at 6:05 PM and stated she reviewed the Narcotic log and discovered that the physician had ordered MS Sulfate in error on the triplicate instead of MS Contin. The pharmacy had not dispensed the medication because the triplicate did not match the physician order. The resident had not received his pain medication (MS Contin) because the medication was not in the facility until 7/30/18. On 4/16/19 at 5:20 PM, the DNS stated the nurses should not be giving resident's own medication without a physician order. She was unable to find an Individual Patient Controlled substance administration record (IPC) for [MEDICATION NAME] from 7-26-18 to 7-30-18. The Pharmacist was interviewed on 4/16/19 at 4 PM and stated that pharmacy received a triplicate dated 7/26/18 on 7/28/18 at 12:21 PM for MS Sulfate. The Script did not reflect the physician order [REDACTED]. The pharmacy staff called the facility on 7/28/18 at 1:43 PM and reported this to the nurse (name not recalled). The next triplicate for [MEDICATION NAME] not received until 7/29/18. The medication was delivered on 7/30/18 at 12:03 PM. 415.18(d)

Based on observation, record review, and interviews during the Recertification Survey the facility did not ensure that residents with limited ambulatory ability received appropriate services to maintain or improve ambulatory ability for 3 (Resident #'s 106, # 116, and # 114) of 3 residents reviewed for Mobility. Specifically, Resident #'s 106, # 116, and # 114 had physician's orders [REDACTED]. The findings are: The facility's undated policy titled Restorative Nursing Program documents the Restorative Nursing Program will be provided by Restorative Nursing CNAs and/or unit CNAs supervised by a Restorative Nursing Coordinator. Each resident on the Restorative Nursing Program will have measurable objectives and interventions documented in the care plan and in the clinical record. The Restorative Nursing CNAs and/or unit CNAs will document interventions provided daily on the residents' medical record. 1) Resident #106 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 3/27/2019 Quarterly Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 5, indicating the resident had severe cognitive impairment. The MDS documented the resident required extensive assist of two staff members for transfers, extensive assist of one staff member for walking in room, walking in the corridor only occurred once or twice, and the resident was only able to stabilize while walking with staff assistance. A Physical Therapy (PT) discharge assessment dated [DATE] documented recommendations that nursing staff was educated on Restorative Nursing Program/Floor Ambulation Program RNP/FAP: FAP 50 feet with rolling walker, assist x 1 with wheelchair to follow BID. A physician's orders [REDACTED]. A PT progress note dated 4/9/19 documented that the patient has been placed on a nursing rehabilitation (rehab) program to maintain current level of function. The primary CNA and nursing staff were educated on RNP program and techniques to encourage participation with ADLs on the unit. A Comprehensive Care Plan (CCP) effective 3/21/19 titled Activities of Daily Living (ADL) Support Services had an intervention added on 4/9/19 for RNP/FAP: FAP 50 feet with rolling walker, assist x 1 with wheelchair to follow BID. The Certified Nursing Assistant (CNA) Resident Nursing Instructions had an instruction added on 4/9/19 for RNP/FAP: FAP 50 feet with rolling walker, assist x 1 with wheelchair to follow BID. The schedule was every day between 8 AM-4 PM. Resident #106 was interviewed on 4/29/19 at 11:07 AM. The resident was in his wheelchair in his room. The resident stated that he does not walk every day. He stated that he walks maybe once or twice a week. Review of the CNA Accountability Record (CNAAR) from 4/9/19 (date of physician's orders [REDACTED]. The resident's 7 AM-3 PM CNA was interviewed on 4/29/19 at 1:32 PM. This CNA documented Not Performed for Nursing Rehab Walking on 4/23/19, 4/24/19, 4/25/19, 4/26/19 and 4/29/19. She stated the resident was discharged from Physical Therapy (PT) and Occupational Therapy (OT) and stated the resident does not walk. She stated that the resident was an assist of two staff members for standing transfer but now requires a Serita lift to stand, so therefore he cannot walk. She stated the resident was on a FAP, but she has not seen the restorative CNAs come to the unit. She stated if she does not see the restorative CNAs on the unit, she documents not performed under the 8 AM-4 PM documentation. She stated that if the resident does not walk, she will let the charge nurse know. The CNA stated the resident has a urinary catheter, so he does not need to use the bathroom for urination and the resident can make his needs known regarding bowel movements, but due to the difficulty of maneuvering the Serita lift in the room, it is easier to take the resident to the unit bathroom with his wheelchair. She further stated there is no walking involved. The PT and the Rehabilitation Department Director were interviewed concurrently on 4/29/19 at 2:27 PM. They stated the resident was on OT and PT services and was discharged on [DATE] to the FAP feet twice a day. They stated at the time of discharge the resident did not need a Serita lift. They stated the resident was re-assessed by PT today (4/29/19) and the resident is still able to transfer without the use of a Serita. The use of the Serita is a nursing decision. They stated the FAP is done by CNAs on the unit or the restorative CNAs. They stated the restorative CNAs are different than the unit care CNAs and there are two restorative CNAs in the facility on the 8 AM-4 PM shift. Either the restorative CNAs or the unit care CNAs document on the CNAAR. They stated there is no reason why the resident should not be walking. The two restorative CNAs were interviewed concurrently on 4/30/19 at 10:37 AM. They stated they receive the assignment for residents on the RNP/FAP from the Rehab Coordinator and it is the responsibility of the unit CNAs and the restorative CNAs to do the FAP. They stated there is a problem with the electronic medical record. The unit CNAs leave at 3 PM and must complete their assignments in the CNAAR, including the 8 AM-4 PM Nursing Rehab Walking. They stated that by the time they attempt to document the Nursing Rehab Walking it is already greyed out and it cannot be overridden. They stated they cannot override or see what the unit CNA documented. They stated Resident #106 did not walk yesterday (4/29/19) because the restorative CNAs were off and there are no other restorative CNAs. In addition, they stated they go home at 4 PM and there are no restorative CNAs working in the evening. The unit Registered Nurse (RN) supervisor was interviewed on 4/30/19 at 11:38 AM. He stated the restorative CNAs are not the only staff that can walk with the resident. He stated any nursing staff member can walk with the resident. Resident #106 was observed walking on 4/30/19 at 11:44 AM with the two restorative CNAs. The resident transferred from the wheelchair with the assist of one of the CNAs and the rolling walker. The resident walked approximately 60 feet. The Director of Nursing Services (DNS) and Rehab Director were interviewed concurrently on 4/30/19 at 12:01 PM. The Rehab Director said that if a resident requires more help with walking, they will be assigned to restorative CNAs because the units CNAs have other care tasks and getting two unit CNAs available to walk with a resident may be difficult. The residents that have the restorative CNAs are assigned by the Rehab Coordinator. The DNS stated the system needs clarification. The RN Rehab Coordinator was interviewed on 4/30/19 at 2:19 PM. He stated the Rehab Department lets him know the residents that require the restorative CNAs and he gives the list to the restorative CNAs. He stated the CNAs must report back to him if the residents are walking or not and if he does not get any feedback from the CNAs then he assumes there are no problems. He stated the CNAs should be telling the unit nurse and the Rehab Coordinator if ambulation is not being done. He also stated there is a problem with the electronic medical record in that even though a resident may be walking twice a day on the restorative nursing program, it can only be documented once. 2) Resident #116 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 3/14/19 Quarterly MDS documented a BIMS score of 15, indicating the resident was cognitively intact. The MDS documented that the resident required extensive assist of two staff members for transfers, extensive assist of two staff members for walking in room, extensive assist of one staff member for walking in the corridor, and that the resident was only able to stabilize while walking with staff assistance. A physician's orders [REDACTED]. A CCP effective 1/29/19 titled ADL Support Services had an intervention added on 3/13/19 for RNP/FAP: FAP 50 feet with rolling walker, assist x 1 with wheelchair to follow BID. The CNA Resident Nursing Instructions had an instruction added on 3/13/19 for RNP/FAP: FAP 50 feet with rolling walker, assist x 1 with wheelchair to follow BID. The schedule was every day between 7 AM-3 PM and 3 PM-11 PM. A PT discharge assessment dated [DATE] documented recommendations that the resident be educated on the importance of participating in the ambulation program with nursing staff to maintain functional goals. The resident verbalized understanding. Nursing staff were educated on proper technique to transfer and ambulate with the resident using a rolling walker, and wheelchair to follow. The resident was discharged to the nursing unit with recommendation for FAP 50 feet with rolling walker, assist x 1 with wheelchair to follow. Resident #116 was interviewed on 4/29/19 at 3:45 PM. The resident stated she was not getting up and walking. She stated this was the first time she was hearing about the floor ambulation program. She stated the extent of her walking has been transferring from the bed to the chair and back. She further stated she does not walk to the bathroom. The bathroom was observed to be adjacent to her bed. Review of the CNAAR for (MONTH) 2019 revealed that a line item titled Nursing Rehab Walking could be documented on for the 7 AM-3 PM and 3 PM-11 PM nursing shifts. During (MONTH) 2019 Not Performed was documented 28 times. An entry in the CNAAR for 4/29/2019 documented that the resident walked 50 feet during the 7 AM-3 PM shift. The resident was interviewed on 4/30/19 at 8:09 AM. She stated that on the day before (4/29/19) she only transferred from her bed to wheelchair and back. She stated she did not walk 50 feet. The CNA who made the 50 feet walking entry on 4/29/19 was interviewed on 4/30/19 at 8:28 AM. She stated the 50 feet entry was a mistake. She stated the resident does not walk in the hallway. Review of the CNAAR revealed that the same CNA documented 50 feet walking entry 16 times. The two restorative CNAs were interviewed concurrently on 4/30/19 at 10:37 AM. They stated they did not walk with Resident #116 and that she was not assigned to them. The RN unit supervisor was interviewed on 4/30/19 at 11:15 AM. She stated that she did not know how far the resident was walking. She stated she would have to check with the CNA. The Director of Nursing Services (DNS) and Rehab Director were interviewed concurrently on 4/30/19 at 12:01 PM. The Rehab Director said that if a resident requires more help with walking they will be assigned to restorative CNAs because the units CNAs have other care tasks and getting two unit CNAs available to walk with a resident may be difficult. The residents that require the restorative CNAs are assigned by the Rehab Coordinator. The DNS said the system needs clarification. The resident was observed walking in the hallway on 4/30/19 at 1:32 PM with a Physical Therapist (PT) and a Physical Therapist Assistant (PTA). The resident transferred to a standing position with the assistance of the PTA and the rolling walker. The resident had to sit and rest after approximately 20 feet and concluded the walk after approximately 80 feet. A 3 PM-11 PM unit CNA was interviewed on 5/1/19 at 10:56 AM. She stated she does not walk with the resident in the hallway. She stated the resident needs a lot of help and can only walk a couple of steps. 3) Resident #114 is [AGE] years old and has [DIAGNOSES REDACTED]. The 9/9/18 and the 3/11/19 Minimum Data Set (MDS) assessments documented the resident required extensive assistance with one staff member to walk in the room and in the corridor. A Physical Therapy discharge note dated 12/10/2018 documented the resident has obtained the highest maximum potential achieved and no longer required services of a skilled clinician. The resident has been placed on a nursing rehab program to maintain the current level of function and to maintain joint stability/integrity. The primary CNA and nursing staff were educated on Restorative Nursing program (RNP) and techniques to encourage participation with ADLs on the nursing unit with good verbalized understanding. The physician orders [REDACTED]. On 4/29/19 at 2:13 PM, the resident's family member complained that the resident has not been ambulated in over 9 months. The family member stated she fears the resident was deteriorating and will require PT to regain his strength. Review of the CNA accountability records from (MONTH) (YEAR)- (MONTH) revealed that the resident's floor ambulation program was not performed as ordered. The Comprehensive Care Plan (CCP) dated 6/4/18 documented the resident transferred with the assistance of 2 staff members and ambulated with a rolling walker and assistance of 2 staff members to and from meals. During an interview with CNA #7 on 4/29/19 at 2:20 PM stated she only ambulates the resident to and from the bathroom. She does not ambulate the resident in the hallway with a wheelchair to follow. CNA #7 stated ambulation is done by nursing rehab. The CNA stated she recorded an error into the computer, indicating that the resident was walked today. During an interview on 4/30/19 at 10:30 AM with the Rehab CNA #4 and CNA #5, they stated they have been walking the resident during in the AM daily up until around mid-March 2019. In (MONTH) 2019, the resident had a decline and the CNAs were unable to do the FAP. This was reported to the Rehab Department and the Nurse on the unit. The CNAs stated they did not document this and do not know who exactly they reported this to. They were not able to document this in the computer due to a computer glitch. CNAs #4 and # 5 stated they only ambulated the resident during the AM shift. CNAS #4 and # 5 stated they leave by 4 PM and do not provide FAP to the resident during the 3-11 PM shift. On 4/30/19 at 12:56 PM the Rehabilitation Director was interviewed and stated when there is a change or a decline, the Rehab CNA brings this to the attention of the nurse. The nurse communicates through the dashboard on the computer and we (the rehab department) then follow up with an evaluation. The Rehabilitation Director stated that if you do not see an evaluation, the concern was never brought to our attention. The Rehabilitation Director further stated there was no communication to our department that a decline occurred to the resident. On 4/30/19 at 2:24 PM, the Rehab Coordinator Registered Nurse (RN) was interviewed and stated he was not made aware about the resident's decline. The Rehab CNAs should have reported this to the charge nurse on the units. The RN stated if the resident does not complete the distance ordered, this should be reported to the charge nurse and himself. The RN further stated that if there is a decline, the Rehab department should be made aware. On 4/30/19 at 2:51 PM, the unit RN Supervisor (#5) was interviewed and stated he could not recall if he or other Nurses were made aware by the rehab CNAs about the Resident's decline. The RN Supervisor stated if he had been made aware, that the resident was no longer able to participate in FAP, he would have notified the Rehab Department and the Physician (MD) to further evaluate the resident. On 4/30/19 at 4:40 PM, CNA#6 who cares for the resident daily during the 3 PM to 11 PM shift was interviewed and stated I do not ambulate him in the evening. He is ambulated in the AM. We do not ambulate in the evening. 415.12(a)(2)

Based on observation, record review and staff interviews during the recertification survey, the facility did not ensure that all residents were free from Unnecessary Medications. This was evident for three of seven residents reviewed for Unnecessary Medications. Specifically,1) Resident # 159 has a primary [DIAGNOSES REDACTED].#5 was prescribed the antipsychotic medication [MEDICATION NAME] for an inaccurate diagnosis; and 3) Resident #129 had no documented evidence a Psychiatric Assessment (per the Diagnostic and Statistical Manual criteria) was completed to evaluate for a [DIAGNOSES REDACTED]. The findings are: 1) Resident # 159 is [AGE] years old and was admitted on [DATE] with diagnosed including: [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had severely impaired cognitive function with no behaviors documented during the assessment period. The resident was documented on the MDS dated [DATE] as severely cognitively impaired. The MDS documented that the resident received seven days of antipsychotic medication without a Psychiatric diagnosis. The physician's orders [REDACTED]. The Behavior Comprehensive Care Plan (CCP) dated 2/21/19 documented the resident had a history of [REDACTED]. The CCP also documented to encourage appropriate verbalization as an intervention. The interventions were non-specific and not resident-centered. The Physician's Progress Note (P/N) dated 3/10/19, documented that the resident was exhibiting behaviors on 3/9/19 and ordered [MEDICATION NAME] (an antianxiety medication) 0.25 mg for Anxiety. The 3/18/19 MDS Assessment documented that the resident had no symptoms of Depression (Mood Score 0), no behavioral symptoms or rejection of care during the assessment period. A Medication Regimen Review by the Pharmacy Consultant dated 3/28/19 recommended to decrease the resident's antipsychotic medication ([MEDICATION NAME]), which the physician agreed to. The [MEDICATION NAME] .25 mg dose HS was discontinued on 4/17/19. An Interdisciplinary Team (IDT) progress note with a review dated 4/24/19 documented that the resident was on antipsychotic medications that are effective in managing behavioral symptoms without resident specific, non-pharmacological interventions documented or assessed. A Nursing progress note dated 4/29/19 documented that the resident was extremely agitated with infrequent yelling out and repetitive movements, will refer to Psychiatry and was seen by Psychiatry. A Psychiatric Nurse Practioner (NP) follow up note dated 4/29/19 documented that the resident reported continued anxiety, energy level was tired with documented diagnoses of Anxiety and Dementia. The recommendations were to continue the [MEDICATION NAME] .25 mg twice daily for Anxiety and to increase the [MEDICATION NAME] back to 0.125 mg every 12 hours and .125 mg every HS for unclear indication. The NP documented that the resident was tense with no delusions and that the resident denied hallucinations and any dangerous behaviors or thoughts. The Behavior CCP was updated 4/30/19 and documented that the resident was agitated with infrequent yelling and repetitive movements during morning care. The update documented that the resident was referred to Psychiatry for medication adjustment. There was no documented evidence in the CCP that the resident's behaviors, interventions or [MEDICAL CONDITION] medications were reviewed or updated by the IDT related to the failed GDR after one documented episode of agitation. The resident was observed on 5/1/19 and 9:45 AM. The resident was in the hallway outside of her room. The resident was making repetitive movements with her hands and repetitive verbalizations. The resident's Certified Nursing Assistant (CNA) was interviewed on 5/1/19 at 9:45 AM. The CNA stated that the resident was anxious during care, but was not aggressive. The CNA stated that the resident was resistive to care and that with two assist during care they were able to complete the care. The CNA also stated that if the resident was refusing care, she would leave the resident and return later. The CNA further stated that the resident was not a danger to other residents or staff. The Registered Nurse/(RN) Unit manager was interviewed on 5/1/19 at 9:50 AM. The RN stated that the resident is noisy most of the time and has not been a danger to herself or others. The RN stated that the resident can be redirected but has fluctuating preferences and when agitated may respond differently to repeated interventions. During the interview with the Psychiatric Nurse Practitioner (NP) on 5/1/19 at 12:00 PM, the NP stated that the resident has been reported to have had agitated behaviors since (MONTH) 2019. The NP stated that the staff does try to distract the resident which had been unsuccessful. The NP was unable to explain the lack of documentation. The NP stated that GDR will continue to be considered for this resident. The Social Worker (SW) was interviewed on 5/1/19 at 12:27 PM. The SW stated that the team does discuss the resident's behavior and that for Resident # 159 no medication recommendations were made. The SW stated that all disciplines are involved in the care plan and that this should have been documented. The Director of Nursing Services (DNS) was interviewed on 5/1/19 at 1:15 PM. The DNS stated that the resident's plan of care should be individualized and resident specific. 2) Resident #5 was admitted to the facility on [DATE] with diagnosed including: [DIAGNOSES REDACTED]. Active diagnoses included [MEDICAL CONDITION], Non-Alzheimer's Dementia, and Arthritis. The hospital discharge Patient Review Instrument (PRI) dated 2/14/17 documented diagnosed including: [DIAGNOSES REDACTED]. There was no [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Review of Psychiatry consults produced by the previous psychiatric consulting service dated 10/12/18 and 11/7/18 documented psychiatric history of Paranoid [MEDICAL CONDITION]. There were no delusions or hallucinations documented in the two consults. Review of Psychiatry consults produced by the current psychiatric consulting service dated 11/30/18, 1/9/19, 2/1/19, 3/2/19, and 3/23/19 revealed documentation of the [DIAGNOSES REDACTED]. A Psychiatric consult produced by the current psychiatric consulting service dated 4/10/19 documented that after a long discussion with the patient's husband it is unclear whether the patient's [DIAGNOSES REDACTED]. Further documentation included that [MEDICATION NAME] was for unclear indication and a GDR was recommended. The resident's family member was interviewed on 4/29/19 at 3:26 PM. He stated that the resident had no psychiatric or mental illness throughout her life until the resident developed Dementia. The Medical Director was interviewed on 5/1/19 at 9:30 AM. He stated the psychiatrists were applying the [MEDICAL CONDITION] [DIAGNOSES REDACTED]. He stated he would expect documentation of the [MEDICAL CONDITION] criteria being met with documentation of symptoms. The Psychiatrist was interviewed on 5/1/19 at 9:34 AM. He stated the [DIAGNOSES REDACTED]. He stated if the resident has a previous history and assessment of [MEDICAL CONDITION] and it is well documented, we may not need to go through a full DSM criteria review. The Psychiatric Nurse Practitioner (NP) was interviewed on 5/1/19 at 11:33 AM. She stated it has been very unclear what the [DIAGNOSES REDACTED]. She stated people do not generally develop that [DIAGNOSES REDACTED]. She reviewed the record and was unable to find a Psychiatric consult or assessment prior to 10/12/18. 3) Resident#129 is [AGE] years old and was admitted to the facility on [DATE] with diagnosed including: [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12 indicating the resident had moderately impaired cognition. The MDS had no documented evidence of the [DIAGNOSES REDACTED]. A Medical Record Diagnoses Record dated 7/19/17 documented diagnosed including: [DIAGNOSES REDACTED]. The Medical Record Diagnoses Record was updated on 12/20/18 and documented a [DIAGNOSES REDACTED]. A physician progress notes [REDACTED]. The Progress Note documented a [DIAGNOSES REDACTED]. A Psychiatry Nurse Practitioner (NP) Note dated 12/7/18 documented the resident stated I am better than last year, I don't want to take any more medications. The NP Progress Note documented the resident's energy level as tired and the resident was calm. The NP Progress Note documented a [DIAGNOSES REDACTED]. An NP Progress Note dated 12/20/18 documented the resident's energy level as tired, sad and anxious. The NP Progress Note documented the resident had hallucinations and recommended to administer [MEDICATION NAME] 12.5 Milligrams (mg) one time a day for a [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Medication Administration Records dated (MONTH) 21,2018 through (MONTH) 31, (YEAR); (MONTH) 1,2019 through (MONTH) 31, 2019; and (MONTH) 1, 2019 through (MONTH) 15, 2019, documented to administer [MEDICATION NAME] 12.5 mg two times a day for a [DIAGNOSES REDACTED]. An NP Progress Note dated 2/23/19 documented the resident's family felt the resident was too sedated and requested to have the [MEDICATION NAME] discontinued. An NP Progress Note dated 4/30/19 documented it is unclear whether there is a true history of [MEDICAL CONDITION], that the family stated the hallucinations appeared to be related to the use of pain medications. There was no documented evidence in the medical record that a Psychiatric Assessment (per the Diagnostic and Statistical Manual criteria) was completed to evaluate for a [DIAGNOSES REDACTED]. An interview was held with the Physician on 5/1/19 at 9:18 AM. The Physician stated he would expect the Psychiatry NP to document a complete diagnostic assessment to determine a [DIAGNOSES REDACTED]. An interview was held with the Psychiatrist on 5/1/19 at 9:40 AM. The Psychiatrist stated that an assessment should have been completed per the Diagnostic and Statistical Manual criteria to determine a [DIAGNOSES REDACTED]. An interview was held with the NP on 5/1/19 at 12:00 PM. The NP stated the [DIAGNOSES REDACTED]. The NP stated elderly residents typically do not develop [MEDICAL CONDITION]. 415.12(1)(2)(ii)

Based on interviews and record review during an abbreviated survey (Complaint # NY 788), the facility did not ensure one (Resident #1) of three residents rights to be free from neglect. Specifically, two Certified Nursing Assistants (CNA) and a Licensed Practical Nurse (LPN) placed the resident back to bed without being assessed by a Registered Nurse (RN) after an unwitnessed fall. Thereafter, the resident exhibited a change in the transfer status that was not reported to the licensed staff. Subsequently, the resident was noted with swelling and external rotation of the right leg and was transferred to the hospital with a [DIAGNOSES REDACTED]. This resulted in actual harm to Resident #1 that is not Immediate Jeopardy. The findings were: The facility's policy titled Accident/Incident (A/I) dated 4/4/18 documented it is the policy of the facility to investigate all accidents/incidents to residents to prevent a recurrence of the same or similar type of incident. Should one witness an incident/accident or find it necessary to aid in an incident/accident victim, one should render immediate assistance. Do not remove the victim until he/she has been examined for possible injuries by an RN/MD. The facility's policy titled Fall Prevention policy 4/6/18 documented when a resident is found on the floor, the facility is obligated to investigate and try to determine how she or he had fallen and put interventions in place to prevent it from reoccurring. Fall refers to unintentionally coming to rest on the ground, or other lower level but not as a result of an overwhelming external force, an episode where a resident lost his/her balance and would fall. The facility policy titled Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property dated 7/20/18 defined Neglect as a failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. All employees shall receive training annually and ongoing as necessary on Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property. The training should include definition and how to report allegations of Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property without fear of reprisals. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-an assessment tool) dated 11/2/18 documented the resident's cognitive status as severely impaired. She required extensive assistance of one person for bed mobility, transfer, walking, locomotion and limited assistance of one for toilet use. The resident was frequently incontinent of bowel and bladder. The balance was not steady, only able to stabilize with staff assistance. The resident had a history of [REDACTED]. CNA #1 and CNA #2 received in-service on 11/8/17 and on 12/18/17 respectively for Abuse, Mistreatment and Neglect and Falls. CNA #3 received in-service (undated) for Falls. CNA #3's personnel file lacked documented evidence that she received in-service related to Activities of Daily Living (ADL) and Abuse. LPN #1 received in-service on Resident Abuse on 6/19/08 and her personnel file lacked documented evidence she had in-service recent in-service on Abuse and Falls. The resident's Fall Risk assessment dated [DATE] documented history of fall in the past 3 months, confusion, antihypertensives, psychoactive medication use and unsteady gait for the resident. The safety measures included call bell, keep resident in high visibility area when out of bed, low bed and non-skid footwear. The Comprehensive Care Plan (CCP) titled Fall/Safety dated 9/8/18, documented the resident's fall risk factors as history of falls in the last 30 days with [MEDICAL CONDITION], a decline in functional status, unsteady gait, impaired balance, and incontinence. Interventions documented to assist with ambulation and transfer as needed, utilize a preventative device such as a low bed and keep call bell within reach. The Resident Nursing Instructions (RNI- CNA plan of care) as of 9/7/18 documented the resident required limited assistance of one person with transfers. The resident was continent of bowel and bladder was scheduled to be toileted every shift and required limited assistance with toilet use. The Nursing Progress Notes (NPN) dated 11/11/18 at 3:05 PM by LPN #1 documented that during transfer the resident attempted to stand and slipped. CNA #1 and LPN #1 stopped her from falling. The RNS (#1) was notified. The resident was not injured. There was no other distress noted. The resident was placed back in the wheelchair. The progress notes lacked documented evidence that the Resident was assessed by the RN/RNS related to the incident. The Resident CNA Documentation dated 11/11/18 documented that bathing toilet use and personal hygiene were not performed during the 3PM-11PM for the resident. The 11 PM-7 AM shift, documentation included that the bed mobility, dressing, and the transfer were not performed, and the resident had no bowel movement. The NPN dated 11/12/18 at 7:46 AM by LPN #2 documented that LPN #2 observed swelling to the right upper and lower leg. The right leg was twisted. The MD was made aware and ordered an x-ray of the right upper and lower extremities to rule out a fracture. LPN #2 called and spoke to the x-ray company representative. The x-ray of right hip dated 11/12/18 at 1:44 PM documented acute comminuted [MEDICAL CONDITION] femur. The NPN dated 11/12/18 at 3:20 PM LPN #3 documented the resident had an x-ray of the right lower extremity and the results showed a [MEDICAL CONDITION]. The MD ordered to transfer the resident to the hospital. At 7:56 PM resident was transferred to the hospital for right [MEDICAL CONDITION]. The A/I report dated 11/12/18 (time not documented) documented that LPN #2 was called by the resident's companion to report the right leg swelling. Tylenol was given, and the resident slept. During morning rounds, LPN #2 observed the right leg was still swollen and twisted. The MD was made aware who ordered an x-ray. RN assessment documented the resident's right lower extremity was swollen with pain. The right lower extremity was externally rotated. The facility's investigation dated 11/12/18 documented on 11/11/18 at approximately 2 PM, LPN #1 reported to RNS #1 that during transfer from bed to chair, Resident #1 lost her balance and was sliding down, CNA #1 and LPN #1 intercepted the fall and sat her in her chair. Resident #1 then attended recreation activity. The next day (11/12/18) at about 7 AM, LPN #2 was called to the room by the resident's private companion to show that the resident's right leg was swollen. The MD was notified. An x-ray was ordered that showed a [MEDICAL CONDITION] hip. Resident #1 was transferred to the hospital for evaluation and treatment. CNA #1 and #2 both stated that they observed Resident #1 on the floor on 11/11/18. They reported it to the nurse (time not documented). After noting that there were no visible injuries and Resident #1 did not complain of pain, CNA #1, CNA #2 and LPN #1 helped Resident #1 back to bed. Then transferred her into the chair to attend a recreational activity. The facility concluded that CNA #1, CNA#2 and LPN #1 did not report an incident accurately and timely. Both CNA's and LPN would be suspended pending investigation due to delay in reporting. As of date, no evidence of abuse, neglect and/or mistreatment was identified. RNS #1 was interviewed on 1/22/19 at 1:47 PM and stated he was approached by the LPN #1 on 11/11/18 at approximately 2:15 PM. She asked him how to proceed when during transfer a resident lost her balance and staff intercepted the fall. RNS #1 asked LPN #1 more than once if the resident touched the floor. LPN #1 said no. RNS #1 told the LPN that occurrence the LPN had described was not considered an Accident or Incident (A/I). According to LPN #1, the resident did not complain of pain. RNS #1 stated if a resident did not touch the floor, it was not considered a fall unless there was a harm/injury. If the resident complained of pain after an episode of interception, there would be an assessment and investigation. RNS #1 stated he was not informed there was a fall. RNS #1 stated he did not assess the resident. The Therapeutic Recreation (TR) was interviewed on 1/22/19 at 3:08 PM and stated on 11/11/18 she was making rounds at approximately 2:00 PM when she noticed Resident #1 was on the floor in her room lying on the right side and yelling. The resident was alone in the room. The TR noticed an aide and a nurse (could not recall the staff names) in the area. She told the aide that Resident #1 was on the floor. The aide came to the room to check and she immediately found the nurse and nurse came and the TR left the area. The 7:00 AM- 11:00 PM CNA #1 was interviewed on 1/22/19 at 4:10 PM and she stated Resident #1 was on her assignment on 11/11/18 during the 7:00 AM to 3:00 PM shift. The TR (could not recall the name) said that Resident #1 was on the floor. CNA #1 called LPN #1. LPN #1 told CNA #1 to get Resident #1 up from the floor. CNA #1 called CNA #2 for help. LPN #1, CNA #1 and CNA #2 picked Resident #1 from the floor and transferred her to the bed. Then they transferred Resident #1 from bed to chair. The resident was taken to attend the activity. CNA #1 stated she was aware that she needed to wait for the RNS to complete an assessment before lifting the resident from the floor. CNA #1 stated that she followed LPN #1's instructions. Resident #1 did not complain of pain. CNA #1 also worked on 3-11 shift that day and assisted CNA #3 in transferring Resident #1 from wheelchair to bed. CNA #1 stated that she did not notify CNA #3 that the resident fell during the day shift. Resident #1 generally required the assistance of one person for the transfer but after the fall during the evening shift Resident #1 had a hard time standing, so they (CNA #1 and CNA #3) lifted her. CNA #1 stated she did not notice any swelling on the resident's leg. The 7:00 AM-3:00 PM CNA #2 was interviewed on 1/22/19 at 3:17 PM and stated on 11/11/18 she was called in the resident's room by CNA #1. Resident #1 was on the floor. CNA #1 and LPN #1 were in the room. LPN #1 asked for help in picking the resident up. The three of them picked Resident #1 from the floor and placed her in the bed. CNA #2 thought the resident was already seen by the RNS. The 7:00 AM-3:00 PM LPN #1 was interviewed on 1/22/19 at 3:24 PM and stated she worked on 11/11/19 and was assigned to Resident #1. She was informed by the TR (could not recall name and time) that Resident #1 had a fall. LPN #1 stated she paged RNS #1 and another RNS. She waited for 10-15 minutes, and no one came. LPN #1 stated CNA #1, CNA #2 and herself assisted Resident #1 up from the floor and placed her onto the bed. Resident #1 was not in pain. Resident#1 was very alert, she wanted to get up and they transferred her from bed to chair to attend an activity. LPN #1 stated she did not notice any injury to Resident #1. LPN #1 did not write an A/I report as it was the end of the shift and she did not inform the next shift about the fall. The 3:00-11:00 PM and 11:00 PM- 7:00 AM CNA #3 was interviewed on 1/22/19 at 3:55 PM and stated that she was assigned to the resident on 11/11/18 during the evening and the night shift. At approximately 7:30 PM CNA #3 went to place the resident to bed. The resident was having difficulty standing up. CNA #2 assisted with the transfer but did not mention that the resident had a fall during the previous shift. Both CNAs (CNA #2 and CNA #3) lifted the resident manually because the resident could barely stand. The resident did not complain of pain. CNA #3 stated she did not notice any swelling or rotation to the resident's right leg. During a subsequent interview with CNA #3 on 1/29/18 at 4:48 PM, she stated that Resident #1 had a private aide all night. CNA #3 checked on Resident #1 at 1:00 AM and between 5:30-6:00 AM and they were both (the resident and the companion) sleeping. CNA #3 stated she did not provide any care to the resident during the night shift because the resident was sleeping. The resident did not ring the call bell or asked for any assistance. Resident #1 slept all night and had no signs or symptoms of pain. The Director of Nursing (DON) was interviewed on 1/22/19 at 4:35 PM and stated the facility had a change in ownership and some of the in-service records for the involved staff (LPN #1 and CNA #3) could not be located. The in-service educator responsible for education in (YEAR) was no longer employed. She had perhaps discarded the records that the facility was not able to locate. The RN Risk Manager (RNRM) was interviewed on 1/22/19 at 5:11 PM, she stated she completed the investigation and concluded that the resident had a fall and was picked up from the floor by LPN #1 and CNA #1 and #2 and they did not inform anyone. There was no abuse, neglect, and mistreatment. There was a failure to follow the facility protocol of not generating an A/I and not reporting the incident. The resident was transferred to the hospital and had surgery. The involved staff were aware of the facility policy. RNS #1 should have investigated further when staff reported about intercepted fall. RNS #1 did not assess the resident. The 11:00-7:00 AM LPN #2 was interviewed on 1/25/19 at 3:29 PM and stated he worked 3-11 and 11-7 shift on 11/11/18. When he came on duty nobody reported to him that Resident #1 had a fall. Resident #1 was in a wheelchair at 3:00 PM, and she was pleasant. He did rounds at approximately 5:00-6:00 PM, 10 PM, 11 PM and in the middle of the night. Resident #1 was sleeping. LPN #2 stated the staff did not report any issues with the transfer. At approximately, 5:00-6:00 AM Resident #1 was awake and did not complain of pain. The private aide called LPN #2 between 6-6:30 AM and reported that Resident #1 did not sleep well and complained that her leg was bothering her. LPN #2 checked, the right leg was swollen and appeared twisted. Prior to this time, the CNAs did not report to him that the resident was complaining of pain or that the resident's leg was swollen or twisted. LPN #2 tried to call RNS #2 but could not reach him. LPN #2 called the MD at 7:00 AM and got an order for [REDACTED].#2 reported it to next shift LPN #3. The 7:00 AM - 3:00 PM RNS #3/Assistant Director of Nursing (ADON) was interviewed on 1/25/18 at 4:42 PM and stated on 11/12/18 he was notified of the x-ray result for the resident. RNS #3 stated Resident #1 had a swelling and external rotation of the right leg. Resident #1 was in pain and was grimacing. RNS #3 documented his assessment (no time document) in the incident report and did not document his findings in the resident's medical record. RNS #3 initiated the incident report when he saw the swelling. Resident #1 was transferred to the hospital during the 3-11 shift for further evaluation. RNS #3 stated if a nurse observes a change in condition the RNS should have been informed. The 7:00 AM-3:00 PM LPN #3 was interviewed on 1/29/19 at 1:49 PM and she stated did not get any report that Resident #1 had a fall or that Resident #1 was observed with swelling of the leg by LPN #2. LPN #3 stated she read the progress notes and read that Resident #1 had an order for [REDACTED].#1 always complained of pain. LPN #3 stated when x-ray result came (could not recall time), she called the MD. The MD ordered to transfer the resident to the hospital. The Primary Medical Doctor (PMD) was interviewed on 1/29/19 at 4:00 PM and he stated he was informed by the nurse (could not recall the name) in the morning on 11/12/18 (could not recall time) that the resident was noted with a twisted leg; he ordered an x-ray. The PMD saw Resident #1 in the afternoon. The resident was observed with a shortened right leg which was a definite sign of a fracture. Resident #1 was not in pain, but she was not comfortable. The x-ray results showed a fracture, and he ordered to transfer the resident to the hospital. PMD stated that he was not informed of a fall on 11/11/18. When he was called in the morning on 11/12/18, the nurse did not mention any fall. 415.4(b)(1)(i)

Based on observation, record review, and staff interviews during the recertification survey, the facility failed to ensure that each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. This was evident in 1 of 2 residents reviewed for Pressure Ulcers (P/U) from a total of 38 Stage 2 sampled residents. Specifically, Resident #435, a resident with no pressure ulcers upon admission to the facility and identified at moderate risk for skin breakdown, developed a Suspected Deep Tissue Injury which later became a Stage 4 Pressure Ulcer (P/U). physician's orders [REDACTED]. Additionally, a treatment order for Dakin's Solution was used in conjunction with Santyl which was not ordered to be administered concurrently. The wound subsequently required surgical debridement. The finding is: Resident #435 had an admission [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Nursing Admission Data form was completed on 3/4/15. The Form documented that the resident was alert and oriented to person but not to place and time, with short and long term memory loss. It also documented no entry or check mark under Skin Section. The resident had limited range of motion (ROM) and required extensive assist of one person for bed mobility. The Braden Scale dated 2/20/15 documented that the resident scored 14 indicating that the resident was at moderate risk for developing a P/U. A Comprehensive Care Plan (CCP) dated 2/21/15 for potential for alteration in Skin Integrity related to incontinence, decreased mobility, sensory deficits, cognitive impairment and [MEDICAL CONDITION] included interventions to: monitor skin integrity daily, provide hygiene/anticipate needs and to monitor skin integrity during care. The Wound Care Progress Note dated 5/21/15 documented an acquired Right Lateral Foot Suspected Deep Tissue Injury P/U which measured 0.5 cm x 0.5 cm x 0 cm. The Wound Order dated 5/21/15 documented to cleanse/irrigate wound with Normal Saline (NS)/water and apply Skin Prep daily (qd). A Diagnostic Report for the Right Foot to rule out [MEDICAL CONDITIONS] dated 5/27/15 documented findings consistent with Severe [MEDICAL CONDITION] without Occlusion. The Wound Care Progress Note dated 5/28/15 documented that the Right Lateral Foot Suspected Deep Tissue Injury Pressure Ulcer measured 2 cm x 2 cm x 0 cm. The Braden Scale dated 6/1/15 documented that the resident scored 11 to indicate that the resident was a high risk of developing a P/U. The Wound Care Progress Note dated 6/4/15 documented that the Right Lateral Foot Suspected Deep Tissue Injury Pressure Ulcer measured 2 cm x 2 cm x 0 cm. A CCP was developed 6/08/15 for an actual pressure ulcer with risk factors including impaired mobility, impaired circulation [MEDICAL CONDITION], and pressure due to always lying on the right side. The Wound Care Progress Note dated 6/11/15 documented a Right Lateral Foot Suspected Deep Tissue Injury P/U, not healed, and measured 1.9 cm x 3 cm x 0 cm. The Wound Order dated 6/11/15 documented cleanse/irrigate the wound with NS/water, apply [MEDICATION NAME] and cover with gauze twice daily (BID). The Wound Care Progress Note dated 6/25/15 documented a Right Lateral Foot Suspected Deep Tissue Injury P/U, not healed, and measured 1.5 cm x 1.0 cm x 0 cm. The Wound Order dated 6/25/15 documented to cleanse/irrigate wound with NS/water, apply Santyl and cover with gauze once daily (qd). Review of the Treatment Administration Record (TAR) for June 2015 revealed that [MEDICATION NAME] was never administered as ordered on [DATE]. It documented that the Skin Prep treatment was continued for the remainder of June 2015. Review of the TAR for June 2015 and July 2015 also revealed that Santyl order was never implemented on 6/25/15. The Santyl treatment was first administered on 7/16/15, 22 days after ordered by the Physician. The TARs documented that Skin Prep treatment was continued until 7/15/15. The Nursing Progress Note dated 7/9/15 documented that the resident's Right Lateral Foot Wound was seen by the Wound Physician that measured 1.5 cm x 1.5 cm x 0 cm. The Wound Care Progress Note dated 7/9/15 documented that the Right Lateral Foot Suspected Deep Tissue Injury Pressure Ulcer measured 1.5 cm x 1.5 cm x 0 cm and had not healed. The Nursing Progress Note dated 7/16/15 documented that the Wound Physician recommended a debridement (the removal of dead or damaged tissue) of the Right Lateral Foot Wound. The Nursing Progress Note dated 7/23/15 documented that the facility was still waiting for the family consent for debridement. The Nursing Progress Note dated 7/31/15 documented that the resident needed debridement for proper wound healing. The Nursing Progress Note dated 8/6/15 documented that the Wound Physician debrided the Right Lateral Foot Wound after the consent was signed and [MEDICATION NAME] (an antibiotic) 500 milligrams was ordered daily. The Wound Care Progress note dated 8/13/15 documented the resident had a unstageable pressure ulcer to the right lateral foot with necrotic tissue (unstageable) and surgical debridement was performed. The Nursing Progress Note dated 8/13/15 documented that the Right Lateral Foot P/U was classified as a Stage IV for the first time and a debridement was done. The Note also documented that [MEDICATION NAME] was discontinued [MEDICATION NAME](an antibiotic) was ordered for 14 days. The Wound Care Progress Note dated 8/20/15 documented that the Right Lateral Foot was now a Stage 4 Pressure Ulcer, not healed and now measured 1.0 cm x 1.0 cm x 0.8 cm. The Nursing Progress Note dated 8/20/15 and 8/27/15 documented debridement to the Stage IV Right Lateral Foot P/U was performed. The Wound Care Progress Note dated 9/3/15 documented a Right Lateral Foot Stage 4 P/U, not healed, and measured 1.1 cm x 1.0 cm x 0.6 cm. The Wound Order dated 9/3/15 documented to cleanse/irrigate wound with NS/water, apply wet to dry [MEDICATION NAME] packing with 1/4 strength Dakin's Solution twice daily (BID). This was a change of treatment from the previously ordered treatment of [REDACTED]. The Wound Care Progress Note dated 9/10/15 documented that the Right Lateral Foot, Stage 4 Pressure Ulcer had not healed and measured 2.5 cm x 2.5 cm x 0.7 cm. Debridement was performed. The Wound Care Progress Note dated 9/17/15 documented a Right Lateral Foot Stage 4 P/U, not healed, and measured 2.0 cm x 3.2 cm x 1.5 cm. The Wound Care Progress Note Details dated 9/24/15 documented a surgical debridement was again performed and that the post debridement measurement was 1.4 cm x 2.6 cm x 1 cm. Review of the TAR for September 2015 and October 2015 revealed that both Santyl and Dakin's Solution were used as treatments concurrently from 9/3/15 to the present (10/09/15). The medical record revealed that the Wound Physician had debrided the right lateral foot P/U on seven occasions: 8/6/15, 8/13/15, 8/20/15, 8/27/15, 9/10/15, 9/17/15, and 9/24/15. The Wound Care Progress Note dated 10/1/15 documented that the Right Lateral Foot Stage 4 Pressure Ulcer had not healed and measured 1.5 cm x 2.5 cm x 2.2 cm with moderate amount serous drainage. During the dressing change observation conducted with the Registered Nurse (RN) Unit Charge/Treatment Nurse on 10/9/15 at 8:45 AM, the following was observed: - the resident had a Right Lateral Foot P/U - the Right Lateral Foot P/U Stage 4 appeared to have a dull-red colored wound bed, macerated periwound area, and visually measured approximately 1.5 cm x 1.5 cm x 0.5 cm. An interview with the Registered Nurse (RN) Unit Charge Nurse was conducted on 10/13/15 at 9:15 AM. The RN stated that Dakin's Solution and Santyl should not be used together. The RN also stated that he did not clarify the Wound Orders with the Wound Physician. An interview with the Director of Nursing Services (DNS) was conducted on 10/13/15 at 11:00 AM. The DNS stated that she was not aware of the Wound Orders and that she would have to review them. An interview with the Wound Physician was conducted on 10/13/15 at 11:45 AM. The Physician stated that the physician's orders [REDACTED]. The Wound Physician did not know that her recommendations were not picked up as ordered or done timely. The Physician also stated that if the nurse had a question on the Wound Orders, the nurse can always clarify the orders with the Wound Physician. The Physician further stated that Skin Prep should not be done in conjunction with [MEDICATION NAME]. The Physician stated that Skin Prep treatment should have been discontinued and the treatment with [MEDICATION NAME] should have been initiated on 6/11/15 as recommended. The Physician further stated that she did not know and was not made aware that her [MEDICATION NAME] recommendation was never implemented. Then the Physician added that Santyl should have been initiated on 6/25/15 as recommended to replace [MEDICATION NAME] treatment. The Physician stated that she was not made aware that the Santyl treatment order was not initiated until 7/16/15, 22 days after recommended by the Wound Physician. In addition, the Physician stated that when she recommended Dakin's Solution on 9/3/15, the Santyl treatment should have been discontinued. The Physician stated that Santyl and Dakins are not to be used at the same time unless it was ordered. The Wound Physician stated that she could not recall that the Unit Nurse had clarified the Wound Orders with her nor that she was made aware that the [MEDICATION NAME] order was never carried out. The Wound Physician also stated that she was not made aware that Santyl was not implemented timely as ordered and also that both Santyl and Dakin's Solution were used at the same time since 9/3/15 to the present. The Wound Physician stated that Right Lateral Foot Wound started as a Suspected Deep Tissue Injury P/U and progressed to Stage 4 P/U. The National Pressure Ulcer Advisory Panel and WoundCareAdvisory.com documented that the National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel stated that a P/U staging cannot be used for venous ulcers. It also stated that a P/U classification system cannot be used to describe tissue loss in wounds other than P/Us. According to the Centers for medicare and medicaid Services (CMS), a P/U that has been surgically debrided remains a P/U, and is not considered a surgical wound. 415.12

Based on staff interviews and record review during an abbreviated and partial extended survey it was determined that the facility failed to ensure a safe environment, failed to provide visual supervision and monitoring to protect the health and safety of each resident. The facility failed to perform functionality checks on the roam alert system and failed to have pictures of all wandering residents posted at the reception desk. Specifically, one (Resident #1) of 11 residents reviewed for accidents and supervision was identified by the facility for unsafe wandering on 1/1/14 when the resident was attempting to get on the elevators. Although a roam alert was placed on the resident, a reassessment for unsafe wandering was not completed. Two weeks later the resident was found by staff in the 1st floor lobby; the resident was not reassessed and the incident not investigated. On 4/12/14, the resident was transported by Activity staff to the 1st floor and left alone outside the elevator. Subsequently, the resident self-propelled her wheelchair and exited the facility undetected by staff via the front door. The resident was found by a visitor face down in the parking lot with an injury to the forehead. This resulted in potential for serious harm that is Immediate Jeopardy and Substandard Quality of Care. Complaint Number: NY 510 The findings are: The Policy and Procedure on Wandering Risk Scale dated 12/11 documented that if the resident is identified as high risk to wander actions to be taken include, but are not limited to, placing photograph at reception desk (if applicable). The Policy and Procedure on Shift Accountability dated 1/12 documented that the nurse in charge and Certified Nursing Assistant (CNA) are responsible for knowing the whereabouts of their resident. All staff are responsible for being aware of the environment of care and ensuring resident safety; intervening as needed to promote resident wellness and safety. The Policy and Procedure on Wandering and Elopement Prevention dated 5/12 documented that Nursing will complete the Wandering Risk Scale in the EMR (electronic medical record) on admission/readmission, quarterly and if there are clinical or behavioral changes noted. The interdisciplinary team will assess the resident based on their history and observed behaviors and will initiate an individualized plan of care for wandering/elopement. The Policy and Procedure on Clinical Alarms dated 2/14 documented that the roam alert system is a tracking system to identify residents who are at risk for wandering and elopement. It is a wandering and elopement prevention system that will alarm when a resident wearing a roam alert tag crosses a threshold designated by the facility. Resident #1 is [AGE] years old and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) (an assessment tool) dated 1/29/14 documented that Resident #1's cognition is severely impaired. The Care Plan Activity Report (CPAR) for Falls/Safety effective 9/7/13 documented Resident #1's risk for falls/safety with presence of risk factors including wandering. Interventions included were to identify and reduce risk factors. The Wandering Risk Scale (WRS) dated 12/19/13 documented that Resident #1 is low risk; no nursing action needed. The Nursing Progress Notes (NPN) dated 1/1/14 documented that, as per staff, resident frequently gets on elevator throughout am (morning) and pm (evening) shift to go to MDR (main dining room) stating she is going for meals. Redirected as needed with poor effects. Roam alert bracelet placed. Wandering protocol implemented. Will continue to monitor. The CPAR for Wandering/Elopement Risk effective 1/1/14 documented Resident #1's wandering/elopement risk related to dementia. Interventions included wearing alarm bracelet and monitor resident ' s whereabouts on unit/facility. The medical record lacked documented evidence that a WRS reassessment was completed. The NPN dated 1/16/14 documented that Resident #1 was found off the unit in the lobby; returned to the unit by staff. Alert bracelet removed from ankle and placed on dominant hand to prevent resident from removing bracelet. There was no documented evidence that an investigation was completed regarding Resident #1 wandering in the lobby. The Social Work MDS Note (SWMDSN) dated 2/10/14 documented Resident #1's cognition as severe impairment related to limited temporal orientation and recall. The SWMDSN documented that the resident has no behavior issues and wandering/elopement risk as no apparent risk. The WRS dated 2/12/14 documented that Resident #1 has no history or episode of wandering and is low risk; no nursing action needed. The Monthly MD (Medical Doctor) Exam dated 3/20/14 documented that Resident #1 is not oriented to place, time or situation. The NPN dated 4/12/14 at 3:03 PM documented that, at 2:15 PM, Activities took Resident #1 to bingo. Resident wandered off out to the front of the building, fell out of wheelchair, hit left side of forehead. Resident transferred to the hospital via ambulance. The NPN dated 4/12/14 at 8:12 PM documented that Resident #1 returned from the hospital with a bruise to the left forehead. The NPN dated 4/12/14 at 8:54 PM documented that, at approximately 2:45 PM, Resident #1 was seen sitting outside to the left of the front entrance by other residents and their family members. As per witness, wheelchair started to roll forward and then tipped off of curb. resident sustained [REDACTED]. The Incident Report dated 4/12/14 at 2:45 PM documented , as per visitor, resident was sitting in front of the building when chair rolled onto grass and then tilted off sidewalk; fell on to left side with back against curb and hit left side of forehead on curb. Lump noted left side of forehead. First aid provided and 911 called. The Investigation Summary Report dated 4/12/14 documented that Resident #1 was brought down to an activity program at about 2:10 PM. She had a roam alert tag in place and functioning when she left the unit. The resident left the activity, where she had been seated with her husband (Resident #2) and rolled self to lobby area. The roam alert did not pick up her tag; she seated herself in front of the facility. Her wheelchair rolled forward onto grass and moved forward causing wheelchair to tilt forward. Resident fell out of wheelchair. Resident has dementia. Prone to bruising and bleeding. Physical findings: lump to left side of forehead. The Activities Attendance for Bingo dated 4/12/14 documented that neither Resident #1 nor her husband were in attendance for bingo. The Medical Progress Notes dated 4/13/14 documented that Resident #1 was seen for follow-up after accident yesterday in which the patient's wheelchair tipped with resultant fall. Assessment: Contusion left frontal area, left orbit. The WRS dated 4/13/14 documented that Resident #1 has had no episode of wandering for the past 6 months. The Summary of Investigation dated 4/14/14 documented that, based on functionality of roam alert tag prior to the incident and after the incident, this was most likely a glitch in the roam alert system which allowed patient to get past the reception desk. The fall was caused by the wheel of her wheelchair going into the grass and tipping over, which caused the resident to hit her head on the curb...resident was taken down to activities; wheeled herself out of the main dining room. Because there was a glitch in the sensor - resident fell , facility will report to NYSDOH (New York State Department of Health)...Update to fall risk and wandering assessment. The Roam Alert System Company Work Order dated 4/15/14 documented that roam alerts were checked at all locations for proper operation. System is functioning per manufacturer's specifications. During an interview with the Director of Nursing (DON) on 4/15/14 at 1:04 PM the DON stated, on 4/12/14, Resident #1 had been in the main dining room with her husband for bingo; no Activities staff saw the resident leave. The DON was unable to say who brought the resident to bingo or if staff were interviewed regarding the resident's whereabouts at the time. The DON concluded and the Administrator agrees that the resident exited the front lobby door due to a glitch in the roam alert system; there was no staff failure. An interview was conducted with the Director of Engineering (DOE) on 4/16/14 at 9:45 AM. The DOE stated that Resident #1 went through the front lobby door on 4/12/14 and the roam alert tag did not sound. It is thought that there was a glitch in the roam alert system; the vendor company did a complete survey of the system and found that it is operating at operator's specifications. The sensor capture zone at the front entrance has been increased. An interview was conducted with a Registered Nurse Supervisor (RNS #1) on 4/16/14 at 10:40 AM. RNS #1 stated that, on 4/12/14 at 2:45 PM, she received a call from the receptionist, who said a resident fell outside. RNS #1 went outside and found Resident #1 lying with her back to the curb and left arm caught behind her; there was a lump to her head. 911 was called and the resident was taken to the hospital; RNS #1 cut off the resident's roam alert. When RNS #1 walked back into the facility, the roam alert sounded at the lobby door. RNS #1 did not know exactly what happened because the resident was at an activity prior to being found. Resident #1's roam alert obviously did not sound at the lobby door and "no one would know she's (Resident #1) a roam alert unless the alarm goes off. You wouldn't be wondering why she's wheeling around because you'd be waiting for the alarm to go off. That's how you know." RNS #1 stated that she read the progress notes for Resident #1 and reassessed the resident as being at risk for wandering but not high risk; "I wouldn't really consider her wandering. It's not like she went out the door." An interview was conducted with a Receptionist #1 (R#1) on 4/16/14 at 11:59 AM. R#1 stated that, on 4/12/14 around 2:45 PM, a visitor came from the outside to the desk saying a resident fell from her wheelchair; she called the supervisor. R#1 stated that she saw a resident from behind going outside but she did not know the resident. She would expect a roam alert to sound if a resident at risk for wandering was at the door because a picture and location of the resident will appear on the computer monitor; an alarm did not sound. There are only a few pictures at the reception desk and Resident #1 was not one of them. "Residents come and go all day long. Some we know and some we don't." An interview was conducted with a Recreation Specialist (RS #1) on 4/16/14 at 12:17 PM. RS #1 stated that, on 4/12/14 around 2:00 PM, she took Resident #1 on the elevator with three other residents from the 2nd floor. An alarm sounded in the elevator and she bypassed it by entering the code. RS #1 stated that she followed the usual process by transporting Resident #1 to the 1st floor, where she took the resident off the elevator and left her outside the elevator for volunteers to bring her to bingo while she returned to the 2nd floor to transport other residents. RS #1 stated that there is no specific monitoring of residents in an activity except for the recreation staff watching out for the residents. Most times, Resident #1 would sit with her husband in the main dining room for bingo but, on 4/12/14, "her husband was not there that day. I would know because I brought them (residents) down." An interview was conducted with RS #2 on 4/16/14 at 12:43 PM. RS #2 stated that, on 4/12/14, she was in charge of running the bingo program, neither Resident #1 nor her husband were present for the bingo activity in the main dining room on 4/12/14. An interview was conducted with RS #3 on 4/16/14 at 1:25 PM. RS #3 stated that, on 4/12/14, she was in the main dining room for the activity program. Resident #1 and her husband were not there for bingo.Residents are brought to the 1st floor for an activity and released to volunteers at the elevator. RS #3 stated that she was unaware that Resident #1 was at risk for wandering until after the incident of the resident being found on the ground outside. "There isn't any specific formula for knowing who is at risk (for wandering/elopement) in activities." An interview was conducted with the 2nd floor Nurse Manager (NM) on 4/16/14 at 1:45 PM. The NM stated that the departments know the residents who are wanderers based on their interaction with the residents. On 1/16/14, Resident #1 was found in the lobby but did not know by whom or why the resident was there. NM stated that she was the nurse manager on duty on 1/16/14 but did not know why a reassessment of the resident's wandering risk was not done or why an investigation was not initiated. The NM also stated that the supervisor is supposed to start an investigation and she was the supervisor. An interview was conducted with the Occupational Therapist (OT) on 4/16/14 at 2:31 PM. The OT stated that Resident #1 could self propel her wheelchair with supervision. "If a resident has a wander guard, that's how you know if they're at risk to wander." An interview was conducted with the assigned Certified Nursing Assistant (CNA #1) on 4/16/14 at 2:44 PM. CNA #1 stated that, on 4/12/14, she changed Resident #1 around 2:00 PM and then Activities staff took the resident off the floor. The resident usually roams around on the unit and tries to get on the elevator. CNA #1 also stated that she doesn't recall the resident ever being found off the unit. During a subsequent interview with the NM on 4/16/14 at 3:10 PM the NM stated that she wanted to clarify earlier statements she made. The NM stated that she did not need to do a reassessment of Resident #1's wandering risk on 1/16/14 because there was no change in the resident's behavior; a reassessment should have been done on 1/1/14 when the roam alert was placed on the resident. Regarding an investigation into 1/16/14, the NM stated, "Most probably and to the best of my knowledge the staff brought her down to the lobby. You can't assume that she (Resident #1) just wandered there." An investigation was not initiated. An interview was conducted with a RNS #2 on 4/16/14 at 3:52 PM. RNS #2 stated that, on 1/1/14, staff made her aware that Resident #1 was trying to get on the elevators and this was not a one-time thing, so RNS #2 placed a roam alert on the resident. A reassessment should have been done. RNS #2 also stated that, if a resident was found off the unit, it should be reported to administration and investigated. An interview was conducted with a Registered Nurse (RN #1) on 4/16/14 at 4:04 PM. RN #1 stated that she is a head nurse for the 2nd floor. Resident #1 will try to get on the elevator. "The resident has a roam alert and that's how we would know. She is monitored by the roam alert. That's how we supervise her." An interview was conducted with the Social Worker (SW) on 4/16/14 at 4:20 PM. The SW stated that she never noticed any signs of Resident #1 wandering. The SW stated she was never notified of the resident ' s risk for wandering and/or elopement. The SW stated that, when she wrote the SWMDSN on 2/10/14, "I looked at her care plans and concluded that she (Resident #1) was not at risk for wandering." An interview was conducted with the Director of Social Work (DSW) on 4/16/14 at 4:37 PM. The DSW stated that she would expect her staff to know which residents are at risk for wandering and elopement and plan interventions accordingly. Nursing would make staff aware of a resident's wandering/elopement risk verbally or during an interdisciplinary team meeting. The DSW further stated that her staff should review all of a resident's care plans at least every quarter and/or if there is a change in behavior. An interview was conducted with the Director of Recreation (DR) on 4/17/14 at 9:45 AM. The DR stated that, when residents are in activities, recreation staff try to observe them but there is no specific supervision of residents. If residents are wandering risks, "They have roam alerts." During a subsequent interview with the DOE on 4/17/14 at 10:04 AM the DOE stated that, if there are any issues with the roam alert system, the vendor is called for service but there is no standard maintenance schedule of the system. An interview was conducted with the Performance Improvement Coordinator (PIC) on 4/17/14 at 12:45 PM. The PIC stated that she received the information regarding the 4/12/14 incident with Resident #1 from RNS #1. "I was confident with what the supervisor told me. She is a good historian." Resident #1 was seated with her husband in the activity and she rolled out of the dining room. "Patients are allowed to move around. It's not a prison." The PIC stated that the investigation was complete and the conclusion reached was that there was some sort of glitch in the roam alert system. An interview was conducted with the In-Service Coordinator (ISC) on 4/17/14 at 12:55 PM. The ISC stated that she does not know how the departments are notified of a resident's wandering risk status and she is not sure how residents on the unlocked units are accounted for when taken off the units for activities. CNAs are assigned to help Activity staff with transportation if needed but not supervision. "It's not a jail. A patient is allowed to move." The ISC further stated that she is not aware as to when a resident's picture is placed at the reception area. An interview was conducted with the Attending Physician (AP) on 4/17/14 at 1:03 PM. The AP stated that Resident #1 has moderate dementia and "may not be knowing what she was doing and may do something that's not safe for her." The resident needs visual supervision at all times. The resident sustained [REDACTED]. The AP further stated that "there are an equal number of residents like her (Resident #1) who also need more attention." An interview was conducted with the Medical Director (MD) on 4/17/14 at 2:30 PM. The MD stated that the presence of a roam alert on a resident is one indicator that a resident is at risk for elopement but "the roam alert is the secondary additional check. Staff should be the primary check to monitor the patient." She further stated that residents with a roam alert should not be allowed to wander on their own. During a latter interview with the NM and DON on 4/17/14 at 3:50 PM, the NM stated that the policy regarding pictures of residents at the front desk is if applicable and means, if the staff feels that a resident is at high risk for wandering, a picture can be posted. The DON stated that a picture should be posted if a resident scores 11 or higher on the WRS. During a subsequent interview with the DON on 4/18/14 at 10:05 AM, the DON stated that she is acting on the Administrator's behalf since the Administrator is on vacation. The Administrator was made aware of the incident. The DON stated that she is in agreement with the investigation conclusion that there was a glitch in the roam alert system resulting in Resident #1 going through the lobby door. Residents' pictures are posted at the receptionist if a resident is high risk for wandering or has a prior history of wandering and/or elopement. A reassessment of a resident's wandering risk is updated if there is a change in behavior or staff observe signs of wandering and elopement. 415.12

Based on staff interviews and record review during an abbreviated and partial extended survey it was determined that the administration failed to ensure that there was system in place to ensure that each resident reached and maintained the highest practicable physical, mental and psychosocial well-being. Specifically, one (Resident #1) of 11 residents reviewed for wandering/elopement behavior lacked documented evidence that the resident was reassessed after a roam alert was implemented for wandering. Two weeks later, the resident was found by staff in the first floor lobby; the resident was not assessed and an investigation was not conducted. On 4/12/14 the resident exited the facility undetected by staff and was found by a visitor face down in the parking lot with an injury to the forehead. Administration failed to conduct a complete investigation, determine the root cause and identify system failures related to residents who are at risk for unsafe wandering. This resulted in potential for serious harm that is Immediate Jeopardy. Complaint Number: NY 510 Cross References: F 323 - Accidents & Supervision F 501 - Medical Director F 520 - Quality Assessment & Assurance The findings are: Resident #1 is [AGE] years old and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) (an assessment tool) dated 1/29/14 documented that Resident #1's cognition is severely impaired. During an interview with the Director of Nursing (DON) on 4/15/14 at 1:04 PM, the DON stated that on 4/12/14, Resident #1 had been in the main dining room with her husband for bingo; no Activities staff saw the resident leave. The DON was unable to say who took the resident to bingo or if staff were interviewed regarding the resident's whereabouts at the time. The DON stated that she has concluded and the Administrator agrees that the resident exited the front lobby door due to a glitch in the roam alert system; there was no staff failure. An interview was conducted with the Director of Engineering (DOE) on 4/16/14 at 9:45 AM. The DOE stated that Resident #1 went through the front lobby door on 4/12/14 and the roam alert tag did not sound. The DOE stated that it is thought that there was a glitch in the roam alert system; the vendor company did a complete survey of the system and found that it is operating at operator's specifications. The sensor capture zone at the front entrance has been increased. During a subsequent interview with the DOE on 4/17/14 at 10:04 AM the DOE stated that, if there are any issues with the roam alert system, the vendor is called for service but there is no standard maintenance schedule of the system. During a subsequent interview with the DON on 4/18/14 at 10:05 AM, the DON stated that she is acting on the Administrator's behalf since he is on vacation. The Administrator was made aware of the incident. The investigation was completed and she was in agreement with the investigation conclusion that there was a glitch in the roam alert system resulting in Resident #1 going through the lobby door. The DON further stated that residents' pictures are posted at the receptionist if a resident is high risk for wandering or has a prior history of wandering and/or elopement. A reassessment of a resident's wandering risk is updated if there is a change in behavior or staff observe signs of wandering and elopement. 415.26

Based on staff interview and record review during an abbreviated and partial extended survey, the Medical Director failed to ensure that residents' care was provided in accordance with current standards of practice to meet the needs of each resident exhibiting wandering behavior. Specifically, one (Resident # 1) of 11 residents reviewed for wandering behavior exited the facility and was found by a visitor in the parking lot with an injury to the forehead. The Medical Director failed to ensure that policies and procedures were implemented to provide visual supervision of resident with history of wandering behavior. This failure resulted in potential for serious harm that is Immediate Jeopardy. Complaint Number: NY 510 Cross References: F 323 - Accidents & Supervision F 490 - Administration F 520 - Quality Assessment & Assurance The findings are: Resident #1 is [AGE] years old and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) (an assessment tool) dated 1/29/14 documented that Resident #1's cognition is severely impaired. An interview was conducted with the Attending Physician (AP) on 4/17/14 at 1:03 PM, the AP stated that Resident #1 has moderate dementia and "may not be knowing what she was doing and may do something that is not safe for her." The resident needs visual supervision at all times, she sustained a contusion of left frontal area as a result of the 4/12/14 incident. The AP further stated "there are an equal number of residents like her (Resident #1) who also need more attention." An interview was conducted with the Medical Director (MD) on 4/17/14 at 2:30 PM, the MD stated that the presence of a roam alert on a resident is one indicator that a resident is at risk for elopement but "the roam alert is the secondary additional check. Staff should be the primary check to monitor the resident." Residents with a roam alert should not be allowed to wander on their own. The MD further stated that she is involved with policy changes on an ongoing basis. There have been no recent policy changes regarding monitoring and supervision of residents. 415.15 (a)

Based on staff interviews and record review during an abbreviated and partial extended survey the facility failed to provide a quality assessment and assurance program that functions to develop and implement appropriate plans of action to readily identify issues with the potential to cause serious harm to the health and safety of residents at risk for unsafe wandering. Specifically, Resident #1 was identified as low risk for wandering. The QAA Committee failed to investigate the root cause of Resident #1's unsafe wandering. Subsequently, the resident was able to exit the building undetected by staff through the front lobby door and was found by a visitor face down in the parking lot. The QAA Committee failed to conduct quality assessment and assurance to ensure the development and implementation of policies and procedures for the monitoring and supervision of residents identified with unsafe wandering. The QAA Committee also failed to identify system failures related to residents who are at risk for unsafe wandering. This resulted potential for serious harm that is Immediate Jeopardy. Cross References: F 323 - Accidents & Supervision F 490 - Administration F 501 - Medical Director The findings are: Resident #1 is [AGE] years old and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) (an assessment tool) dated 1/29/14 documented that Resident #1's cognition is severely impaired. An interview was conducted with the Performance Improvement Coordinator (PIC) on 4/17/14 at 12:45 PM. The PIC stated that she received the information regarding the 4/12/14 incident with Resident #1 from RNS #1. "I was confident with what the supervisor told me. She is a good historian." Resident #1 was seated with her husband in the activity and she rolled out of the dining room. "Patients are allowed to move around. It's not a prison." The PIC stated that the investigation was complete and the conclusion reached was that there was some sort of glitch in the roam alert system. An interview was conducted with the In-Service Coordinator (ISC) on 4/17/14 at 12:55 PM. The ISC stated that she does not know how the departments are notified of a resident's wandering risk status. The ISC stated that she is not sure how residents on the unlocked units are accounted for when taken off the units for activities. CNAs are assigned to help Activity staff with transportation if needed but not supervision. "It's not a jail. A patient is allowed to move." The ISC further stated that she is not aware as to when a resident's picture is placed at the reception area. An interview was conducted with the Attending Physician (AP) on 4/17/14 at 1:03 PM. The AP stated that Resident #1 has moderate dementia and "may not be knowing what she was doing and may do something that's not safe for her. The AP stated that the resident needs visual supervision at all times. The resident sustained [REDACTED]. The AP further stated that "there are an equal number of residents like her (Resident #1) who also need more attention." An interview was conducted with the Medical Director (MD) on 4/17/14 at 2:30 PM. The MD stated that the presence of a roam alert on a resident is one indicator that a resident is at risk for elopement but "the roam alert is the secondary additional check. Staff should be the primary check to monitor the patient." She further stated that residents with a roam alert should not be allowed to wander on their own. During a subsequent interview with the DON on 4/18/14 at 10:05 AM the DON stated that she is acting on the Administrator's behalf since the Administrator is on vacation. The Administrator was made aware of the incident. The DON stated that she is in agreement with the investigation conclusion that there was a glitch in the roam alert system resulting in Resident #1 going through the lobby door. The DON stated that residents' pictures are posted at the receptionist if a resident is high risk for wandering or has a prior history of wandering and/or elopement. A reassessment of a resident's wandering risk is updated if there is a change in behavior or staff observe signs of wandering and elopement. 415.27(a-c)

Based on observation, record review and staff interviews during an abbreviated and partial extended survey it was determined that the facility failed to ensure that each resident assessed and identified at risk for elopement/wandering was provided adequate supervision and monitoring to protect the health and safety of the residents. The facility failed to ensure that residents identified with a history of elopement and unsafe wandering had interventions in place to prevent future elopement. Specifically, one (Resident #1) of 7 residents reviewed with a history of wandering was seen on video exiting the facility through the front lobby on 12/9/11 at 5:18 PM. The facility was unaware that Resident #1 was missing until 4 hours later when it was noticed that the resident did not eat dinner. Resident #1 remained missing for 13 hours until returned to the facility by police. The resident had been identified as low risk for unsafe wandering and/or elopement by the facility's electronic computer system and no interventions were implemented, although the resident had a previous history of elopement. This resulted in no known actual harm with the potential for serious harm that is Immediate Jeopardy and Substandard Quality of Care for 242 residents. Complaint ID Number: NY 747 The findings are: Resident #1 is [AGE] years old and was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 dated 11/26/11 documented that Resident #1 is cognitively intact. The Hospital Emergency Department Record dated 7/18/11 documented that Resident #1 eloped from a sub-acute rehab facility in Queens and wandered the streets until he was found by his sister. The Hospital Patient Review Instrument (PRI) dated 7/18/11 documented Resident #1's primary [DIAGNOSES REDACTED]. The Hospital Psychiatry Consultation dated 7/20/11 documented that "although (Resident #1) is alert and oriented at times, he is confused and not able to understand clearly the risk and benefits of medical condition." The Hospital PRI dated 7/26/11 documented that Resident #1 was in "SAR (sub acute rehab) in Queens, Pt (patient) eloped." The facility's Preadmission assessment dated [DATE] documented that Resident #1 was on one to one supervision in the hospital and "was in sub acute in Queens; walked out wandering streets in Queens." The Nursing Progress Notes (NPN) dated 7/26/11 documented Resident #1's admission to the facility and that the resident was given a "wander bracelet placed on pt (patient). 1:1 (one to one) at bedside." The Social Services Progress Notes dated 7/28/11 documented that Resident #1 "does have a known history of elopement. Wander guard is placed due to this known history." The Comprehensive Care Plan (CCP) for Wandering/Pacing dated 7/27/11 documented that Resident #1 had a history of [REDACTED]. The CCP for Cognitive Impairment dated 7/28/11 documented that Resident #1 has impaired short-term memory, impaired decision-making, no safety awareness, no impulse control and impaired judgment secondary to Traumatic Brain Injury. The Psychiatric Evaluation (PE) dated 7/29/11 documented that Resident #1 had eloped from a nursing home in Queens. The PE documented a [DIAGNOSES REDACTED]." The NPN documented as follows: On 7/30/11, Resident #1 was transferred to the hospital for cranio-surgery. On 8/3/11, Resident #1's readmission to the facility, On 8/4/11, at 3:18 AM Resident #1 was being observed closely for wandering and at 3:59 PM a wander guard was applied to the resident for history of wandering. The CCP for Wandering/Pacing dated 8/4/11 documented that Resident #1 evidenced problems of "wandering: slow to moderate, repetitive, aimless ambulation and exhibits elopement behaviors of attempts to leave unit/facility as per reports observe for wandering off unit." The NPN dated 8/9/11 at 3:13 pm documented that Resident #1 was transferred to the hospital for right temporal lobe hematoma; "watch mate removed." Resident #1 was admitted to the hospital. The Policy and Procedure on Wandering Residents (PPWR) dated 11/10 documented "the facility will ensure the safety of all patients/residents, including residents who have a [DIAGNOSES REDACTED]." The PPWR documented that a resident will be identified as being at risk for wandering "on admission and readmission and on a quarterly basis ...If a resident has a history of wandering/elopement behaviors ...the Interdisciplinary Team will assess the resident based on the above behaviors and will initiate an individualized Plan of Care for wandering." The Policy and Procedure on Wandering Risk Scale (PPWRS) dated 11/10 documented that a resident will be reassessed "after 72 hours of admission, quarterly and whenever there is a change in patient's/resident's clinical status ...The EMR (electronic medical record) will automatically assign a score for each area based upon the answers checked." The Policy and Procedure on Shift Accountability dated 6/10 documented that "all staff are responsible for being aware of the environment of care and ensuring patient/resident safety by ...making periodic rounds to check on assigned patients/residents and intervening as needed to promote patient/resident wellness and safety ...Communication of problems and interventions must be made between the shifts." The NPN dated 8/25/11 documented that Resident #1 was readmitted to the facility status [REDACTED]. The Medical History/Physical Exam (MHPE) dated 8/26/11 documented that Resident #1 has Dementia. The Wandering Risk Scale (WRS) dated 8/28/11 documented that Resident #1 does not wander. The [DIAGNOSES REDACTED]. The WRS documented that Resident #1 was low risk for wandering and no nursing action needed. There was no documented evidence in Resident #'1s medical record of a WRS or plan of care for wandering and/or elopement from 8/29/11 to 12/9/11. There was no documented evidence of Resident #1's history of wandering and/or elopement on the CNA (Certified Nursing Assistant) Resident Plan of Care/Accountability Record dated " Admit 8/25. " The Physical Therapy Discharge Note dated 10/21/11 documented that Resident #1 is to ambulate with close supervision of unit staff. The MHPE dated 9/23/11 documented that Resident #1 has a cognitive impairment and was not oriented to person, time or situation. The MHPE dated 10/21/11 documented that Resident #1 was oriented to person and place but disoriented to time and situation. The MHPE dated 11/18/11 documented that Resident #1 is not oriented to person, time or situation. The Police Department Missing Person Report dated 12/9/11 at 9:30 PM (written by the facility's nursing supervisor) documented "Resident #1 is alert, forgetful and confused at times, requires constant monitoring ...has poor safety awareness, unsteady gait." The Police Department Report (PDR) dated 12/9/11 at 9:40 PM documented that the facility's nursing supervisor reported Resident #1 missing and Resident #1 had been observed walking out the door with another unknown woman known by the sister of the resident. Upon arrival, the facility's security video was reviewed and showed Resident #1 leaving the facility at 5:17 PM alone. The Investigation Summary Report dated 12/9/11 documented that Resident #1 was seen on video camera leaving the building with a jacket, helmet, cane and bag at approximately 5:20 PM. When the resident was unaccounted for between 8:00 PM to 9:00 PM, a Code Yellow (missing resident alert) was called. The resident was not found and the police department was contacted. The resident was located by the police on 12/10/11 at approximately 6:00 AM and returned to the facility. Resident #1 was sent to the hospital for evaluation and returned to the facility on [DATE] in the afternoon. The Summary of Investigation (SI) dated 12/12/11 documented that Resident #1 had not made any attempts to leave facility since admission, was assessed and scored low risk for wandering; therefore, a wander guard was not indicated. Resident #1's act of leaving was premeditated since he took his coat and other items. The SI concluded that there was no reasonable cause to suspect abuse, neglect or mistreatment of [REDACTED]. On 12/14/11 at 12:10 PM, the Administrator stated that there are policies for wandering residents, the WRS and missing residents. There is no specific policy regarding elopement prevention. An interview was conducted with the Registered Nurse Clinical Director (RNCD) on 12/14/11 at 1:40 PM. The RNCD was unable to demonstrate how the computerized WRS scores a resident's risk factors for wandering and stated, "I don't understand how the system works. Let me get (the Director of Nursing)." An interview was conducted with the Director of Nursing (DON) on 12/14/11 at 1:44 PM. The DON stated that the section on Resident #1's 8/28/11 WRS entitled 'Quarterly Update' did not have a score of 5 because the resident's [DIAGNOSES REDACTED]. The DON stated, "He (Resident #1) is at high risk because of the TBI." On 12/14/11 at 2:15 PM during an interview with the Administrator, he stated that the DON had thought the resident would have been at high risk because of TBI but this is not true. The Administrator demonstrated a WRS on the computer and stated that, because Resident #1 did not wander aimlessly within the facility, the computer would not have scored him with a 5. Since Resident #1's elopement from the facility, Resident #1's WRS is scored with 'wanders aimlessly within the facility' which gives Resident #1 the score of 5 which would make the resident at high risk for wandering. The Administrator stated that a dementia [DIAGNOSES REDACTED]. The Administrator further stated that "His (Resident #1 ' s) poor judgment led him to wander for 12 hours." An interview was conducted with the 3:00 PM to 11:00 PM Registered Nurse Supervisor (RNS) on 12/14/11 at 3:16 PM. The RNS stated that any resident with a history of elopement should be considered high risk for wandering. The RNS stated that the WRS only takes into account if a resident has wandered in the facility and since Resident #1 was initially immobile on his first admissions, Resident #1 was scored at low risk. The RNS stated that she does not know how to add something like the resident's history of elopement to the WRS. "He (Resident #1) was following directions so we didn't have him as a high elopement risk. We try to give every resident the benefit of the doubt before putting on a wander guard." An interview was conducted with the 3:00 PM to 11:00 PM Licensed Practical Nurse (LPN #1) on 12/14/11 at 3:34 PM. LPN #1 stated that she was the medication nurse for Resident #1 on the evening the resident eloped. LPN #1 had dining room duty and did not see Resident #1. The resident's assigned aide had told LPN #1 that Resident #1 normally goes outside and will probably come back soon. LPN #1 stated that she was not aware of this, so LPN #1 presumed that Resident #1 was outside in the courtyard but did not check. LPN #1 stated that, a few hours later between 8:30 PM and 9:00 PM, LPN #1 went into the resident's room and the dinner tray was still there untouched. LPN #1 called the supervisor and a search for the resident was started. LPN #1 stated that staff does not usually go looking for residents on her unit, "this is a rehab. we don't look after the patients. If we can't find them, maybe, we'll page overhead for a patient." LPN #1 stated "if a resident is at risk for elopement,the system (roam alert) monitors them (the residents). I never knew he (Resident #1) had a history of [REDACTED]." An interview was conducted with the Receptionist on 12/15/11 at 10:05 AM at the front desk. During this time the Receptionist's computer monitoring screen was observed to be blank. The Receptionist stated that the computer system was uploading, the system uploads everyday automatically and when this is taking place she ( Receptionist) cannot locate a resident until it is completed. The Receptionist further stated, "the system is great when it works." During a subsequent interview with the Receptionist on 12/19/11 at 9:45 AM, the Receptionist stated that the back up system to monitor residents is the roam alert (wander guard) system and "any technology will have its flaws. There is a picture book of residents at risk to wander, but it is not used." An interview was conducted with the Licensed Master Social Worker (LMSW) on 12/15/11 at 11:58 AM. The LMSW stated that Resident #1 has no impulse control or safety awareness. The LMSW stated that Resident #1 is alert and oriented to an extent and Psychiatry deemed Resident #1 without capacity. The LMSW stated that Resident #1 had a wander guard the first two admissions to the facility, but on the admission of 8/25/11, the staff had come to know the resident so the wander guard was stopped. "I guess we could not actually know him in 9 days." The LMSW stated that she was aware of Resident #1's history of elopement but nursing determines if a resident is at risk for wandering and/or elopement. The LMSW stated that based on the nursing assessment there was no care plan for wandering and/or elopement. The LMSW further stated that she is not sure how a resident without a wander guard would be monitored for wandering and/or elopement. An interview was conducted with the assigned 3:00 PM to 11:00 PM CNA #1 on 12/15/11 at 2:00 PM. CNA #1 stated that on 12/9/11 she made rounds when she began her shift and Resident #1 was in his room asking CNA #1 about the weather outside. CNA #1 spent some time with Resident #1 and went to care for other residents before taking her break around 5:15 PM. CNA #1 stated that upon returning from her break she went to the dining room to help feed. While feeding, another aide (CNA #4) said that Resident #1's tray had been served in his room but the resident was not there. CNA #1 stated "sometimes he (Resident #1) says he's going to stretch his legs and will go out to the courtyard or go down the hall by the social work office. He likes to look out the window." CNA #1 stated that later in the evening around 9:00 PM, she had asked LPN #1 if she ( LPN #1) had seen the resident and LPN #1 went into the resident ' s room. CNA #1 stated that Resident #1's meal tray was still there, so LPN #1 called the supervisor and a Code Yellow to search for the resident. CNA #1 stated that she has been assigned to Resident #1 since he came to the facility in July 2011. CNA #1 stated that, when Resident #1 first came to the facility, Resident #1 had a wander guard but he never could get up out of the bed. CNA #1 stated that she was never told that Resident #1 had a history of [REDACTED].#1 taking a walk. CNA #1 stated that, "if someone's a wanderer they have a wander guard. I don ' t know anything different." A subsequent interview was conducted with the RNCD on 12/15/11 at 2:14 PM. The RNCD stated that Resident #1 had poor impulse control and a history of elopement from a previous facility. The RNCD stated that Resident #1 had required assistance of two to three staff members to get out of bed during his first two admissions, but after Resident #1 was readmitted on [DATE], Resident #1 was more independent and he had not been reassessed for wandering again since becoming more independent. "We followed policy." The RNCD also stated " he probably should have been reassessed. " An interview was conducted with the Physical Therapist (PT) on 12/15/11 at 3:02 PM. The PT stated that, when Resident #1 first came to the facility at the end of July 2011 and early August 2011, it would take about 45 minutes to be able to get the resident out of bed. After Resident #1's hospitalization for surgery in August 2011, Resident #1 became progressively more mobile and the PT was more concerned about keeping the resident this way. The PT stated that Resident #1 should never be ambulating without supervision and using his helmet. The PT stated that she had treated Resident #1 for months and, prior to the resident's elopement on 12/9/11, the PT was not aware of or told that Resident #1 had a history of [REDACTED]." An interview was conducted with a 4:00 PM to 10:00 PM CNA #2 on 12/15/11 at 3:10 PM. CNA #2 stated that, although she has not been assigned to the resident in a couple of months, she has seen Resident #1 puttering around off the unit. CNA #2 stated that she did not think Resident #1 was a wanderer so she never said anything to the resident or staff. CNA #2 stated that the only way to know if a resident is a wanderer is if the resident has a wander guard and she (CNA #2) never heard anything about wandering and/or elopement in regard to Resident #1. An interview was conducted with a 3:00 PM to 11:00 PM CNA #3 on 12/15/11 at 3:54 PM. CNA #3 stated that she was not aware of Resident #1 ever being a risk for wandering and/or elopement. CNA #3 stated that "the ADL card doesn't say anything about someone being a risk. If they (residents) don't have a wander guard then we have no way of knowing." An interview was conducted with the 3:00 PM to 11:00 PM charge LPN #2 on 12/16/11 at 10:02 AM. LPN #2 stated that she was on duty on 12/9/11 when Resident #1 eloped. LPN #2 stated that she saw Resident #1 in his room watching television when LPN #2 came on duty at 3:00 PM. LPN #2 stated that, on the evening of 12/9/11, she had a new admission and was awaiting two more admissions to her unit. LPN #2 did not see Resident #1 again after 3:00 PM and was not aware that Resident #1 was missing until sometime after 8:15 PM when she was told by LPN #1 that the resident was missing. LPN #2 stated that she tries to go up and down the hallway looking in resident rooms throughout her shift but "there is no set time for making rounds." LPN #2 stated that, when Resident #1 was first admitted to the facility, Resident #1 was very hard to motivate and could not get him out of bed. Over time, Resident #1 became more independent. LPN #2 stated that she recalled Resident #1 having a wander guard when he first came in but had no idea that Resident #1 had a history of [REDACTED].#2 would have told the CNAs on report. LPN #2 stated that, to her understanding, any resident who has a history with wandering would have a wander guard because there is no other means to keep them safe. LPN #2 stated, "As far as I know, the wander guard always works." LPN #2 stated that she has been taught about Code Yellow when a resident is missing, but could not recall if she had ever received any training regarding identifying residents at risk for wandering and/or elopement. LPN #2 stated that Resident #1 did not have a care plan for wandering and/or elopement. An interview was conducted with a 7:00 AM to 3:00 PM CNA #4 on 12/16/11 at 11:00 AM. CNA #4 stated that she worked the 3:00 PM to 11:00 PM nursing shift on 12/9/11. CNA #4 stated that Resident #1 was not assigned to her but CNA #4 knows the resident. CNA #4 stated that she was assigned to pass out dinner trays and brought Resident #1's tray to his room at an unrecalled time. Resident #1 was not in his room and CNA #4 told his assigned CNA#1, who told CNA #4 that Resident #1 was probably taking a walk in the courtyard and would be back. CNA #4 stated that Resident #1 "doesn't comprehend things when you tell him, but I don't know why. His mental stuff comes and goes. He might be talking complete sense one day and the next day doesn't make any sense." CNA #4 did not know Resident #1 had a history of [REDACTED].#1) walks really good with his cane. I never see him in the dining room but I ' I've seen him walk down off the unit." CNA #4 further stated, "Most of the time those residents have a wander guard. That's what we're taught." An interview was conducted with the 7:00 AM to 3:00 PM CNA #5 on 12/16/11 at 11:18 AM. CNA #5 stated that she has been assigned to Resident #1 since the resident's elopement. Resident #1 is difficult because he likes to have his own space and the resident will get mad if he's not left to do what he wants. CNA #5 stated that, prior to Resident #1's elopement, "the only thing I can remember being told is, because he (Resident #1) has a helmet, don't leave him alone. I don't really remember being told about him wandering or leaving somewhere." Regarding in-service training, CNA #5 further stated, "I can't remember anything about wandering. We get in-serviced about missing patients." An interview was conducted with a 3:00 PM to 11:00 PM LPN #3 on 12/16/11 at 12:24 PM. LPN #3 stated that she was the nurse on duty when Resident #1 was readmitted to the facility on [DATE]. LPN #3 stated that she had known about Resident #1's history of elopement and that the resident had a wander guard on the two previous admissions. LPN #3 stated that she did not place a wander guard on Resident #1 when he was readmitted . LPN #3 stated, "When he (Resident #1) came back in August he was pretty independent than before. I don't really have a rationale for it (not placing a wander guard)." LPN #3 further stated Resident #1 should have had a wander guard, because " usually we should go by the history." LPN #3 stated that she did not recall ever talking to CNAs about Resident #1's history of elopement. An interview was conducted with the Attending Physician on 12/16/11 at 1:10 PM. The AP stated that Resident #1 can follow simple directions but "his abstraction and judgment are not really there." Resident #1's cognition is "a total disconnect from brain to body." The AP stated that she would not normally be involved in whether or not a resident wears a wander guard because it is nursing judgment and there is no need for a physician's orders [REDACTED]. The AP stated, "He's (Resident #1) always at risk for wandering. I don't believe that he actually meant to leave and not come back, but, when he got out there he couldn't come back. His (Resident #1 ' s) brain function is unable to navigate the world. He's not safe on his own. He ' ll always need supervision." The AP further stated that she is the Medical Director for the facility and has looked at policies and procedures regarding wandering since the incident but there have been no policy changes. The AP stated, "We have not looked at the system yet. It's too new (the elopement incident). We have to sit down and talk to everyone and see if we missed something." An interview was conducted with the 11:00 PM to 7:00 AM charge LPN #4 on 12/16/11 at 1:46 PM. LPN #4 stated that she did not know why she would have written on Resident #1's 8/4/11 care plan to observe for wandering off unit, because Resident #1 "didn't have a history of elopement." LPN #4 stated that she did not remember if she had been in-serviced regarding wandering and/or elopement. An interview was conducted with a 3:00 PM to 11:00 PM CNA #6 on 12/16/11 at 2:00 PM. CNA #6 stated that she knew Resident #1 and believes "the facility gave the resident permission to go out by himself," although CNA #6 could not recall from whom she heard this. CNA #6 stated that she has, at times, taken care of Resident #1 and "did not trust him one bit." CNA #6 stated that Resident #1 would wrap utensils in towels and keep them with him. CNA #6 stated that she was not aware that Resident #1 had a history of [REDACTED]. An interview was conducted with a 7:00 AM to 3:00 PM CNA #7 on 12/16/11 at 2:09 PM. CNA #7 stated that she had Resident #1 on her assignment up until the resident's elopement on 12/9/11. CNA #7 stated that Resident #1 always seemed to like her and CNA #7 would walk with him. CNA #7 stated that she never knew that Resident #1 had a history of [REDACTED]. An interview was conducted with the In-Service Coordinator (ISC) on 12/19/11 at 10:18 AM. The ISC stated that staff is in-serviced every January regarding elevator codes, making sure resident alarms and exit alarms are on, and what to do if a resident goes missing. The ISC stated that she considers this to be elopement prevention. A subsequent interview was conducted with the DON on 12/19/11 at 10:24 AM. The DON stated that "there is no back up system in place as such" to the wander guard system. All CNAs are expected to make rounds on residents at frequent intervals but at no specific time. The DON stated that in regard to elopement prevention, the facility has a Code Yellow Missing Resident Policy. Regarding preventative measures for wandering and/or elopement in place for Resident #1 prior to his elopement, the DON stated, "I don't know; I don't work on the unit." During a subsequent interview with the Administrator on 12/19/11 at 10:26 AM, the Administrator stated that he was advised of Resident #1's elopement on 12/9/11 at approximately 9:30 PM by the RNS. The Administrator stated that a "Code Yellow" had already been called and Resident #1 was not located. The Administrator gave the RNS instructions to contact the police and file a Missing Person Report. The Administrator kept contact with facility staff throughout the night until Resident #1 was returned by police on 12/10/11 at approximately 6:30 AM. The Administrator concluded that Resident #1's assigned aide should have known the whereabouts of the resident and the receptionist should have seen Resident #1 exiting the facility as he passed the front desk. 415.12 (h) (1) (2)

Based on observation, record review and staff interviews during an abbreviated and partial extended survey it was determined that the administration of the facility failed to ensure that there was a system in place to assure that each resident reached and maintained the highest practicable level of physical and psychosocial well being. Resident #1 had a known history of elopement and was not provided the necessary supervision to protect his health and safety. Resident #1 successfully eloped from the facility on 12/09/11 through the front lobby. The facility was unaware that the resident was missing until 4 hours later when it was noticed that the resident did not eat dinner and the resident remained missing for approximately 13 hours until found by the police. The facility also failed to perform a thorough investigation to determine root cause to prevent further instances of unsafe wandering and failed to identify system failures related to residents who are at risk for unsafe wandering and/or elopement. This resulted in no known actual harm with the potential for serious harm that is Immediate Jeopardy for 242 residents. Refer also to F 323 - Accidents and Supervision and F -520 Quality Assessment and Assurance The findings are: During an interview with the Administrator on 12/14/11 at 12:10 PM, the Administrator stated that there are policies for wandering residents, the Wandering Risk Scale (WRS) and missing residents. There is no specific policy regarding elopement prevention. An interview was conducted with the Attending Physician (AP) on 12/16/11 at 1:10 PM. The AP stated that Resident #1 can follow simple directions but "his abstraction and judgment are not really there." Resident #1's cognition is "a total disconnect from brain to body." The AP stated that she would not normally be involved in whether or not a resident wears a wander guard. The AP stated, "He's (Resident #1) always at risk for wandering." Resident #1's "brain function is unable to navigate the world. He's not safe on his own. He'll always need supervision." The AP further stated that she is the Medical Director for the facility and has looked at policies and procedures regarding wandering since the incident but there have been no policy changes. The AP stated, "We have not looked at the system yet. It's too new (the elopement incident). We have to sit down and talk to everyone and see if we missed something." An interview was conducted with the In-Service Coordinator (ISC) on 12/19/11 at 10:18 AM. The ISC stated that staff is in-serviced every January regarding elevator codes, making sure resident alarms and exit alarms are on, and what to do if a resident goes missing. The ISC stated that she considers this to be elopement prevention. An interview was conducted with the DON on 12/19/11 at 10:24 AM. The DON stated that "there is no back up system in place as such" to the wander guard system and all CNAs are expected to make rounds on residents at frequent intervals but at no specific time. The DON stated that, in regard to elopement prevention, the facility has a Code Yellow Missing Resident Policy. Regarding preventative measures for wandering and/or elopement in place for Resident #1 prior to his elopement, the DON stated, "I don't know. I don't work on the unit." During a subsequent interview with the Administrator on 12/19/11 at 10:26 AM, the Administrator stated that he was advised of Resident #1's elopement on 12/9/11 at approximately 9:30 PM by the RNS. The Administrator stated that a "Code Yellow" had already been called and Resident #1 was not located. The Administrator gave the RNS instructions to contact the police and file a Missing Person Report. The Administrator kept contact with facility staff throughout the night until Resident #1 was returned by police on 12/10/11 at approximately 6:30 AM. The Administrator concluded that Resident #1's assigned aide should have known the whereabouts of the resident and the receptionist should have seen Resident #1 exiting the facility as he passed the front desk. 415.26

Based on record review and staff interviews during the abbreviated and partial extended survey the facility failed to provide a quality assessment and assurance program that functions to develop and implement appropriate plans of actions to readily identify issues with the potential to cause serious harm to the health and safety of residents at risk for wandering. Specifically, the QAA Committee failed to conduct quality assurance and assessment of the facility's electronic computer system to determine if the system appropriately scored residents who may be at risk for wandering based on pre-determined criteria. The QAA Committee also failed to perform an investigation to determine the root cause and prevent further instances of unsafe wandering and failed to identify systems failures related to residents who are at risk for unsafe wandering. One ( Resident #1) of seven residents reviewed for elopement with a known history of elopement was reassessed by the facility's electronic computer system as low risk for unsafe wandering/elopement and no interventions were implemented to prevent the possibility of future elopement. Resident #1 left the facility and remained missing for approximately 13 hours until found by the police. This resulted in no known actual harm with the potential for serious harm that is Immediate Jeopardy for 242 residents. Complaint Number: NY 747 The findings are: The Summary of Investigation (SI) dated 12/12/11 documented that Resident #1 had not made any attempts to leave facility since admission, was assessed and scored low risk for wandering; therefore, a wander guard was not indicated. Resident #1's act of leaving was premeditated since he took his coat and other items. The SI concluded that there was no reasonable cause to suspect abuse, neglect or mistreatment of [REDACTED]. The Performance Improvement (PI) dated 12/12/11 documented that the Shift Accountability Policy and Guest Registry Policy were reviewed in relation to Resident #1's elopement. The PI documented that there is no issue with orientation and staff in-servicing and found the process deficiency to be related to individual failures on the parts of Resident #1's assigned CNA and the receptionist. On 12/14/11 at 12:10 PM, the Administrator stated that there are policies for wandering residents, the WRS and missing residents. There is no specific policy regarding elopement prevention. An interview was conducted with the Attending Physician (AP) on 12/16/11 at 1:10 PM. The AP stated that Resident #1 can follow simple directions but "his abstraction and judgment are not really there." Resident #1's cognition is "a total disconnect from brain to body." The AP stated that she would not normally be involved in whether or not a resident wears a wander guard because it is nursing judgment and there is no need for a physician's orders [REDACTED]. The AP stated, "He's (Resident #1) always at risk (for wandering). I don't believe that he actually meant to leave and not come back, but, when he got out there he couldn't come back." The AP stated that Resident #1's "brain function is unable to navigate the world. He 's not safe on his own. He'll always need supervision." The AP further stated that she is the Medical Director for the facility and has looked at policies and procedures regarding wandering since the incident but there have been no policy changes. The AP stated, "We have not looked at the system yet. It ' s too new (the elopement incident). We have to sit down and talk to everyone and see if we missed something." An interview was conducted with the In-Service Coordinator (ISC) on 12/19/11 at 10:18 AM. The ISC stated that staff is in-serviced every January regarding elevator codes, making sure resident alarms and exit alarms are on and what to do if a resident goes missing. The ISC further stated that she considers this to be elopement prevention. An interview was conducted with the DON on 12/19/11 at 10:24 AM. The DON stated that "there is no back up system in place as such" to the wander guard system. All CNAs are expected to make rounds on residents at frequent intervals but at no specific time. The DON stated that in regard to elopement prevention, the facility has a Code Yellow Missing Resident Policy. Regarding preventative measures for wandering and/or elopement in place for Resident #1 prior to his elopement, the DON stated, "I don't know. I don't work on the unit." An interview was conducted with the Administrator on 12/19/11 at 10:26 AM. The Administrator stated that he was advised of Resident #1's elopement on 12/9/11 at approximately 9:30 PM by the RNS. The Administrator stated that a 'Code Yellow' had already been called and Resident #1 was not located. The Administrator gave the RNS instructions to contact the police and file a Missing Person Report. The Administrator kept contact with facility staff throughout the night until Resident #1 was returned by police on 12/10/11 at approximately 6:30 AM. The Administrator concluded that Resident #1's assigned aide should have known the whereabouts of the resident and the receptionist should have seen Resident #1 exiting the facility as he passed the front desk. 415.27 (a-c)