Every finding on record at Medford Multicare Center For Living

Based on record review and staff interviews during the survey, the facility failed to ensure that each resident received adequate supervision and assistance to prevent accidents. This was identified for one (Resident #111) of three residents reviewed for falls. Specifically, Resident #111 was totally dependent on two staff members for bed mobility and for personal hygiene as per the comprehensive care plan. On 12/09/2025, Certified Nursing Assistant #1 did not follow the resident's plan of care and provided toileting care by themselves while the resident was in bed. The resident fell out of bed and sustained a fracture to the right lower leg bones. This resulted in actual harm to Resident #111 that was not Immediate Jeopardy.The findings include: The facility's policy titled Activities of Daily Living effective 01/2026 documented the resident will be expected to maintain reasonable standards of hygiene and grooming during their stay at the facility and will be offered all necessary supplies and assistance to do so. When autonomy and independence are no longer possible or feasible, the resident care staff will provide the necessary support in all activities of daily living functioning.Resident #111 was admitted with diagnoses that included anoxic brain damage (brain injury due to lack of oxygen), quadriplegia (paralysis affecting all limbs), and seizure disorder. A quarterly Minimum Data Set (a resident assessment tool) dated 10/19/2025 documented the resident had short term and long-term memory problems, had no behavioral symptoms, and was dependent on staff for all aspects of daily living including the bed mobility (helper does all of the effort. The Resident does none of the effort to complete the activity; or the assistance of two or more helpers is required for the resident to complete the activity.) The resident had functional limitations in range of motion to both the upper and lower extremities. The resident had an external catheter and was always incontinent of the bowel. The nursing Falls Risk evaluation dated 11/05/2025, documented the resident's fall risk score was 13, which indicated the resident was at a moderate risk for falls. The Activity of Daily Living care plan initiated on 07/05/2024 and last revised 02/13/2025, documented the resident was totally dependent on two staff members for repositioning, turning in bed, personal hygiene, and bathing. The Risk for Falls Care Plan dated 07/05/2024 last revised 02/12/2025, documented the resident was at high risk for falls related to seizure disorder and diagnosis of osteopenia (a condition where your bone density is lower than normal). The interventions included to anticipate and meet the resident's needs, educate the resident/family/caregivers about safety reminders, and what to do if a fall occurs. A nursing progress note written by Registered Nurse #7 dated 12/09/2025, documented that at 05:30 PM they were notified that the resident fell out of bed while being changed by Certified Nursing Assistant #6. The resident was assessed by Registered Nurse #7 and had edema (swelling), redness, and excessive warmth to the right knee. An Accident and Occurrence report dated 12/09/2025 at 5:30 PM, documented Resident #111 fell out of bed to the floor. The resident required two-person assistance with care but assigned Certified Nursing Assistant #6 provided care [brief change] to Resident #111 by themselves. A written statement by Certified Nursing Assistant #6 dated 12/09/2025, documented that the resident was soiled and their wound dressing needed to be changed. Certified Nursing Assistant #6 notified Licensed Practical Nurse #6 of the need for the treatment change. While the resident was turned on their side, Certified Nursing Assistant #6 was washing the resident's backside; the resident slipped which caused the floor mat to move and the resident's lower body hit the floor. A written statement by Licensed Practical Nurse #6 dated 12/09/2025, documented that they were called by Certified Nursing Assistant #6 to administer wound care to Resident #111's sacral wound. While they were gathering supplies, Certified Nursing Assistant #6 again asked them to come to the resident's room. Upon entering the room, Resident #111 was lying on the floor with feces on them. The undated Final Investigation Summary and Determination documented on 12/09/2025, the resident was rolled to their side for wound care and attempted to assist with bed mobility and fell out of bed. The facility documented there was no reasonable cause to believe any alleged abuse, mistreatment, or neglect had occurred. A nursing progress note dated 12/10/2025 at 12:05 AM, documented the resident left the facility at 8:30 PM (12/09/2025) with emergency services. The hospital Discharge summary dated [DATE] documented the resident was admitted [to the hospital] on 12/09/2025 due to being logrolled while being changed and fell out of the bed. The resident was admitted to the hospital with right tibial and fibula (lower leg bones) fracture. During an interview on 05/29/2026 at 1:49 PM, Certified Nursing Assistant #6 stated they were assigned to Resident #111 on 12/09/2025 during the 3:00 PM -11:00 PM shift. Certified Nursing Assistant #6 stated that the resident was soiled with feces, and they had to change the resident's brief. The resident also had a sacral wound, and the wound dressing was also soiled and needed to be changed. Certified Nursing Assistant #6 stated they knew that two staff members were required to turn and position the resident during care while in bed. Licensed Practical Nurse #6 had instructed them to start cleaning the resident. Certified Nursing Assistant #6 stated they started to clean the resident without a second staff member's help because they wanted the resident ready for the wound treatment. Certified Nursing Assistant #6 stated they were able to turn the resident to their left side so that the nurse would be able to provide the wound care and the resident fell out of the bed. Certified Nursing Assistant #6 stated they should have asked for assistance from a second staff member before providing care to Resident #111.During an interview on 06/01/2026 at 3:21 PM, Licensed Practical Nurse #6 stated Certified Nursing Assistant #6 reported to them that the resident's brief was soiled and that the sacral wound dressing needed to be changed. Licensed Practical Nurse #6 stated that they instructed Certified Nursing Assistant #6 to wait until they checked the treatment orders and got the supplies. The resident required two person assistance with care and Certified Nursing Assistant #6 should not have moved the resident alone. Licensed Practical Nurse #6 stated that they gathered the wound care supplies and were on their way to the resident's room when Certified Nursing Assistant #6 told them to hurry to the resident's room. Licensed Practical Nurse #6 stated that when they entered the resident's room, they observed the resident on the floor. Licensed Practical Nurse #6 stated that they did not instruct Certified Nursing Assistant #6 to start care without them being in the room. During an interview on 06/01/2026 at 3:37 PM, Registered Nurse #7 stated they were the nursing supervisor on duty on 12/09/2025 and were notified that while Certified Nursing Assistant #6 was changing Resident #111's brief, the resident fell out of bed. Registered Nurse #7 stated Certified Nursing Assistant #6 was providing care to Resident #111 by themself. Registered Nurse #7 stated that Certified Nursing Assistant #6 should not have administered any care to the resident by themselves and should have waited for Licensed Practical Nurse #6 or asked another certified nursing assistant for assistance. Registered Nurse #7 stated upon assessment, the resident was noted with edema, redness and warmth to their right knee. Registered Nurse #7 stated that the fall could have been prevented if Certified Nursing Assistant #6 provided care to the resident with a second staff member present in the room. During an interview on 06/01/2026 at 4:09 PM, the Director of Nursing Services stated that Certified Nursing Assistant #6 should not have initiated any care for Resident #111 without a second staff member present in the room to assist them. The Director of Nursing Services stated Certified Nursing Assistant #6 did not follow Resident #111's plan of care. Based on the investigation, the resident sustained a fracture as a direct result of the fall. The Director of Nursing Services stated that this fall could have been avoided if Certified Nursing Assistant #6 had waited for assistance. During an interview on 06/02/2026 at 8:46 AM, the Medical Director stated that the staff should have followed the resident's plan of care to ensure the safety of the resident. The Medical Director further stated that Resident #111's leg fracture was a result of the fall and that the fall could have been prevented if Certified Nursing Assistant #6 had followed the plan of care.10 New York Code Rules Regulations 414.12(h)(2)

Based on observations, record review, and interviews, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of infectious diseases. This was identified for one (Resident #260) of five residents reviewed for infection control; two (Unit 1C medication cart and Unit 3C medication cart low side) of nine medications carts reviewed during the Medication Storage Task; and for two residents (Resident #75 and Resident #234) during the lunch meal dining observation. Specifically, 1) Resident #260 had a physician's order for contact precautions related to an infection with a carbapenem-resistant organism. Certified Nursing Assistant #3 was observed in Resident #260's room assisting the resident in the bathroom and to the wheelchair without wearing the required personal protective equipment; 2) Registered Nurse #4 and Licensed Practical Nurse #2 cleaned the glucometer machine with alcohol wipes instead of the manufacturer recommended Protection Agency (EPA) approved disinfectant to disinfect the shared glucometer; and 3) Licensed Practical Nurse #9 did not perform hand hygiene after they assisted Resident #75 with their meals and before assisting Resident #234 with their meals. The findings include: The facility policy titled Transmission Based Precautions last revised on 02/2026 documented isolation procedures are instituted whenever there is a risk of spreading infections. Transmission based isolation procedures are designed to protect other residents, personnel, and visitors from the spread of a confirmed or suspected infection or contagious disease. The Infection Prevention Nurse or designee will inform all applicable department heads of isolated residents to ensure all precautions, applicable to their department, are in place and staff in contact with the residents are aware and educated on the appropriate personal protective equipment to be used. The facility policy titled Cleaning of Glucometers in Long Term Care Facility dated 02/2026 documented cleaning the glucometer with a wipe from the purple top (EPA-registered disinfecting wipe) after each individual use. Allow the glucometer to air-dry to ensure the appropriate wet time for adequate sanitation. The facility's Hand Washing policy and procedure revised 03/2026 documented hands should be washed in between handling individual residents. 1) Resident #260 was admitted with diagnoses that included acute respiratory failure (lungs cannot properly oxygenate), epilepsy (recurrent unprovoked seizures), and tracheostomy (an opening surgically created through the neck into the windpipe to establish an airway). The admission Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 12, indicating the resident had moderate cognitive impairment. A physician's order dated 05/16/20026, documented contact precautions [in sputum]. A Comprehensive Care Plan dated 05/26/2026 documented Resident #260 had carbapenem-resistant organism (CRO) Enterobacter in sputum. Interventions included placing the resident on contact precautions and for staff to utilize proper personal protective equipment when caring for the resident. During an observation on 05/26/2026 at 12:28 PM, a contact precaution signage on Resident #260's room door documented that everyone must clean their hands before entering and when leaving the room. The signage indicated that providers and staff must also put on a gown and gloves before entering the room and discard the gown and gloves before exiting the room. Resident #260 was observed in the bathroom within their bedroom with Certified Nursing Assistant #3. Certified Nursing Assistant #3 was wearing gloves but did not wear a gown. Certified Nursing Assistant #3 then exited the bathroom with Resident #260. During an interview on 05/26/2026 at 12:34 PM, Certified Nursing Assistant #3 stated they took the resident to the bathroom to use the toilet and helped them into the wheelchair afterwards. Certified Nursing Assistant #3 stated they were not sure why they did not put on the gown prior to entering Resident #260's room. Certified Nursing Assistant #3 stated they heard the call bell and went into the room without thinking. Certified Nursing Assistant #3 stated they should have read the signage and put on the appropriate personal protective equipment before going into the room. During an interview on 06/01/2026 at 12:49 PM, Registered Nurse Educator/Infection Preventionist #1 stated Certified Nursing Assistant #3 should have put on a gown prior to entering Resident #260's room because the resident was on contact precautions for a drug-resistant organism. During an interview on 06/02/2026 at 8:05 AM, the Director of Nursing Services stated the staff should follow the transmission-based precaution instructions that are posted on the door signage. Contact precautions require a gown and gloves to be worn when entering the room and staff should remove the gown and gloves when exiting the room. 2) The blood glucose meter manufacturer's instruction manual last revised on 2018 documented the glucose meter must be disinfected between patient uses by wiping it with an Environmental Protection Agency-registered disinfecting wipe in between tests. The disinfection process reduces the risk of transmitting infectious diseases if it is performed properly. During an observation of the Unit 1 C cart and an interview with Registered Nurse #2 on 05/27/2026 at 6:05 AM, Registered Nurse #2 stated they clean and disinfect the glucometer with alcohol wipes between each resident use. Registered Nurse #2 then used a 70% alcohol pad to clean the glucometer. Registered Nurse #2 stated they use microbial wipes for cleaning the blood pressure cuffs, the stethoscope, and the medication cart. Registered Nurse #2 stated they were educated by the facility to use the alcohol wipes to clean the glucometer. During an interview on 05/28/2026 at 11:30 AM, Registered Nurse Clinical Care Coordinator #3 stated nurses should clean the glucometer with a microbial wipe and let the device air-dry before using the device on another resident. During an observation of the Unit 3C medication cart and an interview with Licensed Practical Nurse #2 on 05/29/2026 at 8:05 AM, Licensed Practical Nurse #2 stated they use alcohol wipes to clean and disinfect the glucometer between each resident use. Licensed Practical Nurse #2 then used a 70% alcohol prep pad to clean the glucometer. During an interview on 06/01/2026 at 12:49 PM, Registered Nurse Educator/Infection Preventionist #1 stated nurses should wipe down the glucometer with the Environmental Protection Agency-registered disinfecting wipe and wait two minutes for the glucometer to dry. Infection Preventionist #1 stated that alcohol wipes are not effective against the blood born pathogen and other microbes and are also not effective in preventing the spread of microorganisms from one resident to another resident. During an interview on 06/02/2026 at 8:02 AM, the Director of Nursing Services stated nurses should clean and disinfect the glucometer with the Environmental Protection Agency-registered disinfecting wipe and wait two minutes for the glucometer to air-dry. The Director of Nursing Services stated alcohol wipes would not kill all microbes on the glucometer. 3) During a dining room observation on 05/26/2026 at 1:10 PM, in the unit dining room, Licensed Practical Nurse #9 was observed assisting Resident #75 with their meal. After assisting Resident #75, Licensed Practical Nurse #9 was observed opening the food items on Resident #234's meal tray and feeding the resident without washing or sanitizing their hands. -Resident #75 had diagnoses that included Alzheimer's disease and hypertension. A significant change Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental score of 00, which indicated the resident had severely impaired cognition. The resident had no impairment to their upper and lower extremities, required set up help or clean up assistance for eating, and had no swallowing problems. The Certified Nursing Assistant Documentation report dated 05/2026 documented the resident required set up or clean up assistance for breakfast; however, required maximal assistance for the supper and on occasion for lunch meal. A Nutrition Comprehensive Care Plan, last reviewed 03/12/2026, documented to encourage the resident to eat slowly, chew food thoroughly before swallowing, monitor for meal and fluid completion and weight changes; monitor, document and report choking, coughing, and holding food in their mouth. -Resident #234 has diagnoses that included non-Alzheimer's dementia and diabetes mellitus. A significant change Minimum Data Set assessment dated [DATE] documented the resident had short and long term memory problems. The resident required supervision or touch assistance for eating. The Certified Nursing Assistant Documentation report dated 05/2026 documented the resident on occasion can feed themselves with set up help and required maximal assistance for completion of their meals. A Nutrition Comprehensive Care Plan dated 11/05/2025 documented the resident had potential nutritional problems. Interventions included to monitor/document/report any signs and symptoms of dysphagia (difficulty or discomfort in swallowing) such as pocketing (the act of storing food, pills, or liquid in the cheeks, lips, or under the tongue without swallowing), choking, coughing, drooling, holding food in mouth. Monitor nutritional status, serve diet as ordered, monitor intake and record. During an interview on 05/26/2026 at 1:30 PM, Licensed Practical Nurse #9 stated that Resident #75 and Resident #234 can usually feed themselves; however, at times they need assistance from staff to complete their meals. Licensed Practical Nurse #9 stated after feeding Resident #75, they should have performed hand hygiene before assisting Resident #234. During an interview on 06/01/2026 at 12:50 PM, the Infection Preventionist stated that Licensed Practical Nurse #9 should have performed hand hygiene in between providing care to each resident. During an interview on 06/02/2026 at 7:25 AM, the Director of Nursing Services stated that prior to feeding Resident #234, Licensed Practical Nurse #9 should have performed hand hygiene before assisting Resident #234. 10 New York Code Rules and Regulations 415.19(a)(1-3) (b)(4)

Based on record review and staff interviews during the survey, the facility failed to ensure that injuries of unknown origin were thoroughly investigated to rule out abuse, neglect, and mistreatment. This was identified for one (Resident #141) of five residents reviewed for accidents. Specifically, Resident #141 was observed on the floor secondary to an unwitnessed fall. The facility investigation did not include statements from all involved staff to determine the root cause and rule out abuse, neglect, and mistreatment. The findings include: The facility's Accident and Incident policy revised 04/21/2026 documented within 24 hours of the reported incident or accident, the risk manager or nurse supervisor must complete the Resident Accident & Incident Summary Report to determine if there is reason to believe that abuse, neglect, mistreatment or misappropriation has occurred and to determine the underlying cause of the reported accident or incident. The policy documented to properly document all events surrounding an accident and /or incident immediately at the time of the occurrence in order to complete a comprehensive investigation.Resident #141 was admitted with diagnosis that included severe dementia, anxiety, and cerebral vascular accident. An admission Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status Score of 2, which indicated the resident had severely impaired cognition. The resident had no impairment to the upper and lower extremities. The resident required supervision or touch assistance for all areas of mobility including transfers.A Fall Risk assessment dated [DATE] documented a score of 14, which indicated the resident was at a moderate risk for falls.A Comprehensive Care Plan for Falls dated 05/08/2026 documented the resident is at a high risk for falls related to confusion and generalized weakness. Interventions included ensuring the resident's call light is within reach and encouraging the resident to use the call bell for assistance as needed. The care plan was updated on 05/14/2026 and documented the resident had an unwitnessed fall and was transferred to the hospital. A Comprehensive Care Plan dated 05/08/2026 for Activities of Daily Living documented the resident had self-care performance deficit related to aggressive behaviors, confusion, and dementia. Interventions included supervision or touch assistance for transfers. A nursing progress note dated 05/14/2026, written by Registered Nurse Supervisor #8, documented that Resident #141 was observed on the floor secondary to an unwitnessed fall. Upon assessment, Resident #141 was observed laying on their back on the floor with no visible injuries noted. Resident #141 complained of a lot of pain to their right hip. Physician's orders were received to send the resident to the hospital for further evaluation. An Accident and Occurrence Report dated 05/14/2026 documented the resident was observed on the floor lying on their back secondary to an unwitnessed fall and was complaining of pain to the right hip. The Final Summary and Determination dated 05/14/2026 documented the resident's behavior and observed history showed the resident attempted to ambulate independently on an impulsive basis. The resident was sent to the hospital for evaluation. The facility documented there was no reasonable cause to believe any alleged abuse, neglect, or mistreatment regarding this resident had occurred.A nursing readmission note dated 05/20/2026 documented the resident was readmitted to the facility with a diagnosis of right hip fracture and had a right hip intramedullary (IM) nailing (a specialized metal rod inserted into the hollow medullary cavity of a long bone). During an interview on 06/02/2026 at 06:41 AM, Certified Nursing Assistant #10 stated that they were assigned to Resident #141 on 05/13/2026 -05/14/2026 on the 11:00 PM-7:00 AM shift. Certified Nursing Assistant #10 stated that the resident was not on any monitoring and was at risk for falls. Certified Nursing Assistant #10 stated that they made routine rounds to check on the resident. Certified Nursing Assistant #10 stated that they made rounds on 05/14/2026 at 02:45 AM before they went on their break. The resident was sleeping in bed at the time, and their brief was dry. Certified Nursing Assistant #10 stated they went for their break for an hour at 3:00 AM and when they returned they were told by a nurse (name not recalled) that the resident fell. During an interview on 06/02/2026 at 06:56 AM, Licensed Practical Nurse #7 stated they were on duty from 05/13/2026-05/14/2026 on the 11:00 PM to 7:00 AM shift. Licensed Practical Nurse #7 stated they were not assigned to Resident #141, and the assigned Licensed Practical Nurse #8 and Certified Nursing Assistant #10 were on break at the time of the resident's fall. Licensed Practical Nurse #7 stated they were sitting at the nurse's station and heard someone calling for help and the sound was coming from Resident #141's room. when they heard someone calling for help. Licensed Practical Nurse #7 stated they went to Resident #141's room and observed the resident lying on the floor in their room. Licensed Practical Nurse #7 stated they immediately notified the nursing supervisor.During an interview on 06/02/2026 at 10:50 AM, the assigned Licensed Practical Nurse #8 stated that were they on duty on 05/13/2026 into 05/14/2026 on the 11:00 PM -7:00 AM shift. Licensed Practical Nurse #8 stated that the resident was not on a specific monitoring schedule according to their care plan. Licensed Practical Nurse #8 stated they were on break when the incident occurred. When they returned from their break, the resident was sitting in a wheelchair at the nurse's station and was complaining of right hip pain. The facility investigation did not include statements from all staff who were working on the unit while Resident #141's assigned Certified Nursing Assistant and Licensed Practical Nurse were on break. During an interview on 06/02/2026 at 11:12 AM, Registered Nurse #8 stated they were informed by Licensed Practical Nurse #7 that the resident fell. Registered Nurse #8 stated that they assessed the resident and there were no visible injuries; however, the resident was complaining of right hip pain. Registered Nurse #8 stated they notified the Physician and were instructed to transfer the resident to the hospital for evaluation. Registered Nurse #8 stated they initiated the investigation and obtained statements from Certified Nursing Assistant #10 and Licensed Practical Nurse #7. Registered Nurse #8 stated they did not think they needed to obtain statements from other staff members who were on the unit at the time of the incident. During an interview on 06/02/2026 at 11:57 AM, the Assistant Director of Nursing Services, who was also the Risk Manager, stated the Incident report was initiated by Registered Nurse #8 who was covering the unit. Registered Nurse #8 should have obtained statements from all staff that were on duty to rule out abuse, neglect, and mistreatment. During an interview on 06/02/2026 at 12:00 PM, the Director of Nursing Services stated statements should have been obtained from all staff and going forward a statement will be obtained not just from the assigned staff but from other staff who worked on the unit at the time of the incident. 10 New York Code Rules and Regulations 415.4(b)(3)

Based on observations, record review, and interviews during survey, the facility failed to ensure that a comprehensive person-centered care plan was implemented for each resident to meet each resident's medical and nursing needs. This was identified for one (Resident #310) of five residents reviewed for Accidents. Specifically, Resident #310 had a physician's order for padded half side rails with for seizure precautions. On two separate occasions, Resident #310 was observed without the padded side rails.The findings include: The facility policy for Person Centered Care Planning: Care Plan Process last reviewed on October 2025 documented the care for each resident will be delivered according to the identified goals and interventions on the comprehensive care plan. The facility policy titled Seizure Precautions last revised in 2025 documented that staff members will maintain seizure precautions to minimize the risk of injury or complications associated with seizure activity. Siderails may be needed on an ongoing basis for the resident with an unstable seizure disorder or may be needed for short-term use if the resident has experienced a seizure. Padded siderails may be used to protect a resident with marked chronic activity. Resident #310 was admitted with diagnoses including seizure disorder, heart failure, and traumatic cerebral edema (brain swelling). The Quarterly Minimum Data Set, dated [DATE] documented the resident has a Brief Interview of Mental status of 10. No rejection of care. Impairment of range of motion both upper and lower extremities. The resident required assistants with all Activity of Daily Living care. The current physician's orders documented padded half siderails for seizure precautions. The comprehensive care plan revised on 03/12/2026 documented Resident #310 had padded half side rails for safety related to seizure diagnosis. Interventions included to ensure the half side rail padding is in place. During an observation on 05/26/2026 at 11:50 AM, Resident #310 was in bed with two half side rails. The half side rail on the right side of the bed was padded, and the left half side rail was not padded. During an observation on 05/28/2026 at 04:07 PM, Resident #310 was in their bed and both side rails were not padded. During an interview on 05/28/2026 at 04:08 PM, Certified Nurse Assistant #7 stated they assigned to the resident today during the 03:00 PM-11:00 PM shift and were also assigned to the resident during the 07:00 AM-03:00 PM shift on 05/26/2026. Certified Nurse Assistant #7 stated they did not know why the resident needed padded side rails. Certified Nurse Assistant #7 stated they keep forgetting to reapply the siderail pads after they provide care to Resident #310. During an interview on 06/02/2026 at 10:17 AM, Licensed Practical Nurse #3 stated that the resident has seizure disorder, and the half side rails must always be padded for seizure precautions. Licensed Practical Nurse #3 stated Nurses and Certified Nurses' Assistants should follow the plan of care for seizure precautions and make sure the siderails are padded. During an interview on 06/02/2026 at 10:27 AM, Registered Nurse #6 stated the resident has padded side rails as a safety precaution to prevent injury due to seizure disorder. Registered Nurse #6 stated the Nurses and Certified Nurses Assistants were responsible for implementing the care plan for seizure precautions. During an interview on 06/02/2026 at 11:09 AM, the Director of Nursing Services stated nursing staff must follow the resident's plan of care. The Director of Nursing Services stated to prevent injury, the nursing staff must ensure the siderails were padded for Resident #310. 10 New York Code Rules and Regulations 415.11(c)(1)

Based on observations, record review, and interviews during survey, the facility failed to ensure drugs and biologicals used in the facility were labeled and stored in accordance with currently accepted professional principles. This was identified for one (Unit 3 C, low side Medication Cart) of nine medication carts reviewed for the Medication Storage Task and for one (Resident #194) of five residents reviewed for Accident Hazards. Specifically, 1) a Novolog FlexPen (insulin medication to control high blood sugar) was observed unopened and stored in the medication cart. The manufacturer's guidelines indicated that the Novolog FlexPen should be stored in the refrigerator before opening. 2) Resident #194 was observed on multiple occasions with Biotin supplement (helps the body convert food into energy) bottles at their bedside. The findings include: The facility policy titled Medication Storage and Handling last revised June 2025 documented medications and biologicals are stored in locked compartments under proper temperature controls. Licensed nursing staff will ensure that medications requiring refrigeration are to be labeled and kept in a refrigerator in the locked medication room to ensure an optimal level of effectiveness. 1) During the medication storage task observation on 05/29/2026 at 08:05 AM, an unopened Novolog (100 unit per milliliter) FlexPen was observed in the Unit 3C, low side, medication cart. During an interview on 05/29/2026 at 08:05 AM, Licensed Practical Nurse #2 stated the unopened Novolog FlexPen should not be stored in the medication cart and should be stored in the refrigerator until it is ready for use. Licensed Practical Nurse #2 they were not sure why the pen was stored in the medication cart instead of the refrigerator. During an interview on 06/02/2026 at 07:58 AM, the Director of Nursing Services stated the Novolog FlexPen should be stored in the refrigerator upon receipt from pharmacy and kept there until ready to use. During an interview on 06/02/2026 at 08:24 AM, the Licensed Pharmacist #1 stated the Novolog (100 unit per milliliter) FlexPen needs to be stored in the refrigerator prior to opening as per the manufacturer's recommendations to maintain the effectiveness of the medication. 2) Resident #194 was admitted with diagnoses that included obesity, bipolar disorder, and major depressive disorder. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 13, which indicated the resident had intact cognition. During an observation on 05/26/2026 at 12:32 PM, Resident #194 was observed in bed. There were two bottles of Biotin supplement on the resident's bedside table. A review of current physician's orders revealed there were no orders for the use of Biotin supplement. During an observation and interview on 05/28/2026 at 12:15 PM, Resident #194 was observed in bed. There were two bottles of Biotin supplement on the bedside table. Resident #194 stated they were alert enough to have their own supplements and did not need a physician's order for the Biotin supplement. A review of the resident's medical record lacked documented evidence that a self – medication administration was completed. During an interview on 5/28/2026 at 12:45 PM, Unit Registered Nurse Manager #6 stated they were not aware the resident was self-administering the Biotin supplement. Unit Registered Nurse Manager #6 stated a physician's order is required for the resident to self-administer the medications including the vitamin supplement. During an interview on 05/28/2026 at 11:21AM, Licensed Practical Nurse # 5 stated they were not aware of the Biotin supplement at the resident's bedside. Licensed Practical Nurse #5 stated the resident had a physician's order to self-administer a different supplement in the past, but the resident went to the hospital and may not be able to self-administer medications because the resident had a decline in condition. During an interview on 05/29/2026 at 10:17 AM, the Director of Nursing Services stated that when a resident wants to self-administer medications, an assessment should be completed by the Social Worker and the Nurse. The Director of Nursing Services stated the nurse should contact the Physician to obtain an order for self-administration of the medications. The Director of Nursing Services stated the interdisciplinary team should confirm that the residents have a locked drawer to store the medications and nursing staff are expected to ensure the resident used the locked drawer. 10 New York Code Rules and Regulations 415.18(e) (1-4)

Based on observation, interview, and record review during the survey, the facility failed to accurately document the resident population, the overall acuity, the care required by the resident population, and the resources needed, in the facility assessment. This was identified for one (Unit 1C) of eight nursing units reviewed for sufficient and competent nurse staffing task. Specifically, the facility has a dedicated ventilator unit with certified ventilator beds, occupied by ventilator dependent residents who receive ventilator-related respiratory care. The facility assessment did not include the ventilator dependent residents to determine what resources were necessary to care for those residents including the use of competent and qualified Respiratory therapists. The findings include:The facility policy titled Facility assessment dated [DATE] documented the facility will conduct and document a facility wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The purpose of this assessment is to allow the facility to strategically plan for emergent and non-emergent events, assess all needs of residents, and provide resident services based on this analysis. Assessment will include current census; resident demographics; resident care matrix; facility floor plan; facility staffing and requirements for all departments; competencies; facility utilized equipment; documentation of required facility policies; infection control; services provided; contracts; risk assessment; and the electronic medical record system.A review of the Facility assessment dated [DATE] did not indicate that the facility cared for the ventilator dependent residents on unit 1C and that the facility utilized services of respiratory therapists. The facility assessment also did not include the education, training, and competencies related to resident care for the respiratory therapists. During an observation of Unit 1C on 5/26/2026 between 10:30 AM and 11:30 AM there were 21 out of 33 residents who were ventilator dependent. The residents on ventilator were receiving care from nursing staff and respiratory therapists.During an interview on 06/02/2026 at 2:29 PM, the Administrator stated the facility provided care to the ventilator dependent residents; however, the facility assessment did not include use of the respiratory therapists. The Administrator stated that the facility assessment should have identified unit 1C as a ventilator unit and that respiratory therapists were assigned on the unit to provide respiratory care. 10 New York Code Rules and Regulations 415.26

Based on record review and interviews during the Abbreviated Survey (NY00377991) initiated on 6/2/2025 the facility did not ensure that all incidents including allegations of abuse were thoroughly investigated. This was identified for one (Resident #1) of three residents reviewed for abuse. Specifically, on the morning of 4/14/2025 Resident #1 stated they had been punched in the ribs by nursing staff. There was no documented evidence that the facility obtained statements from the overnight staff to rule out abuse. The finding is: The facility's policy titled, Abuse Prevention Program with a revised date of September 2024 documented the residents have the right to be free from abuse and all alleged or suspected incidents will be thoroughly investigated and findings documented in a report format. The investigative process will include, but is not limited to, statements from staff, witness, resident, interviews with staff, witness, resident, medical record review if applicable and review of employee records. Resident #1 had diagnoses that included a Fractured Rib, Chronic Obstructive Pulmonary Disease and Chronic Kidney Disease. The 5-Day Minimum Data Set assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status score of 11, indicating the resident had a moderate cognitive impairment. Resident #1 had Comprehensive Care Plan for an alteration in musculoskeletal status related to a right rib fracture. Interventions included to monitor, document and report, as needed signs and symptoms or complications related to but not limited to pain, decline in mobility, and pain after exercise. A Nursing Progress Note dated 4/14/2025 documented Resident #1 reported they were punched in the ribs on both sides. A full body assessment was completed, and no bruising, discoloration, or redness was noted. Resident #1's next of kin was notified and the next of kin stated Resident #1 has done this (made allegations) a few times in the past while at two other facilities. Resident #1's Visual/Bedside Kardex Report (a nursing tool for recording patient information) documented Resident #1 was a two-person approach for care. The facility's investigation summary dated 4/21/2025 documented it was determined through the investigation that the facility did not substantiate abuse, neglect or mistreatment. The conclusion was made from employees who were interviewed, a physical assessment by the Registered Nurse Supervisor, and through the resident recanting their statement and a pattern of behavior that was confirmed by Resident #1's next of kin. There was no documented evidence that the overnight staff persons were interviewed to rule out abuse. The facility's accident and incident report was reviewed. A statement from the Occupational Therapist #1 to whom Resident #1 reported that nursing staff had punched them in the ribs four times was included in the incident report. A statement from Resident #1's assigned Certified Nursing Assistant on the morning of the allegation (Certified Nursing Assistant #1) documented that Resident #1 said they were punched last night. A statement from the assigned Licensed Practical Nurse (Licensed Practical Nurse #1) documented they were made aware by the therapist that Resident #1 was punched in the ribs by nursing staff. An addendum dated 6/4/2025 was submitted by the Director of Nursing Services. The addendum documented that verbal interviews were conducted with the night shift. The addendum did not include documented evidence of the verbal interviews. During an interview on 6/2/2025 at 10:48 AM, Certified Nursing Assistant #1 stated they were the assigned Certified Nursing Assistant for Resident #1 on 4/14/2025 during the 7AM-3PM shift. Certified Nursing Assistant #1 stated they did not recall exactly what day but Resident #1 reported they were punched in the ribs by nursing staff during the night. Certified Nursing Assistant #1 stated they reported it to Registered Nurse #1 and they may have also spoken to Licensed Practical Nurse #1. During an interview on 6/2/2025 at 1:17 PM, Licensed Practical Nurse #1 stated Resident #1 went to rehabilitation therapy on 4/14/2025 and when they returned from therapy the Occupational therapist reported they were punched. Licensed Practical Nurse #1 could not recall any more details about the allegation. Licensed Practical Nurse #1 stated they reported the incident to Registered Nurse #1. During an interview on 6/2/2025 at 1:34 PM, Registered Nurse #1 stated they did not have a clear memory of the incident. Registered Nurse #1 stated Resident #1 reported they were beat up by a gang of boys and later Resident #1 stated it was a gang of girls that beat them up. Registered Nurse #1 stated they assessed Resident #1 and there was no bruising or redness to the skin identified. During an interview on 6/2/2025 at 2:12 PM, the Occupational Therapist stated on the morning of 4/14/2025 they went to Resident #1's room to take them to therapy. The Occupational Therapist stated they asked Resident #1 if they wanted pain medications prior to therapy and Resident #1 declined. The Occupational Therapist stated when they completed therapy Resident #1 stated their ribs hurt and nursing staff punched them four times in the ribs. The Occupational Therapist stated Resident #1 did not identify what day or time alleged abuse occurred. During an interview on 6/2/2025 at 2:26 PM, the Director of Nursing Services stated the Occupational Therapist reported to the Unit Manager that Resident #1 stated they had been hit the night before. The Director of Nursing Services stated they recalled the concerns taking place on the overnight shift, but they did not recall who reported that. The Director of Nursing Services stated they interviewed the nursing staff from the overnight shift, but they did not document or include the interviews in the investigation report and should have. The Director of Nursing Services stated they believed they did a thorough investigation even though they did not document the overnight staff's interviews. During an interview on 6/2/2025 at 2:26 PM, the Administrator stated the overnight staff were interviewed and because they had to get the investigation completed and out to the Department of Health in a two-hour time frame, they did not document the interviews even though they were conducted. 10NYCRR 415.4 (b) (3)

Based on observation of the facility videotape, record review and interviews, during an abbreviated survey (Complaint # NY00378355), the facility did not ensure one of three residents (Resident#1) ) reviewed for abuse were free from physical abuse by a staff member. The review of video surveillance dated 04/09/25 at 11:00:56 AM showed Certified Nursing Assistant #1 using both hands to hold Resident #1's shoulders while seated in wheelchair and the Certified Nurse's Aide was pulling the resident back and forth in a shaking motion. There was no other staff or resident present in view of the surveillance video at the time of the incident. Findings include: The Review of the facility policy dated 9/2024 entitled Abuse documented Physical abuse is defined as hitting, slapping, punching, and kicking. Resident #1 was admitted on [DATE] with diagnosis that include neurocognitive disorder with Lewy bodies, chronic obstructive pulmonary disease, and Parkinson's Disease. Resident #1 had a Minimum Data Set Brief Interview of Mental Status score of 99 on 03/19/2025 indicating resident could not be assessed due to cognitive decline. The review of the Comprehensive Care Plan (CCP) documented, dated 4/18/2025 at risk for being a victim due to inability to understand surroundings, secondary to cognitive impairment, disruptive behavior, the interventions documented assess resident for signs of abuse and or neglect. The review of the Comprehensive Care Plan (CCP) documented, elopement, a wanderer risk secondary 11/15/2023 and the interventions distracts resident from wandering by offering pleasant diversions, structured activities, food conversation, television or book. The review of the facility investigation dated 4/18/2025 for Allegation Type: Physical Abuse documented there is reasonable cause to believe that abuse, neglect or mistreatment occurred. The report further documented the event was unwitnessed and therefore not reported (Resident #1 is cognitively impaired and not interview able or able to self-report). The accused Certified Nurse's Aide #1 appears to approach Resident #1 who seated in wheelchair outside of a room from behind and repositions Resident#1 roughly in chair, almost appearing to be shaking Resident #1. Resident #1 did not exhibit any change in behavior after this incident nor were there any report of injury or skin impairment from staff caring for the resident post incident. Medical Doctor made aware, facility notifying Next of Kin and law enforcement informed. During an interview with Certified Nursing Assistant #1 on 4/28/2025 at 3:00 PM they stated Resident #1 was trying to go into the room of two residents of the opposite sex. They further stated Resident #1 leans forward and propels themselves and could fall. The Certified Nurse's Aide stated to reposition Resident #1, they held the residents' shoulders to pulled Resident #1 back. Certified Nursing Assistant denied pulling them back and forth stating they never saw the video. During an interview with Administrator on 04/28/2025 at 1:02 PM they stated on 4/18/2025 while reviewing the camera for another incident. The footage of Certified Nursing Assistant #1 handling of Resident #1 was observed. They stated they immediately suspended Certified Nursing Assistant and subsequently terminated them. They stated on interview Certified Nursing Assistant #1 stated it was a playful exchange with Resident #1. The Administrator stated Certified Nursing Assistant #1's actions constituted abuse because of how they approached the resident from behind and handled them. 415.4(b)

Based on observations, record review, and interviews during the Recertification Survey initiated on 2/24/2025 and completed on 2/28/2025, the facility did not establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. This was identified for one (Resident #521) of three residents reviewed for the Infection Control Task, and one (Resident #147) of five residents reviewed for Respiratory Care. Specifically, 1) Resident #521 had a physician's order for Contact Precautions due to Clostridium difficile infection. On 2/25/2025 at 8:09 AM, Certified Nursing Assistant #3 was observed coming out of Resident#521's room carrying two meal trays without wearing any Personal Protective Equipment including a gown or gloves. 2) Specifically, Resident #147 was ventilator dependent and was readmitted to the facility on [DATE] from the hospital with a Multidrug-Resistant Organism (MDRO) Pneumonia infection. On 2/27/2025, Respiratory therapist #1 was observed changing the tracheostomy inner cannula without wearing a face mask or face shield. The findings are: The facility's policy titled Transition Based Isolation last reviewed 9/2024, documented each infectious disease is considered individually so that only those precautions (private rooms, masks, gowns, and gloves) that are indicated to interrupt transmission for that disease is recommended. All isolation procedures will be in accordance with recommendations for isolation precautions as required by the Centers for Disease Control. 1) Resident #521 was admitted with diagnoses that include Enterocolitis (inflammation in both intestines at once) due to Clostridium difficile, End Stage Renal Disease, and Malignant Neuroendocrine Tumors. The Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 12, indicating Resident #521 had moderately impaired cognition. The Minimum Data Set documented Resident #521 had a Multidrug-Resistant Organism. A physician's order dated 1/25/2025 documented Contact Precautions (Clostridium difficile) every shift. This order was discontinued on 2/25/2025 at 8:33 AM. The Comprehensive Care Plan for Diagnosis of Colitis with a history of Clostridium difficile dated 1/25/2025 documented interventions that included Contact Isolation and staff to wear gowns and gloves. During an observation on 2/25/2025 at 8:09 AM, a Contact Precaution sign was outside Resident #521's room which documented that everyone must clean their hands before entering the room and after exiting the room. Providers and staff must put on gowns and gloves before entering the room. Certified Nursing Assistant #3 was observed walking out of Resident #521's room carrying two meal trays that were used by Resident #521 and their roommate for their breakfast meal. Certified Nursing Assistant #3 was not wearing any Personal Protective Equipment including a gown or gloves. Certified Nursing Assistant #3 placed the used meal trays on the meal truck with other used meal trays, cleansed their hands with a hand sanitizer, and did not use soap and water. During an interview on 2/25/2025 at 8:09 AM, Certified Nursing Assistant #3 stated they were told that the resident was no longer on Contact Precautions and the signage should have been taken down. Certified Nursing Assistant #3 stated they were not sure who told them that the resident was no longer on contact precautions. They stated they should have put on Personal Protective Equipment and followed the Contact Precaution signage on the door for Contact Precautions. During an interview on 2/27/2025 at 10:49 AM, the Registered Nurse/Infection Preventionist stated the staff should have followed the Contact Precautions signage and should have put on appropriate Personal Protective Equipment as indicated on the sign. During an interview on 2/28/2025 at 1:32 PM, the Director of Nursing Services stated staff should have followed the Contact Precaution signage and put on appropriate Personal Protective Equipment. 17585 2) The Centers for Disease Control (CDC) Multidrug-Resistant Organisms (MDRO) Management Guidelines dated 3/18/2024 documented to use of masks according to Standard Precautions when performing splash-generating procedures (e.g., wound irrigation, oral suctioning, intubation) and when caring for patients with open tracheostomies and the potential for projectile secretions. Resident #147 was admitted with diagnoses including Multidurg-Resistant Organism (MDRO) Pneumonia. The Minimum Data Set assessment dated [DATE] did not include a Brief Interview for Mental Status because the resident was rarely/never understood. The resident received tracheostomy care and was ventilator-dependent. A Comprehensive Care Plan titled Pseudomonas (bacteria) in the sputum evidenced by positive wound culture effective 1/2/2025 documented the resident had an active infection requiring universal [standard] precautions when providing resident care. Interventions included administering antibiotics as per the physician's orders and maintaining universal precautions when providing resident care. The hospital infectious disease consult dated 2/10/2025 documented the resident was positive for Pseudomonas of the Sputum. The Patient Review instrument ( an assessment tool to determine patient placement) dated 2/17/2025 documented the resident required Contact Isolation Precautions secondary to Pseudomonas Multidrug-Resistant Organisms (MDRO) infection. A medical readmission note dated 2/18/2025 documented the resident was seen on telemedicine for readmission medication reconciliation. The patient's chart, discharge papers, and the discharge medication lists were reviewed Ventilator-associated pneumonia. A Physician's order dated 2/18/2025 documented Contact Precautions. A Physician's order dated 2/18/2025 documented a Tracheostomy Tube, Uncuffed; provide tracheal suctioning as needed; tracheostomy tube change every 12 weeks and as needed; change the Ventilator Circuit monthly and as needed; ensure ventilator tubing is off the floor. A medical progress note dated 2/20/2025 documented sputum culture with Pseudomonas. During an observation and interview on 2/27/2025 at 2:13 PM, Resident #147 was lying in bed in their room. A sign outside the resident's room documented Contact Precaution: Put on gloves and a gown before entering the room. The Respiratory Therapist #1 was observed wearing a gown and gloves. Respiratory Therapist #1 set up their equipment on the bedside table, then proceeded to suction the resident via tracheostomy tube through a closed suction system. The resident was observed coughing during suctioning. Respiratory Therapist #1 then cleansed the tracheostomy stoma area and applied a clean tracheostomy stoma dressing. Respiratory Therapist #1 performed hand hygiene and donned (put on) new gloves, disconnected the ventilator tubing from the tracheostomy, and removed the old inner cannula from the tracheostomy. Respiratory Therapist #1 then applied a new inner cannula, and re-attached the ventilator tubing. Respiratory Therapist #1 was not wearing a mask or eye protection while the ventilator tubing was disconnected and the tracheostomy inner cannula was being changed. Respiratory Therapist #1 was immediately interviewed and stated that the resident had a closed tracheostomy system connected to the ventilator and therefore they were not required to wear a mask. During an interview on 2/27/2025 at 2:43 PM, the Infection Control Registered Nurse #1 stated they reviewed the resident's Patient Review instrument with the admission nurse and the resident's Physician. The Physician only ordered Contact precautions and under Contact precautions, the Respiratory Therapist is only supposed to wear gloves and a gown. During an interview on 2/28/2025 at 9:51 AM, the Infectious Disease Physician stated the Respiratory Therapist caring for the resident with Multidrug-Resistant Organisms should have worn a mask. The Infectious Disease Physician stated a face shield and a surgical mask should be worn to prevent the spread of the infection while performing procedures that have the potential to generate aerosolized particles. Not wearing a mask or face shield increases the likelihood of the caregiver's exposure to oral secretions and sputum. During an interview on 2/28/2025 at 9:54 AM, the Medical Director stated Respiratory Therapist #1 should have worn a mask and a face shield when changing the tracheostomy inner cannula due to the risk of exposure to the Pseudomonas, Multidrug-Resistant Organisms in the sputum. 10 NYC RR 415.19(a)(1-3)

Based on observations, record review, and interviews during the Recertification Survey initiated on 2/24/2025 and completed on 2/28/2025 the facility did not ensure that a Baseline Care Plan for each resident included instructions needed to provide effective person-centered care that meets professional standards of quality care. This was identified for one (Resident #519) of three residents reviewed for Infection Control. Specifically, Resident #519 was admitted with Coronavirus (COVID-19) positive infection and had a physician's order for Droplet and Contact Precautions for ten days. There was no care plan developed and implemented for the Droplet and Contact Precautions. The finding is: The facility's policy, titled Person-Centered Care Plan last reviewed 10/2024 documented upon admission the facility shall conduct a comprehensive Person-Centered Care Plan, including an accurate assessment of each resident's functional capacity. All care planning begins upon admission. The care of each resident will be delivered according to the identified goals and interventions of the Comprehensive Care Plan. The Care Plan is developed within seven (7) calendar days from the admitted after completing the comprehensive assessment. Resident #519 was admitted with diagnoses including Coronavirus (COVID-19) infection, Rhabdomyolysis (medical condition where skeletal muscles break down), and Alzheimer's Disease. Resident #519 was recently admitted to the facility and did not have a Minimum Data Set assessment completed. The admission physician's order dated 2/20/205 documented Droplet/Contact precautions during every shift for Coronavirus (COVID-19) infection for 10 days. The order was discontinued on 2/27/2025. The Social Work Admission assessment dated [DATE] documented a Brief Interview for Mental Status score of 8, indicating the resident had moderate cognitive impairment. A review of Resident #519's electronic medical record revealed there was no documented evidence of a care plan for Droplet and Contact Precautions. During an observation on 2/24/2025 at 8:23 AM, Resident #519 was observed in bed unable to answer interview questions. A Droplet and Contact Precautions sign and a cart with Personal Protective Equipment was placed outside the resident's room door. During an interview on 2/27/2025 at 10:10 AM, Registered Nurse Clinical Care Coordinator #1 stated the Infection Preventionist removed the contact sign today because Resident #519's isolation was discontinued. Registered Nurse Clinical Care Coordinator #1 stated today was day 11 since the resident had a positive Coronavirus (COVID-19) test result. Registered Nurse Clinical Care Coordinator #1 stated they were not aware that Resident #519 did not have a care plan for Droplet and Contact Precautions, and they should have initiated the care plan when the resident was first admitted . Registered Nurse Clinical Care Coordinator #1 stated the admission nurse, the Infection Preventionist, or themselves could have developed the care plan. During an interview on 2/27/2025 at 10:49 AM, Registered Nurse Infection Preventionist #1 stated when a resident is placed on Droplet and Contact Precautions, a care plan should be developed with individualized goals and interventions. Registered Nurse Infection Preventionist #1 stated they were unsure why Resident #519 did not have a care plan for Droplet and Contact Precautions. Resident #519 was placed on Droplet and Contact precautions because they (the resident) came from the hospital with Coronavirus (COVID-19) infection. The facility discontinues the Droplet and Contact precautions after 10 days based on the hospital diagnosis from 2/15/2025. During an interview on 2/28/2025 at 1:29 PM, the Director of Nursing Services stated care plans should be developed timely and accurately. The Director of Nursing Services stated the admission nurse should have created a care plan upon admission because Resident #519 was admitted with a positive Coronavirus infection and was placed on Contact and Droplet Precautions. 10 NYCRR 415.11

Based on observations, record review, and interviews during the Recertification Survey initiated on 2/24/2025 and completed on 2/28/2025 the facility did not ensure parenteral fluids were administered consistent with current professional standards of practice, physician orders, and the comprehensive person-centered care plan. This was identified for one (Resident #242) of three residents reviewed for Hydration. Specifically, Resident #242 was admitted to the facility with a Peripheral Inserted Central Catheter (PICC) in their right arm from the hospital. There was no documentation the facility was Monitoring the Peripheral Inserted Central Catheter (PICC) site or measuring the length of the external catheter. The finding is: The facility's policy titled Peripheral Inserted Central Catheter (PICC) line last reviewed 6/2024, documented to assess the insertion site and surrounding tissue for any inflammation, tenderness, or drainage and if observed, report the findings to the physician. The policy did not include guidance for measuring the external catheter for the Peripheral Inserted Central Catheter (PICC). Resident #242 was admitted with diagnoses that include Kidney Stones and Sepsis. The Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 8, which indicated the resident had moderate cognitive impairment. The Minimum Data Set assessment documented Resident #242 had intravenous access and received intravenous antibiotics. The Patient Review Instrument (an assessment tool used to determine patient placement) dated 1/31/2025 documented Resident #242 had a Peripheral Inserted Central Catheter (PICC) placed in their right arm on 1/29/2025. A physician's order dated 1/31/2025 documented to flush the Peripheral Inserted Central Catheter (PICC) with 10 milliliters of Normal Saline every shift **RN ONLY.** A physician's order dated 2/01/2025 documented Cefepime Intravenous Solution (an antibiotic) use 2 grams intravenously every 12 hours for Sepsis due to Serratia & Pseudomonas infection until 3/02/2025. The Comprehensive Care Plan dated 2/12/2025, developed after 12 days the resident was admitted to the facility, documented Resident #242 had a Peripheral Inserted Central Catheter (PICC) for intravenous antibiotics administration. Interventions included monitoring the site every shift and as needed. A physician's order dated 2/25/2025 documented to monitor the Peripheral Inserted Central Catheter (PICC) line site each shift, and notify the Physician of any redness, tenderness, edema, or excessive bleeding. The order did not include measuring the Peripheral Inserted Central Catheter (PICC) line length externally to monitor the migration of the catheter. The Medication Administration Record for February 2025 indicated no documented evidence that the Peripheral Inserted Central Catheter (PICC) was assessed or measured each shift from 2/1/2025 to 2/24/2025. The Treatment Administration Record for February 2025 indicated no documented evidence that the Peripheral Inserted Central Catheter (PICC) was assessed or measured each shift from 2/1/2025 to 2/24/2025. During an observation and interview on 2/25/2025 at 8:50 AM, Resident #242 was sitting in bed having breakfast. A Peripheral Inserted Central Catheter (PICC) line was observed on the right arm. Resident #242 stated the Peripheral Inserted Central Catheter (PICC) line was for administering the antibiotics. During an interview on 2/26/2025 at 2:25 PM Registered Nurse Clinical Care Coordinator #1 stated this resident came from the hospital with the Peripheral Inserted Central Catheter (PICC) in place. They stated there was no order to measure the Peripheral Inserted Central Catheter (PICC) external catheter or for the assessment of the Peripheral Inserted Central Catheter (PICC) daily. The Peripheral Inserted Central Catheter (PICC) line should be monitored each shift, and the external catheter should be measured weekly to ensure the catheter did not migrate causing infiltration, or the medication not being delivered. The nurse who admitted the resident should have made sure the order was in place. Clinical Care Coordinator #1 stated they should have made sure that a care plan was in place. During an interview on 2/28/2025 at 8:39 AM, the Registered Nurse Educator stated the order should state the nurse should measure the external catheter length during a dressing change and document the length in the Medication Administration Record or the Treatment Administration Record. During an interview on 2/28/2025 at 12:35 PM, Licensed Practical Nurse #1 stated they do not provide Peripheral Inserted Central Catheter (PICC) line care. The Registered Nurses are responsible for completing the task including flushing the Peripheral Inserted Central Catheter (PICC) line, and hanging the antibiotic medications on the Peripheral Inserted Central Catheter (PICC). Licensed Practical Nurse #1 stated when the Registered Nurse completes their task they (Licensed Practical Nurse #1) then document on the Medication Administration Record that the task was completed. During an interview on 2/28/2025 at 1:26 PM, the Director of Nursing stated the facility policy did not include measuring the external catheter length for the Peripheral Inserted Central Catheter (PICC). The staff should have monitored and documented their findings each shift. 10 NYCRR 415.12(k)(2)

Based on observations, record review, and interviews during the Recertification Survey initiated on 2/24/2025 and completed on 2/28/2025, the facility did not ensure that each resident who needs respiratory care is provided such care consistent with professional standards of practice and the comprehensive person-centered care plan. This was identified for one (Resident #32) of three residents reviewed for Respiratory Care. Specifically, Resident #32 was observed receiving oxygen therapy without a Physician's order. The finding is: The facility's policy titled Oxygen Administration dated February 2024 documented to ensure adequate oxygenation of the body's vital organs. Residents with a clinical diagnosis or clinical indication will receive concentrations of oxygen in doses higher than those found in the atmosphere. Oxygen [therapy] is administered by licensed nursing staff on the written order of the attending Physician. The Physician writes an order for oxygen therapy with a rationale. Resident #32 was admitted with diagnoses including Cerebral Infarction, Heart Failure, and Diabetes Mellitus. The Minimum Data Set assessment dated [DATE] documented the resident had severely impaired cognition and was rarely or never understood. The Minimum Data Set (MDS) assessment documented the resident received oxygen therapy. A review of the medical record indicated there was no care plan developed for the oxygen therapy. A Physician's order dated 1/20/2025 documented to obtain a Pulmonary consultation for Resident #32 related to shortness of breath. The Pulmonary Consultant note dated 1/23/2025 documented that Resident #32 was referred for an evaluation due to shortness of breath and Hypoxia (lack of oxygen to the tissues). The Pulmonologist's recommendations included to monitor the oxygen saturation level while on room air and to provide oxygen therapy as needed to maintain an oxygen saturation level above 92%. A review of Resident #32's medical record revealed there was no evidence of a physician's order for oxygen therapy and to monitor the resident's oxygen saturation level. The Pulmonary Consultant note dated 2/18/2025 documented that at the time of the evaluation, Resident #32 received oxygen therapy at a flow rate of 2 liters per minute via nasal cannula. The Pulmonologist recommended titrating oxygen supplementation as needed to keep the oxygen saturation above 92%. During an observation on 2/24/2025 at 9:56 AM, Resident #32 was lying in bed receiving oxygen therapy via nasal cannula from an oxygen concentrator set to a flow rate of 2 liters per minute. During an observation on 2/27/2025 at 10:00 AM, Resident #32 was lying in bed receiving oxygen therapy via nasal cannula from an oxygen concentrator set to a flow rate of 2 liters per minute. During an observation on 2/28/2025 at 11:00 AM, Resident #32 was lying in bed receiving oxygen therapy via nasal cannula from an oxygen concentrator set to a flow rate of 2 liters per minute. During an interview on 2/28/2025 at 9:35 AM, Licensed Practical Nurse #9 stated all nurses are responsible for oxygen therapy administration. Licensed Practical Nurse #9 stated Resident #32 has been receiving oxygen therapy at 2 liters per minute via nasal cannula since October 2024. Licensed Practical Nurse #9 stated they did not realize there was no physician's order for oxygen therapy and there should have been an order in place. Licensed Practical Nurse #9 stated they check Resident #32's vital signs, including the oxygen saturation level, once a week. During an interview on 2/28/2025 at 9:56 AM, Registered Nurse Manager #1 stated the resident returned from the hospital in October 2024 and has been receiving oxygen therapy at 2 liters per minute via nasal cannula since then. Registered Nurse Manager #1 stated they did not know that there was no physician's order for oxygen therapy. Registered Nurse Manager #1 stated the resident needed oxygen therapy because they (the resident) had shortness of breath. During an interview on 2/28/2025 at 10:44 AM, Physician #1 stated Resident #32 received oxygen therapy at 2 liters per minute since October 2024. Physician #1 stated oxygen therapy administration requires a Physician's order. Physician #1 stated they were unaware there was no physician's order in place. Physician #1 stated they entered the Physician's order on 2/28/2025 after the facility informed them that the resident received oxygen therapy without a physician's order. During an interview on 2/28/2025 at 12:55 AM, the Director of Nursing Services stated they were not aware the resident received oxygen therapy without a physician's order. The Director of Nursing Services stated oxygen therapy administration requires a physician's order. 10 NYCRR 415.12(k)(6)

Based on observation, record review, and interview during the Recertification survey initiated on 2/24/2024 and completed on 2/28/2025, the facility did not ensure the Physician reviewed the resident's total program of care, including medications and treatments, at each visit. This was identified for one (Resident #32) of five residents reviewed for Respiratory care. Specifically, Resident #32 received Oxygen therapy without a physician's evaluation and physician's order. The finding is: The facility's policy titled Oxygen Administration dated February 2024 documented to ensure adequate oxygenation of the body's vital organs. Residents with a clinical diagnosis or clinical indication will receive concentrations of oxygen in doses higher than those found in the atmosphere. Oxygen [therapy] is administered by licensed nursing staff on the written order of the attending Physician. The Physician writes an order for oxygen therapy with a rationale. Resident #32 was admitted with diagnoses including Cerebral Infarction, Heart Failure, and Diabetes Mellitus. The Minimum Data Set assessment dated [DATE] documented the resident had severely impaired cognition and was rarely or never understood. The Minimum Data Set (MDS) assessment documented the resident received oxygen therapy. A review of the medical record indicated there was no care plan developed for the oxygen therapy. A Physician's order dated 1/20/2025 documented to obtain a Pulmonary consultation for Resident #32 related to shortness of breath. The Pulmonary Consultant note dated 1/23/2025 documented that Resident #32 was referred for an evaluation due to shortness of breath and Hypoxia (lack of oxygen to the tissues). The Pulmonologist's recommendations included to monitor the oxygen saturation level while on room air and to provide oxygen therapy as needed to maintain an oxygen saturation level above 92%. A review of Resident #32's medical record revealed there was no evidence of a progress note or a physician's order for the use of oxygen therapy and to monitor the resident's oxygen saturation level. The Pulmonary Consultant note dated 2/18/2025 documented that at the time of the evaluation, Resident #32 received oxygen therapy at a flow rate of 2 liters per minute via nasal cannula. The Pulmonologist recommended titrating oxygen supplementation as needed to keep the oxygen saturation above 92%. A review of Resident #32's medical record revealed there was no evidence of a progress note or a physician's order for the use of oxygen therapy and to monitor the resident's oxygen saturation level. During an observation on 2/24/2025 at 9:56 AM, Resident #32 was lying in bed receiving oxygen therapy via nasal cannula from an oxygen concentrator set to a flow rate of 2 liters per minute. During an observation on 2/27/2025 at 10:00 AM, Resident #32 was lying in bed receiving oxygen therapy via nasal cannula from an oxygen concentrator set to a flow rate of 2 liters per minute. During an observation on 2/28/2025 at 11:00 AM, Resident #32 was lying in bed receiving oxygen therapy via nasal cannula from an oxygen concentrator set to a flow rate of 2 liters per minute. During an interview on 2/28/2025 at 9:56 AM, Registered Nurse Manager #1 stated the resident returned from the hospital in October 2024 and has been receiving oxygen therapy at 2 liters per minute via nasal cannula since then. Registered Nurse Manager #1 stated they did not know that there was no physician's order for oxygen therapy. Registered Nurse Manager #1 stated the resident needed oxygen therapy because they (the resident) had shortness of breath. During an interview on 2/28/2025 at 10:44 AM, Physician #1 stated Resident #32 received oxygen therapy at 2 liters per minute since October 2024. Physician #1 stated oxygen therapy administration requires a Physician's order. Physician #1 stated they were unaware there was no physician's order in place and did not realize there were recommendations provided by the Pulmonologist. Physician #1 stated they entered the Physician's order on 2/28/2025 after the facility informed them that the resident received oxygen therapy without a physician's order. During an interview on 2/28/2025 at 12:55 AM, the Director of Nursing Services stated they were not aware the resident received oxygen therapy without a physician's order. The Director of Nursing Services stated oxygen therapy administration requires a physician's order. 10 NYCRR415.15(b)(1)(i)(ii)

Based on interviews and record review during a Recertification Survey initiated on 4/17/2024 and completed on 4/26/2024, the facility failed to ensure that all allegations of abuse, neglect, and mistreatment were thoroughly investigated. This was identified for one (Resident #26) of seven residents reviewed for abuse. Specifically, on 3/30/2024 Resident #26 reported to Licensed Practical Nurse #1 that they were sexually abused by Certified Nursing Assistant #1. There was no documented evidence Licensed Practical Nurse #1 took steps to initiate an investigation into the allegation. On 4/1/2024, Resident #26 reported the same allegation to Certified Nursing Assistant #3. Certified Nursing Assistant #3 informed Registered Nurse #1 of the allegation. There was no documented evidence Registered Nurse #1 took steps to initiate an investigation into the allegation. Through 4/18/2024, Certified Nursing Assistant #1 continued to be assigned to and worked on the same unit where Resident #26 resided. As of 4/18/2024, the facility had failed to provide documented evidence that it had conducted and completed a thorough investigation within 5 days of the allegations of sexual abuse. This resulted in Immediate Jeopardy for Resident #26, with the potential for serious injury, serious harm, serious impairment, or death to 40 other residents who resided on Resident #26's unit. The finding is: The facility Investigation Policy and Procedure on Resident Accidents and Incidents with a revision date of 4/2024, directed that within 24 hours of the reported incident or accident, the risk manager or nurse supervisor must complete the Resident Accident & Incident Summary Report to determine if there is reason to believe that abuse, neglect, mistreatment, or misappropriation has occurred, and to determine the underlying cause of the reported accident or incident. The facility has 2 hours to report abuse to the New York State Department of Health. The policy further documented to thoroughly investigate every accident/incident for potential abuse, neglect, mistreatment, or misappropriation. If there is a cause to believe abuse, neglect or mistreatment has occurred, or that an accident and incident meets the New York State Department of Health reporting requirements (injury of unknown origin, choking, burn, suicide attempt, care plan violation, etc.), the risk manager or reporting Registered Nurse must inform the Director of Nursing Services or the Administrator immediately. Any employee suspected of abuse, neglect, or mistreatment must immediately be removed from the work schedule pending the results of the investigation by facility administration. Resident #26 was admitted with diagnoses that included Major Depressive Disorder, Bipolar Disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), and Anxiety Disorder. The annual Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status score was 14 which indicated intact cognition. The resident had no behavioral or mood symptoms at the time of assessment. A Comprehensive Care Plan dated 4/18/2024, initiated after the allegation was brought to the facility's attention by the surveyor, documented the resident was at risk of being a victim due to dependence on caregivers for activities of daily living. The resident has a history of accusatory and physically abusive behaviors. Interventions included to assess the resident for signs and symptoms of abuse and or neglect and report to appropriate resources; investigate all allegations of abuse and neglect promptly; provide support and ensure the resident is free from abuse. During an initial tour on 4/18/2024, Resident #26 was interviewed at 1:15 PM. Resident #26 stated approximately two months ago Certified Nursing Assistant #1 inserted their finger into their (Resident #26's) vagina while providing care. Resident #26 stated they reported the incident to Licensed Practical Nurse #1. The facility's Grievance Reports and Accident and Incident Reports for February 2024, March 2024, and April 2024 were reviewed on 4/19/2024. There was no documented evidence that a report was initiated for the allegation of sexual abuse for Resident #26. There was no documented evidence that an investigation was initiated related to the sexual abuse allegation made by Resident #26. During an interview on 4/18/2024 at 2:05 PM, Certified Nursing Assistant #1 stated they worked at the facility as a part-time employee during the 7:00 AM - 3:00 PM shift. They usually covered Certified Nursing Assistant #3's assignment when Certified Nursing Assistant #3 was off. Certified Nursing Assistant #1 stated the assignment included providing care to Resident #26, who required two staff members for activities of daily living. Resident #26 was a two-staff approach (two staff required to interact with the resident) because the resident had accusatory behavior towards staff. Certified Nursing Assistant #1 stated on 3/31/2024 they provided daily care for Resident #26, including washing the resident's buttocks and perineal (genital) area. Certified Nursing Assistant #1 stated a second Certified Nursing Assistant was present during care. Certified Nursing Assistant #1 could not recall the name of the Certified Nursing Assistant who assisted them with Resident #26. Certified Nursing Assistant #1 stated when they returned to work on Tuesday (4/2/2024) they were told Resident #26 had accused them of massaging their back, rubbing their buttocks, and sticking their finger in the resident's vagina (could not recall who notified them of the allegation). Certified Nursing Assistant #1 stated that at no time did their finger enter the resident's vagina. Certified Nursing Assistant #1 stated that even after the allegation was made, they were still assigned to provide care for Resident #26. Certified Nursing Assistant #1 stated they questioned Licensed Practical Nurse #1 as to why they were still assigned to Resident #26 after they were accused of sexual abuse. Certified Nursing Assistant #1 stated Licensed Practical Nurse #1 told them Resident #26 was a two-person approach. and that Certified Nursing Assistant #1 had to care for the resident. During an interview with Registered Nurse #1 on 4/18/2024 at 4:06 PM, they stated they were the Clinical Care Coordinator during the 7:00 AM - 3:00 PM shift on 4/1/2024. Registered Nurse #1 stated on 4/1/2024 Certified Nursing Assistant #3 reported the resident had made an allegation of sexual abuse against Certified Nursing Assistant #1. Registered Nurse #1 stated they went to speak with the resident and reminded the resident they had been accusatory towards the staff in the past. Registered Nurse #1 stated they did not assess the resident at the time but should have. Registered Nurse #1 stated they did not report the allegation to the administration and did not initiate an investigation because the resident told them they (Resident #26) made up the allegation as they wanted Certified Nursing Assistant #1 to be taken off their assignment. Registered Nurse #1 stated they were aware that when an allegation of abuse is reported to them, they are responsible for initiating an investigation, interviewing the resident, and escalating as needed. Registered Nurse #1 stated they were supposed to report the allegation of abuse to the Director of Nursing and the Assistant Director of Nursing Services. During an interview on 4/19/2024 at 10:09 AM, Certified Nursing Assistant #3 stated they worked the 7:00 AM to 3:00 PM shift and were regularly assigned to Resident #26. Certified Nursing Assistant #3 stated they had no issues with Resident #26 and the resident was cooperative with care. Certified Nursing Assistant #3 stated approximately a month ago Resident #26 told them that Certified Nursing Assistant #1 stuck their finger into their vagina. Certified Nursing Assistant#3 stated they did not recall the exact date the resident made the allegation. Certified Nursing Assistant #3 stated they reported this information to Licensed Practical Nurse #1 because Registered Nurse #1 was not available. Certified Nursing Assistant #3 stated they did not receive any instructions or updates from Licensed Practical Nurse #1 after they reported the allegation. Certified Nursing Assistant #3 stated approximately a week after they reported the allegation to Licensed Practical Nurse #1, the resident again reported the incident to Certified Nursing Assistant #3 on 4/1/2024. Certified Nursing Assistant #3 then reported the incident to Registered Nurse #1 on 4/1/2024. Registered Nurse #1 asked them (Certified Nursing Assistant #3) to be a witness and to accompany Registered Nurse #1 to Resident #26's room when they spoke with Resident #26 because the resident was a two-person approach. Certified Nursing Assistant #3 stated Registered Nurse #1 asked Resident #26 if Certified Nursing Assistant #1 had stuck their finger into their (Resident #26) vagina. Certified Nursing Assistant #3 stated the resident did not retract their allegation during the interview. Certified Nursing Assistant #3 stated that they were in-serviced on abuse and reporting and knew to immediately report the allegation of sexual abuse to Registered Nurse #1. During an interview on 4/19/2024 at 9:39 AM, the Director of Nursing Services stated that Registered Nurse #1 did not notify them of the sexual abuse allegation made by Resident #26 until 4/18/2024 at approximately 2:30 PM. The Director of Nursing Services stated that once Registered Nurse #1 was made aware of the allegations, they were responsible for immediately notifying them (Director of Nursing Services) or the facility Administrator and for initiating the investigation. The Director of Nursing Services stated that as soon as the allegation was made, Registered Nurse #1 should have assessed the resident and removed the alleged Certified Nursing Assistant #1 from the unit. The physician and the resident's designated representative should have been notified; statements from all staff involved, and any potential witnesses should have been obtained. The Director of Nursing Services stated Registered Nurse #1 should have also documented the assessment in the medical record and updated the resident's care plan regarding the allegation. During an interview on 4/19/2024 at 10:12 AM, the Administrator stated they were first made aware of Resident #26's allegation of sexual abuse on 4/18/2024 at 5:10 PM. The Administrator stated they expected the facility staff to notify them of any abuse allegations immediately after the resident first reported the occurrence. The Administrator stated that the resident should have been assessed for physical injuries, and psychological changes reflected in the resident's behavior, and the assessment should have been documented in the resident's medical record. The Administrator stated if they were notified of the allegations, they would have instructed staff to remove Certified Nursing Assistant #1 from the schedule immediately; ensured that an assessment was completed, the physician was notified, and the resident was provided emotional support along with the psychological services; and they would have reported the incident to the New York State Department of Health. During an interview on 4/26/2024 at 12:47 PM, the Medical Director stated the Director of Nursing Services first made them aware of Resident #26's allegation of sexually inappropriate behavior by staff on 4/18/2024. The Medical Director stated they expect inappropriate behaviors toward the residents should not occur; however, when the resident made such an allegation, the accused staff should have been removed from the daily schedule and the allegation should have been investigated and reported promptly. The Medical Director stated regardless of the resident's accusatory behavior, any allegation of abuse of any kind should be fully investigated. The Medical Director stated that residents who have accusatory behaviors are at higher risk for abuse because they are not taken seriously and can often be taken advantage of because of this behavior. The Medical Director stated that Registered Nurse #1 should have reported the allegations of sexual abuse to the Director of Nursing Services, and it was not Registered Nurse #1's decision to decide not to investigate the allegation. 10 NYCRR 415.4(b)(3)

Based on interviews and record review during a Recertification Survey initiated on 4/17/2024 and completed on 4/26/2024, the facility failed to ensure that allegations of sexual abuse were reported to the Administrator or other officials immediately (or within two hours) after the allegations were made. This was identified for one (Resident #26) of seven residents reviewed for abuse. Specifically, on 3/30/2024 Resident #26, with intact cognition, reported to Licensed Practical Nurse #1 they were sexually abused by Certified Nursing Assistant #1. Licensed Practical Nurse #1 failed to report the allegations to the facility Administrator/designee or other officials. Resident #26 again reported the same allegation of sexual abuse to Certified Nursing Assistant #3 on 4/01/2024. Certified Nursing Assistant #3 informed Registered Nurse #1 of the allegation. Registered Nurse #1 failed to report the allegation to the facility Administrator/designee, or other officials. Certified Nursing Assistant #1 continued to be assigned to the same unit where Resident #26 resided and had access to the resident through 4/18/2024. This resulted in Immediate Jeopardy for Resident #26 with the potential for serious injury, serious harm, serious impairment, or death to 40 other residents who resided on Resident #26's unit. The finding is: The facility policy and procedure titled, Requirements for Reporting Suspected Case of Abuse, Neglect or Mistreatment, revised February 2024, documented mandatory reporters are required to report when they have a reasonable cause to believe that a person receiving care or services in a residential health care facility has been physically abused, mistreated, or neglected. When a suspicious incident occurs, it is the policy of this facility that the administrator and director of nursing or designee be made aware immediately by the staff reporting it. Employees are in-serviced on this policy upon hire, annually, and as needed to ensure compliance. The occurrence must be reported immediately to the Administrator, Director of Nursing Services, or designee, and to the New York State Department of Health but not later than 2 hours after the allegation is made. Resident #26 was admitted with diagnoses that included Major Depressive Disorder, Bipolar Disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), and Anxiety Disorder. The annual Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status score was 14 which indicated intact cognition. The Minimum Data Set documented the resident had no behavioral or mood symptoms at the time of assessment. A Comprehensive Care Plan dated 4/18/2024, initiated after the allegation was brought to the facility's attention by the surveyor, documented the resident was at risk of being a victim due to dependence on caregivers for activities of daily living. The resident has a history of accusatory and physically abusive behaviors. Interventions included to assess the resident for signs and symptoms of abuse and or neglect and report to appropriate resources; investigate all allegations of abuse and neglect promptly; provide support and ensure the resident is free from abuse. During an initial tour on 4/18/2024 Resident #26 was interviewed at 1:15 PM. Resident #26 stated approximately two months ago Certified Nursing Assistant #1 inserted their finger into their vagina while providing care. Resident #26 stated they reported the incident to Licensed Practical Nurse #1. The facility's Grievance Reports and Accident and Incident Reports for February 2024, March 2024, and April 2024 were reviewed on 4/19/2024. There was no documented evidence that a report was initiated for the allegation of sexual abuse made by Resident #26. During an interview on 4/18/2024 at 2:05 PM Certified Nursing Assistant #1 stated they worked at the facility as a part-time employee during the 7:00 AM - 3:00 PM shift. They usually covered Certified Nursing Assistant #3's assignment when Certified Nursing Assistant #3 was off. Certified Nursing Assistant #1 stated the assignment included providing care to Resident #26, who required two staff members for activities of daily living. Resident #26 was a two-staff approach (two staff required to interact with the resident) because the resident had accusatory behavior towards staff. Certified Nursing Assistant #1 stated on 3/31/2024 they provided daily care for Resident #26 including washing the resident's buttocks and perineal (genital) area. Certified Nursing Assistant #1 stated a second Certified Nursing Assistant was present during care. Certified Nursing Assistant #1 could not recall the name of the Certified Nursing Assistant who assisted them with Resident #26. Certified Nursing Assistant #1 stated when they returned to work on Tuesday (4/2/2024) they were told that Resident #26 had accused them of massaging their back, rubbing their buttocks, and sticking their finger in the resident's vagina (could not recall who notified them of the allegation). Certified Nursing Assistant #1 stated that at no time did their finger enter the resident's vagina. Certified Nursing Assistant #1 stated that even after the allegation was made, they were still assigned to provide care for Resident #26. Certified Nursing Assistant #1 stated they questioned Licensed Practical Nurse #1 as to why they were still assigned to Resident #26 after they were accused of sexual abuse. Certified Nursing Assistant #1 stated Licensed Practical Nurse #1 told them Resident #26 was a two-person approach and that Certified Nursing Assistant #1 had to care for the resident. A review of the Daily Assignment Sheets from 3/30/2024 to 4/18/2024 documented Certified Nursing Assistant #1 was assigned to Resident #26 on 3/30/24, 3/31/24, 4/2/24, 4/4/24, 4/11/2024, 4/13/2024, 4/14/2024, 4/16/2024 and 4/18/2024. During an interview with Registered Nurse #1 on 4/18/2024 at 4:06 PM they stated they were the Clinical Care Coordinator during the 7:00 AM - 3:00 PM shift on 4/1/2024. Registered Nurse #1 stated on 4/1/2024, Certified Nursing Assistant #3 reported to them, Resident #26 had made an allegation of sexual abuse against Certified Nursing Assistant #1. Registered Nurse #1 stated they went to speak with the resident and reminded the resident they had been accusatory towards the staff in the past. Registered Nurse #1 stated they did not assess the resident at the time but should have. Registered Nurse #1 stated they did not report the allegation to the administration and did not initiate an investigation because the resident told them they made up the allegation, as they wanted Certified Nursing Assistant #1 to be taken off their assignment. Registered Nurse #1 stated they were aware when an allegation of abuse is reported to them, they are responsible for initiating an investigation, interviewing the resident, and escalating as needed. Registered Nurse #1 stated they were supposed to report the allegation of abuse to the Director of Nursing and the Assistant Director of Nursing Services. During an interview on 4/19/2024 at 10:09 AM, Certified Nursing Assistant #3 stated they worked the 7:00 AM to 3:00 PM shift and were regularly assigned to Resident #26. Certified Nursing Assistant #3 stated they had no issues with Resident #26 and the resident was cooperative with care. Certified Nursing Assistant #3 stated approximately a month ago Resident #26 told them Certified Nursing Assistant #1 stuck their finger into their vagina. Certified Nursing Assistant#3 stated they did not recall the exact date the resident made the allegation. Certified Nursing Assistant #3 stated they reported this information to Licensed Practical Nurse #1 because Registered Nurse #1 was not available. Certified Nursing Assistant #3 stated they did not receive any instructions or updates from Licensed Practical Nurse #1 after they reported the allegation. Certified Nursing Assistant #3 stated approximately a week after they reported the allegation to Licensed Practical Nurse #1, the resident again reported the incident to Certified Nursing Assistant #3 on 4/1/2024. Certified Nursing Assistant #3 then reported the incident to Registered Nurse #1 on 4/1/2024. Registered Nurse #1 asked them to be a witness and to accompany Registered Nurse #1 to Resident #26's room when they spoke with Resident #26 because the resident was a two-person approach. Certified Nursing Assistant #3 stated Registered Nurse #1 asked Resident #26 if Certified Nursing Assistant #1 had stuck their finger into their (Resident #26's) vagina. Certified Nursing Assistant #3 stated the resident did not retract their allegation during the interview. Certified Nursing Assistant #3 stated they were in-serviced on abuse, and reporting, and knew to immediately report the allegation of sexual abuse to Registered Nurse #1. During an interview on 4/19/2024 at 9:39 AM, the Director of Nursing Services stated that Registered Nurse #1 did not notify them of the sexual abuse allegation made by Resident #26 until 4/18/2024 at approximately 2:30 PM. The Director of Nursing Services stated that once Registered Nurse #1 was made aware of the allegations, they were responsible for immediately notifying the Director of Nursing Services or the facility Administrator, and for initiating the investigation. The Director of Nursing Services stated that as soon as the allegation was made, Registered Nurse #1 should have assessed the resident and removed the alleged Certified Nursing Assistant #1 from the unit. The physician and the resident's designated representative should have been notified; statements from all staff involved, and any potential witnesses should have been obtained. The Director of Nursing Services stated Registered Nurse #1 should have also documented the assessment in the medical record and updated the resident's care plan regarding the allegation. During an interview on 4/19/2024 at 10:12 AM, the Administrator stated they were first made aware of Resident #26's allegation of sexual abuse on 4/18/2024 at 5:10 PM. The Administrator stated they expected the facility staff to notify them of any abuse allegations immediately after the resident first reported the occurrence. The Administrator stated that the resident should have been assessed for physical injuries, and psychological changes reflected in the resident's behavior, and the assessment should have been documented in the resident's medical record. The Administrator stated if they were notified of the allegations, they would have instructed staff to remove Certified Nursing Assistant #1 from the schedule immediately; ensured that an assessment was completed, the physician was notified, the resident was provided emotional support along with the psychological services and would have reported the incident to the New York State Department of Health. During an interview on 4/19/2024 at 12:35 PM, Licensed Practical Nurse #1 stated they were regularly assigned to Resident #26's unit during the 7:00 AM-3:00 PM. Licensed Practical Nurse #1 stated that no one reported any sexual abuse allegations to them. During an interview on 4/26/2024 at 12:47 PM, the Medical Director stated that the Director of Nursing Services first made them aware of Resident #26's allegation of sexually inappropriate behavior by staff on 4/18/2024. The Medical Director stated that they expect inappropriate behaviors toward the residents should not occur; however, when the resident made such an allegation, the accused staff should have been removed from the daily schedule and the allegation should have been investigated and reported promptly. The Medical Director stated regardless of the resident's accusatory behavior, any allegation of abuse of any kind should be fully investigated. The Medical Director stated that residents who have accusatory behaviors are at higher risk for abuse because they are not taken seriously and can often be taken advantage of because of this behavior. The Medical Director stated Registered Nurse #1 should have reported the allegations of sexual abuse to the Director of Nursing Services, and it was not Registered Nurse #1's decision to decide not to investigate the allegation. 10 NYCRR 415.4(b)(2)

Based on observations, record review, and interviews during the Recertification Survey initiated on 4/17/2024 and completed on 4/26/2024, the facility did not ensure that drug records were in order and accounted for all controlled drugs. This was identified in three (Unit 1C, Unit 3C, and Unit 3B) of seven nursing units reviewed for Medication Storage. Specifically, 1) the daily control drug count sheet on Unit 1C was not signed by two Licensed Nurses to reflect a physical count of the available controlled medications. Additionally, the daily control drug count sheet was not reconciled to reflect the available controlled medications in the medication blister pack for Resident #130 (Unit 1C). 2) the daily control drug count sheet on Unit 3C was not signed by two licensed nurses to reflect a physical count of the available controlled medications. Additionally, the Controlled Drug Record form on Unit 3C was not reconciled to reflect the available controlled medications in the medication blister pack for Resident #170 (Unit 3C). 3) the daily control drug count sheet on Unit 3B was not signed by two licensed nurses to reflect a physical count of the available controlled medications. The findings are: 1) Resident #130 was admitted with diagnoses including Cerebral Palsy, Chronic Pain Syndrome, and Aphasia. The 4/9/2024 Quarterly Minimum Data Set assessment documented Resident #130 had a short/long term memory problem and severely impaired cognition for daily decision making. A physician's order effective 4/11/2024 documented to administer Oxycodone (a controlled substance used to treat pain) 5-milligram tablet, one tablet via Gastrointestinal Tube every 12 hours for generalized pain for seven days. During an observation of Unit 1C's medication room, with Licensed Practical Nurse #5, on 4/25/2024 at 2:50 PM, the daily control drug count sheet was reviewed for the period of 4/21/2024 to 4/27/2024. Licensed Nurses' signatures were noted to be missing at the beginning of the shift for the 7:00 PM-7:00 AM count on 4/21/2024, the 7:00 AM-7:00 PM count on 4/22/2024, the 7:00 PM-7:00 AM count on 4/22/2024, and the 7:00 AM-7:00 PM count on 4/25/2024. A manual count of Resident #130's controlled medications was performed by Licensed Practical Nurse #5 in the presence of one of the registered nurse surveyors. Resident #130's daily control drug count sheet for Oxycodone documented 29 tablets of Oxycodone were remaining; however, the blister pack for Oxycodone had 30 tablets. Licensed Practical Nurse #5 was interviewed on 4/25/2024 immediately after the observation. Licensed Practical Nurse #5 stated they may have taken the Oxycodone tablet from Resident #130's other blister pack and recorded the count inaccurately in the record. Licensed Practical Nurse #5 stated that they forgot to sign the drug control sheet at the beginning of their shift on 4/25/2024. Licensed Practical Nurse #5 stated that the error was an oversight and that the drug control sheet should have been signed in the presence of another nurse to reflect an accurate count of the controlled substance at hand. An observation was conducted immediately after the interview with Licensed Practical Nurse #5 on 4/25/2024 related to the remaining Oxycodone blister packs for Resident #130. The count was found to be accurate as documented for the other blister packs. The Medical Director was interviewed on 4/26/2024 at 1:10 PM and stated that reconciliation of controlled substances by licensed nurses is necessary at the change of every shift to keep track of controlled substances. The Director of Nursing Services was interviewed on 4/26/2024 at 1:15 PM and stated that a manual count and signing of the daily control drug count sheet must be done by two licensed nurses at the commencement of every shift because reconciliation of the daily control drug count sheet is necessary to keep track of controlled substances. 44963 2) Resident #170 was admitted with diagnoses including Dementia with Anxiety, Major Depressive Disorder, and Altered Mental Status. The Admission Minimum Data Set assessment dated [DATE] documented that Resident #170 had a Brief Interview for Mental Status score of 8 which indicated moderately impaired cognition. Resident #170 did not receive any Anti-Anxiety medication at admission. A physician's order dated 4/11/2024 documented to administer Xanax (a controlled substance used to reduce Anxiety) 0.25-milligram tablet, one tablet by mouth every 12 hours as needed for anxiety. During an observation of Unit 3C's medication room on 4/26/2024 at 10:24 AM, the low side unit's daily control drug count sheet was reviewed for the period of 4/21/2024 to 4/27/2024. Licensed nurses' signatures were noted to be missing at the beginning of the shift for the 11:00 PM-7:00 AM count on 4/24/2024, the 3:00 PM-11:00 PM count on 4/25/2024, and the 7:00 AM-3:00 PM count on 4/26/24. Licensed Practical Nurse #9, who was the assigned nurse to work on the low side of Unit 3C on 4/26/2024, was interviewed at on 4/26/2024 10:26 AM. Licensed Practical Nurse #9 stated they had counted and reconciled the narcotic count sheet with the outgoing nurse at the beginning of their shift today (4/26/2024). Licensed Practical Nurse #9 stated they forgot to initial the daily control drug count sheet after completing the count and it was an oversight. Licensed Practical Nurse #9 stated the daily control drug count sheet should be initialed by both nurses after the count is completed. During the observation, the unit's high-side daily control drug count sheet was reviewed on 4/26/2024 at 10:31 AM. A manual count of Resident #170's controlled medications was conducted with Licensed Practical Nurse #6. Resident #170's blister pack of Xanax 0.25 milligram had 32 remaining tablets and the Controlled Drug Record form for Resident #170's Xanax documented 32 tablets remaining; however, the daily control drug count sheet that was reconciled by Licensed Practical Nurse #6 indicated 31 tablets were remaining. Licensed Practical Nurse #6 was interviewed on 4/26/2024 immediately after the observation and stated that they counted and reconciled all residents' controlled drugs with the outgoing nurse at the beginning of their shift (7:00 AM-3:00 PM) today, 4/26/2024. Licensed Practical Nurse #6 stated they saw the number of tablets remaining on the Controlled Drug Record form matched the actual count in the blister pack and that is why they initialed the daily control drug count sheet. Licensed Practical Nurse #6 stated they did not notice the daily control drug count sheet documented an inaccurate count of Resident #170's Xanax. Licensed Practical Nurse #6 stated that the daily control drug count sheet should document 32 tablets of Xanax instead of 31 tablets. The Director of Nursing Services was interviewed on 4/26/2024 at 4:26 PM and stated that both outgoing nurses and incoming nurses at the beginning of each shift must conduct a count of all narcotic medications together. The Director of Nursing Services stated that nurses must ensure the blister pack, the Controlled Drug Record form, and the daily control drug count sheet should reflect the accurate count of each narcotic available on the unit. The Director of Nursing Services further stated that each nurse must initial the daily control drug count sheet together. 41051 3) During an observation of Unit 3B's medication room on 4/26/2024 at 10:26 AM, the low side unit's daily control drug count sheet was reviewed for the period of 4/21/2024 to 4/27/2024. Licensed nurse signatures were noted to be missing at the beginning of the shift for the 3:00 PM-11:00 PM count on 4/21/2024, the 11:00 PM- 7:00 AM count on 4/21/2024, and the 7:00 AM-3:00 PM count on 4/26/2024. Licensed Practical Nurse #10, who was the assigned nurse to work on the low side of Unit 3B on 4/26/2024, was interviewed on 4/26/2024 at 10:29 AM. Licensed Practical Nurse #10 stated they had counted and reconciled the daily control drug count sheet with the outgoing nurse at the beginning of their shift on 4/26/2024. Licensed Practical Nurse #10 stated they did not sign the unit's daily control drug count sheet that morning because they normally sign the book at the end of their shift. Licensed Practical Nurse #10 stated they were never trained or in-serviced on how the count was supposed to be done and when they should sign for it. The Inservice Coordinator/Staff Educator was interviewed on 4/26/2024 at 10:43 AM. The Inservice Coordinator/Staff Educator stated that during training, the licensed nurses should have been trained to sign off on the unit's daily control drug count sheet at the beginning of their shift when they conducted the count. The Inservice Coordinator/Staff Educator stated when a Licensed Practical Nurse is new to the facility they initially work with a mentor nurse on the unit who trains the new nurse and the training includes the procedure for the narcotic drug count. The Director of Nursing Services was interviewed on 4/26/2024 at 4:21 PM and stated that both the outgoing nurse and the incoming nurse must conduct a count of all narcotic medications together. The Director of Nursing Services stated once the count is completed both licensed nurses should sign the unit's daily control drug count sheet. 10 NYCRR 415.18(b)(1)(2)(3)

Based on observations, record review, and interviews during the Recertification Survey initiated on 4/17/2024 and completed on 4/26/2024 the facility did not ensure each resident's environment was free from accident hazards and each resident received adequate supervision and assistance devices to prevent accidents. This was identified for one (Resident #226) of four residents reviewed for accident hazards. Specifically, Resident #226 was assessed as at risk for falls and had a history of falls. The resident's comprehensive care plan indicated a high floor mat as an intervention and a Dycem non-slip mat under the floor mat to prevent the high floor mat from slipping away from the resident's bed. During multiple observations, the Dycem non-slip mat was not observed under the high floor mats in Resident #226's room as indicated in the resident's comprehensive care plan. The finding is: The facility's policy titled, Resident Incidents and Accidents dated 2/2024 documented that the safety of the residents we serve is the facility's priority. The purpose of this policy is to maintain a proactive safety program congruent with the quality of life in which each resident is provided with a safe environment. Resident #226 was admitted with diagnoses that included Cerebral Infarction (a stroke), Hemiplegia (paralysis of one side of the body), and Hemiparesis (a weakness or the inability to move on one side of the body) affecting the Right Dominant Side, and Dementia. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score was not completed because the resident was rarely or never understood. A Comprehensive Care Plan for falls initiated on 5/8/2023 documented that Resident #226 was at risk for falls and injury due to a history of falls, impulsive behavior, and decreased range of motion. Interventions included but were not limited to floor mats to be placed on both sides of the bed and Dycem mats to be placed underneath both floor mats. A Nursing Progress Note dated 6/11/2023 documented Resident #226 was observed on the floor between the bedframe and high mat. A Nursing Progress Note dated 10/31/2023 documented Resident #226 was found lying on the floor by their bed. A Nursing Progress Note dated 11/15/2023 documented at approximately 4:00 AM Resident #226 was found sitting in between the bed and floor mat with their buttocks on the floor and their left leg under the floor mat. A Nursing Progress Note dated 11/21/2023 documented the resident was observed sitting upright with buttocks on the floor and their back against the bed with their extremities in front of them. The high mat was pushed away from the bed. A Comprehensive Care Plan for behavior initiated on 11/23/2023 documented Resident #226 had a behavior problem as evidenced by resident intentionally sliding and wiggling their way out of bed to the floor. An intervention was put in place for floor mats at the bedside with the addition of a Dycem mat to prevent sliding and wedging between the bed and the mat. A Nursing Progress Note dated 12/2/2023 documented Resident #226 was observed sitting next to the bed with their back against the bed and the high mats were pushed out to the side. On 4/17/2024 at 10:46 AM Resident #226 was observed in bed and to the right and left side of the resident's bed high floor mats were in place. On 4/24/2024 at 11:15 AM Resident #226 was observed in bed and high floor mats were placed to the right and left side of the bed. The floor mat on the left side of the bed was placed between the wall and the bed and did not move when pushed. There was no Dycem mat beneath the high floor mat. The high floor mat on the right side of the bed easily slipped out of place and there was no Dycem non-slip mat beneath the floor mat. On 4/24/2024 at 1:03 PM, an observation was made in the presence of Licensed Practical Nurse #11. Resident #226 was observed in bed with high floor mats in place and there were no Dycem mats beneath the high floor mats. Licensed Practical Nurse #11 was interviewed on 4/24/2024 immediately after the observation and stated they had observed Resident #226 suspended between the bed and the high floor mat. Licensed Practical Nurse #11 could not recall the day or time of this observation and stated they did not document the occurrence because the resident was not on the floor. Licensed. Licensed Practical Nurse #11 stated they were aware that Dycem mats had to be placed beneath the high floor mats to prevent the high floor mats from sliding away from the bed. Licensed Practical Nurse #11 looked in Resident #226's nightstand and located non-slip rug pads but Dycem mats were not located. Licensed Practical Nurse #11 placed the non-slip rug pads beneath the high floor mats. Certified Nursing Assistant #12 was interviewed on 4/24/2024 at 1:51 PM. Certified Nursing Assistant #12 stated they had never witnessed Resident #226 on the floor. Certified Nursing Assistant #12 stated the high floor mats were always in place and they have seen the non-slip rug pads beneath the high floor mats but have never seen Dycem mats in place. Certified Nursing Assistant #12 stated they do not recall the last time they saw the non-slip rug pads beneath the high mats. Certified Nursing Assistant #12 stated they did not document whether or not the Dycem mats were in place. Registered Nurse #7 was interviewed on 4/24/2024 at 2:04 PM and stated Resident #226 has a history of falls and the Dycem mats should be in place beneath the high mats to prevent the high mats from sliding away from the bed. The Director of Nursing Services was interviewed on 4/26/2024 at 4:43 PM and stated it was not acceptable to put the non-slip rug pads in place of the Dycem mats and that the Dycem mat should always be in place and checked by the Certified Nursing Assistants. The Certified Nursing Assistants were responsible for reporting missing Dycem mats to the charge nurse and the charge nurse would place a request in the maintenance log or if a safety concern call the maintenance department directly. 10 NYCRR 483.25(d)(1)(2)

Based on observation, record review, and interviews during the Recertification Survey initiated on 4/17/2024 and completed on 4/26/2024, the facility did not ensure a person-centered comprehensive care plan was reviewed and revised to address each resident's needs. This was identified for 1) one (Resident #114) of two residents reviewed for rehabilitation and restorative services; 2) one (Resident #227) of four residents reviewed for respiratory care; and 3) one (Resident #186) of five residents reviewed for unnecessary medications. Specifically, there was no documented evidence that the comprehensive care plans for Resident #114, Resident #227, and Resident #186 were reviewed and revised by the interdisciplinary team after each comprehensive and quarterly review assessment. The finding is: The facility's policy and procedure titled, Comprehensive Care Planning: Initial/Interim Care Plan effective 6/1/2002 and last reviewed in 4/2024, documented that an assessment will be completed on each newly admitted resident; the assessment information will be the basis of an Initial/Interim Care Plan, designed to guide caregivers until such time as the Comprehensive Care Planning Team can complete the formal care plan. The facility policy and procedure did not include that the comprehensive care plans are reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. 1) Resident #114 was admitted with diagnoses that included Diabetes Mellitus with diabetic neuropathy, vitamin-dependent Rickets, and generalized Osteoarthritis. The quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 15 indicating the resident was cognitively intact. The resident required partial/moderate assistance for eating and was dependent on staff for bed mobility and transfer. The quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 13 indicating the resident had intact cognition; the resident required partial/moderate assistance for eating and was dependent for bed mobility and transfer. A comprehensive care plan titled Limited Physical Mobility related to difficulties with hands was created on 3/8/2023, with the last revision date of 9/19/2023. The comprehensive care plan documented the resident has been prescribed palm guards. The interventions included palm guards to be utilized as per the physician's order; providing a gentle range of motion as tolerated with daily care; and assistance with mobility as needed. There was no documented evidence that the comprehensive care plan was reviewed and or revised with the Minimum Data Set assessment schedule dated 11/3/2023 and 2/13/2024. Licensed Practical Nurse #3 was interviewed on 4/26/2024 at 12:35 PM and stated that the Licensed Practical Nurses are not allowed to initiate a care plan, but they are able to maintain/update and ensure that the plan of care is being followed. Licensed Practical Nurse #3 stated that the Registered Nurses are responsible to complete the quarterly care plan updates. Registered Nurse #4 was interviewed on 4/26/2024 at 12:54 PM and stated the care plans are reviewed and revised quarterly, annually, with significant change, and on an as-needed basis. The care plan review corresponds with the Minimum Data Set schedule. Registered Nurse #4 stated that the Minimum Data Set department is responsible for ensuring that all care plans are updated before the assessment is submitted to the Centers for Medicare and Medicaid Services. 2) Resident #227 was admitted with the diagnoses of Parkinson's Disease, Dementia, and Heart Failure. The 5-day Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 10 which indicated the resident had moderately impaired cognition. The resident was dependent on staff for eating. The resident received oxygen and occupational and physical therapies. The quarterly Minimum Data Set, dated dated dated [DATE] documented a Brief Interview for Mental Status score of five which indicated the resident had severely impaired cognition. The resident required partial/moderate assistance with eating. The resident received speech-language and occupational therapies. The physician's orders dated 4/25/2024 Apixaban 5 milligrams every 12 hours for Atrial Fibrillation; Ceftriaxone (antibiotic medication) 1 gram intravenously every 24 hours for pulmonary infection for one week; and Ipratropium-Albuterol Solution 3 milliliter inhaler every six hours as needed for shortness of breath. A comprehensive care plan titled, Respiratory created 12/2/2023 with no revision date, documented the resident had altered respiratory status related to Chronic Obstructive Pulmonary Disease. The interventions included but were not limited to administering medication/puffers as ordered, monitoring for effectiveness and side effects, monitoring for signs and symptoms of respiratory distress, and reporting to the physician as needed. There was no documented evidence that the comprehensive care plan was reviewed and revised in accordance with the scheduled Minimum Data Set assessment dated [DATE]. Registered Nurse #2 was interviewed on 4/25/2024 at 12:25 PM and stated they are responsible for initiating and revising the residents' care plans. Registered Nurse #2 stated that the registered nurse on duty at the time of admission would initiate the care plans. Registered Nurse #2 stated that the comprehensive care plans are reviewed and revised at the care plan meetings, which correspond to the Minimum Data Set assessment schedule. Registered Nurse #2 stated they would also update the care plan if there were changes at the care plan meeting. 3) Resident #186 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, Hypertension, and Depression. A quarterly Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview of Mental Status was 14 which indicated the resident had intact cognition. Resident #186 required set-up assistance for eating and supervision for bed mobility and transfer. Resident #186 received antidepressant and anticoagulant medications. A quarterly Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview of Mental Status was 11 which indicated the resident had moderately impaired cognition. Resident #186 required set-up assistance for eating and supervision for bed mobility and transfer. Resident #186 received antidepressant, hypnotic, anticoagulant, and diuretic medications. A comprehensive care plan titled, Respiratory created on 6/14/2023 documented the resident was at risk for impaired gas exchange related to a history of Pneumonia and Chronic Obstructive Pulmonary Disease. The interventions included administering aerosol or bronchodilators as ordered, monitoring/documenting any side effects and effectiveness, monitoring for difficulty breathing (Dyspnea) on exertion, monitoring vital signs as per order, and supplemental oxygen as per physician orders. There was no documented evidence that the comprehensive care plan was reviewed and revised in accordance with the scheduled assessment of 11/3/2023 and 2/3/2024. A comprehensive care plan titled, Anticoagulant Therapy, created on 6/12/2023 documented the resident was on anticoagulant therapy, Eliquis related to Atrial Fibrillation. The interventions included administering anticoagulant medications as ordered by the physician, and monitoring for side effects and effectiveness every shift. There was no documented evidence that the comprehensive care plan was reviewed and revised in accordance with the scheduled assessment of 11/3/2023 and 2/3/2024. The Director of the Minimum Data Set was interviewed on 4/25/2024 at 12:41 PM and stated that the Minimum Data Set assessment is done by the Minimum Data Set coordinator and that nurses are responsible to initiate and review the care plans. The Director of the Minimum Data Set stated the registered nurse manager should be reviewing the care plan episodically (acute illness), if there is a change in status/medication, then the care plan should be updated. The Director of the Minimum Data Set stated that the care plans are reviewed and updated at each care plan meeting. An interview was conducted with the Director of Nursing Services on 4/25/2024 at 2:07 PM and stated that a Minimum Data Set assessment is completed on admission, quarterly, and annually. The Director of Nursing Services stated that at a minimum, the care plan should be reviewed with the Minimum Data Set schedule. 10 NYCCR 415.11(c)(2) (i-iii)

Based on observations, interviews, and record review during the Recertification Survey initiated on 4/17/2024 and completed on 4/26/2024, the facility did not ensure that the interdisciplinary team had determined that self-administration of medications was clinically appropriate for each resident. This was identified for one (Resident #186) of five residents reviewed for choices. Specifically, resident #186 was observed with multiple inhalers (Ventolin, Atrovent, Breo Ellipta) medications, on top of their room dresser. There was no documented assessment by the interdisciplinary team to determine if the resident could safely self-administer and store these medications in their room. The finding is: A facility policy and procedure titled, Medication: General Administration Guidelines last revised in October 2023, documented the facility maintains clinical records on all residents and assures that all Medication Administration Records note residents identifying information. Only physicians or licensed nurses may administer medication unless the resident is permitted to administer her/his own medications on the recommendation of the comprehensive care plan team and subsequent written order of the physician. Resident #186 was admitted with diagnoses of Chronic Obstructive Pulmonary Disease, Hypertension, and Depression. A quarterly Minimum Data Set, dated dated dated [DATE] documented the resident's Brief Interview of Mental Status score was 14, indicating intact cognition. A quarterly Minimum Data Set, dated dated dated [DATE] documented the resident's Brief Interview of Mental Status score was 11, indicating moderately impaired cognition. Resident #186 required set-up assistance for eating and supervision for bed mobility and transfer. Resident #186 received antidepressant, hypnotic, anticoagulant, and diuretic medications. A current physician's order documented to administer Breo Ellipta Aerosol Powder Breath Activated 200-25 MCG/INH (Fluticasone Furoate-Vilanterol) 1 puff inhale orally one time a day at 0900 for Chronic Obstructive Pulmonary Disease, administered by Clinician. A current physician's order documented to administer Albuterol Sulfate hydrofluoroalkane. Inhalation Aerosol Solution 108 (90 Base) micrograms/activation, two puff inhale orally every 4 hours as needed for Chronic Obstructive Pulmonary Disease, administered by Clinician. A physician's order dated 4/25/2024, Ipratropium Bromide hydrofluoroalkane. Aerosol Solution 17 micrograms/activation, one puff inhale orally every 12 hours for Chronic Obstructive Pulmonary Disease, administered by Clinician. During an observation on 4/17/2024 at 10:57 AM Resident #186 was observed in their room. Three different inhalers (Ventolin, Atrovent, Breo Ellipta), were observed on the top of the resident's dresser. The observation, the resident stated that they use the medications by themselves. During an observation on 4/18/2024 at 11:58 AM, Resident #186 was observed in their room. Three different inhalers (Ventolin, Atrovent, Breo Ellipta), were observed on the top of the resident's dresser. The observation, the resident stated that they use the medications by themselves. The medical record lacked documented evidence of a physician's order for self-administration of medications including the inhalers. Licensed Practical Nurse #2 was interviewed on 4/18/2024 at 12:30 PM and stated that the doctor must write an order for the resident to self-administer medications. Licensed Practical Nurse #2 stated they did not know who had left the inhalers in the resident's room. When they were administering medication to Resident #186 this morning they observed using the inhalers. Licensed Practical Nurse #2 stated the nurse must ensure that the resident is oriented enough to self-administer the medication. Resident #182 only self-medicates inhalers. Registered Nurse Manager #2 was interviewed on 4/18/2024 at 12:35 PM and stated to self-medicate, there needs to be a physician's order and a care plan in place. Registered Nurse Manager #2 did not know what should be done if medication is observed in a room. Primary Care Physician #1 was interviewed on 4/26/2024 at 9:44 AM and stated the physician should assess the resident's ability to self-administer their medication. Primary Care Physician #1 was not sure if Resident #186 was assessed or not. Nurse Practitioner #2 was interviewed on 4/26/2024 at 10:06 AM and stated that they are not aware of any formal facility policy for a resident to self-administer medications. Nurse Practitioner # 2 stated for a resident to self-administer the medication the type of medication and the resident's ability to administer the medications has to be considered. 10 NYCRR 415.3 (f)(1) (vi)

Based on observation, interviews, and record review during the Recertification Survey initiated on 4/17/2024 and completed on 4/26/2024 the facility did not ensure that each resident is treated with respect and dignity and cared for in a manner that promotes or enhances the resident's quality of life. Specifically, on two separate occasions, Resident #92 was observed in bed from the hallway with their urinary bag attached to the bed frame. The urinary bag had no privacy bag and was observed to contain urine. The finding is: The facility policy and procedure on Resident Privacy revised 4/2024 documented the goal of the policy is to ensure that all residents' right to privacy is respected and maintained in all aspects of care delivery and that all staff members respect the privacy and dignity of residents at all times. Resident #92 was admitted with diagnoses that included Hypertension, Renal Insufficiency, and Renal Failure. The Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status score was 15 which indicated intact cognition. The resident was dependent on staff for toileting and had an indwelling Foley catheter. A Comprehensive Care Plan dated 4/4/2024 documented the resident had a Foley Catheter secondary to Obstructive Uropathy and Chronic Kidney Disease. Interventions included to change the catheter as needed, and to position the catheter bag and tubing below the level of the bladder and away from the entrance room door. A Physician's order dated 3/28/2024 documented to maintain a Foley catheter: size 16 French with the 10-centimeter balloon for diagnoses of Chronic Kidney Disease. Resident #92 was observed on 4/18/2024 at 11:00 AM in bed from the hallway. The resident's Foley drainage bag was observed hanging from the bed frame and was half filled with urine. There was no privacy bag in place. Resident #92 was observed on 4/18/2024 at 1:20 PM in bed from the hallway. The resident Foley drainage bag was observed hanging from the bed frame half filled with urine without a privacy bag in place. Certified Nursing Assistant #9 was interviewed immediately on 4/18/2024 at 1:20 PM and stated that they were assigned to Resident #92. Certified Nursing Assistant #9 stated that they provided care to the resident and knew that the resident's Foley bag did not have a privacy bag. Certified Nursing Assistant #9 stated that they should have asked the Registered Nurse in charge for a privacy bag. Registered Nurse #5 was interviewed on 4/18/2024 at 1:25 PM and stated that Certified Nursing Assistant #9 should have informed the medication nurse that they needed a privacy bag for Resident #92's Foley bag. Registered Nurse #5 stated that the resident's Foley drainage bag should have been covered with a privacy bag. The Director of Nursing Services was interviewed on 4/23/2024 at 2:24 PM and stated that during care the resident's Foley drainage bag did not need a privacy bag; however, after the care was provided Certified Nursing Assistant #9 should have ensured a privacy bag was in place to cover the Foley bag. The Director of Nursing Services stated that if the resident's Foley drainage bag was in full view from the hallway, then a privacy bag should have been in place. 10 NYCRR 415.3(d)(1)(i)

Based on interviews and record review during an abbreviated survey (Complaint Number: NY 366) the facility staff did not effectively implement interventions to prevent an avoidable accident. Specifically, one (Resident #1) of three residents reviewed for accident required two persons assistance for bed mobility. On 12/19/17, the assigned Certified Nursing Assistant (CNA #1) placed a mechanical lift sling under Resident #1 by herself. Resident #1 rolled out of bed and sustained laceration to his left eyebrow. Resident #1 was transferred to the hospital and was diagnosed with [REDACTED]. This resulted in acutual harm to Resident #1 that is not Immediate Jeopardy. The findings are: The Policy and Procedure titled Hoyer Lifter dated 6/1/2012 and revised on 05/13/2013 documented that a transfer with the aid of a Hoyer lifter was always a two person lift, at minimum. The procedure documented placing the sling under the resident by side-rolling the resident with at least 2 staff members. The Policy and Procedure titled Activities of Daily Living (ADL) dated 6/1/ 2002 revised on 03/31/2016 defined bed mobility as how a resident moves to and from lying position, turns side to side and positions body while in bed or chair. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documented the resident's cognitive status as being severely impaired. He required total assistance of 2 persons with bed mobility, transfer, dressing, toilet use and personal hygiene. Resident had impairment in range of motion on bilateral upper and lower extremity. The undated lesson plan titled Hoyer-Lesson Plan documented a procedure to complete a Hoyer transfer correctly and safely by placing sling with two assistants and placing resident on (Hoyer) sling by turning from side to side. The Fall Risk assessment dated [DATE] documented resident was at risk for falls. The Comprehensive Care Plan (CCP) titled Falls/Injury dated 06/04/2016 documented resident at risk for falls/injury related to history of falls, loss of voluntary movement, impaired balance, impaired gait and dementia. Interventions included to instruct/reinforce safety measures including transfer technique. The CCP titled ADLs dated 06/04/2016 included an intervention that the resident required total assist of 2 persons with personal hygiene. The Resident Nursing Instructions (Resident Care Plan-RCP) documented Resident #1 required 2-person total assistance for bed mobility and one-person physical assistance for personal hygiene. The interim physician order [REDACTED]. The Medical Progress Note (MPN) dated 12/19/2017 at 11:35 AM documented MD was called by the nurse because the patient had fall from his bed and he had injury and laceration on his temporal area. Resident was transferred to hospital for CT scan of the head specifically because resident was on [MEDICATION NAME] full dose blood thinner; to rule out intra-cranial bleeding. The NPN dated 12/19/2017 at 3:10 PM documented resident was called to resident's room by CNA to assess patient status [REDACTED]. Resident had a laceration to left eyebrow approximately ½ inches to ¾ inches and bleeding. The NPN dated 12/19/17 at 7:40 PM documented Resident was admitted to the hospital at 7:00 PM with [DIAGNOSES REDACTED]. The undated facility's Investigative Summary documented that on 12/19/2017 at 10:40 AM, the RN was called to evaluate Resident #1 since he was witnessed falling out of bed. Upon the RN's arrival to the room, the resident was lying on his left side, next to his bed and floor mat. According to the aide attending to the resident, she had just completed care on resident and was attempting to pace Hoyer pad under his body and he rolled off the air mattress and fell in between the bed and the floor mat. resident sustained [REDACTED]. The facility investigative summary also documented that the Certified Nursing Assistant #1 (CNA #1) was interviewed and ascertained that the resident required an assist of two for bed mobility and transfer per plan of care and resident care profile. The hospital Computerized Tomographic (CT) scan dated 12/20/17 documented new large left hemispheric intraparenchymal hemorrhage (intracranial bleeding). The hospital discharge summary dated 1/10/18 documented the patient was presented to the emergency room (ER) after a fall. CT showed very large subdural hematoma. The patient was admitted to the trauma service. On 12/25/17 patient with status pot traumatic head injury, underwent [MEDICAL CONDITION]. Final Diagnosis: [REDACTED]. The CCC was interviewed on 12/27/2017 at 11:37 AM and stated Resident #1 required total assistance of two persons for bed mobility (boosting and turning). On 12/19/17 around 10:30 AM CNA #1 came to her and told her that Resident #1 fell . Upon assessment Resident #1 was found to have a small laceration to his left eyebrow and was bleeding. He was non-verbal, awake and conscious. CNA #1 told the CCC that she was placing the Hoyer pad underneath Resident #1 and he rolled off the bed. The CCC stated that placing the Hoyer pad underneath a resident was considered bed mobility, CNA #1 was expected to have another person to assist for placing a Hoyer pad underneath Resident #1. CNA #2 was interviewed on 12/27/17 at 12:19 PM and stated that she had cared for Resident #1 occasionally. She checked the RCP to determine what care was needed for each resident assigned to her prior to providing care. Resident #1 required total assistance with all ADL care. CNA #2 stated that she checked the RCP for all care needs of each resident and followed the instructions provided in the RCP. CNA #2 stated when placing a pad underneath, Resident #1 required 2 persons assistance. CNA #2 stated that CNA #1 did not ask for her assistance for Resident #1's care on 12/19/2017. CNA #3 was interviewed on 12/27/17 at 12:28 PM and she stated that Resident #1 was not on her assignment, however, she assisted other CNAs providing care to Resident #1. CNA #3 stated that Resident #1 required two persons assistance with all ADL care. When providing personal hygiene care Resident #1 tightened up his body and that was why two people were needed to provide any care to him. CNA #3 stated that she checked the RCP for each assigned resident to ascertain their care needs prior to providing care. CNA #3 stated when placing a pad underneath, Resident #1 required 2 persons assistance. CNA #3 stated that CNA #1 did not ask for her assistance for Resident #1's care on 12/19/2017. CNA #4 was interviewed on 12/27/17 at 12:45 PM and stated CNA #4 stated when placing a pad underneath. Resident #1 required assistance of two persons. CNA #4 stated that CNA #1 did not ask for her assistance for Resident #1's care on 12/19/2017. LPN #2 was interviewed on 12/27/2017 at 1:30 PM, she stated Resident #1 was not on her assignment and she was administering treatment with another resident when the a CNA called her name and told her that the CCC needed her in Resident #1's room. Upon entering Resident #1's room she observed Resident #1 laying on the floor with small amount of blood on the floor. She assisted the CCC and transferred Resident #1 back to bed. LPN #2 called the MD (physician). LPN #2 stated that CNA #1 did not ask for her assistance with Resident #1. The Director of Nursing (DON) was interviewed on 12/27/2017 at 3:49 PM. The DON stated that the staff including CNA #1 were in-serviced and had demonstrated proper procedures regarding Hoyer lift transfers on 12/4/17. The DON stated that he was notified of the incident on 12/19/17. Upon investigation the facility concluded that the plan of care for Resident #1 was not followed by CNA #1. The DON stated that during reenactment of the incident CNA #1 placed the Hoyer pad underneath Resident #1 by herself. The DON stated CNA #1 was aware that Resident #1 required 2 persons assistance with bed mobility and transfers. The DON stated that CNA #1 did not follow the plan of care and was suspended and was going to be terminated. CNA #1 stated to the DON that she did not believe she needed two persons assistance because she was not transferring the resident but was placing the Hoyer sling under Resident #1. The DON stated the Hoyer lift competency that was completed on 12/4/2017 documented that when placing sling under a resident, 2 persons assistance was required. The competency record was signed by CNA #1. The Primary Care Physician (PCP) was interviewed on 1/2/18 at 1:08 PM, and stated that he was the assigned PCP for Resident #1. On 12/19/17 he got a call from a nurse who informed him that Resident #1 had fallen and hit his head. The PCP stated that he worried about intracranial bleeding because Resident #1was on [MEDICATION NAME] and he ordered to transfer Resident #1 to the hospital for a CT scan. After 3 hours, he called the ER (emergency room ) to follow up on CT scan result. The ER staff informed him that CT scan revealed subdural hematoma. The facility was later informed by the hospital that Resident #1 (date not recalled) passed away. 415.4 (b)

Based on interviews and record review during an abbreviated survey (Complaint Number: NY 366), the facility did not ensure resident rights to be free from neglect. Specifically, one (Resident #1) of three residents reviewed for neglect, required two-person assistance for bed mobility and mechanical lift (Hoyer) for transfers as documented in the Comprehensive Care Plan (CCP). A Certified Nursing Assistant (CNA #1) willfully neglected to implement the CCP. CNA #1 placed a Hoyer sling under Resident #1 by herself and did not call for assistance. This negligence resulted in Resident #1 falling out of bed; the resident sustained [REDACTED]. Resident #1 was transferred to the hospital and diagnosed with [REDACTED].#1 died at the hospital on [DATE]. This resulted in actual harm to Resident #1 that is not Immediate Jeopardy. The Findings are: The Policy and Procedure titled Hoyer Lifter dated [DATE] and revised on [DATE] documented that a transfer with the aid of a Hoyer lifter was always a two-person lift, at minimum. The procedure documented placing the sling under the resident by side-rolling the resident with at least 2 staff members. The Policy and Procedure titled Activities of Daily Living (ADL) dated [DATE] revised on [DATE] defined Bed mobility as how a resident moved to and from lying position, turned side to side and positioned body while in bed or chair. The Policy and Procedure titled Resident Abuse, Mistreatment, Neglect and Exploitation revised ,[DATE] defined neglect as failing to provide timely, consistent, safe, adequate and appropriate services, treatment and/or care to a resident of a residential care facility while resident is under the supervision of the facility. The policy also documented a federal definition of neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documented the resident's cognitive status as being severely impaired. He required total assistance of 2 persons with bed mobility, transfer, dressing, toilet use and personal hygiene and had impairment in range of motion on bilateral upper and lower extremities. The undated lesson plan titled Hoyer-Lesson Plan documented a procedure to complete a Hoyer transfer correctly and safely by placing the sling with two assistants and placing resident on sling by turning from side to side. The Fall Risk assessment dated [DATE] documented the resident was at risk for falls. The CCP titled Falls/Injury dated [DATE] documented the resident was at risk for falls/injury related to history of falls, loss of voluntary movement, impaired balance, impaired gait and dementia. Interventions included to instruct/reinforce safety measures including transfer technique. The CCP was updated on [DATE] and documented the resident fell after personal care and sustained a laceration to left eyebrow approximately ½ inches to ¾ inches and bleeding. Resident was sent to the hospital. The CCP titled ADLs dated [DATE] documented resident was non-ambulatory. Interventions included mechanical lift with assist of 2 for transfers. An intervention dated [DATE] documented the resident required total assist of 2 persons with bed mobility and personal hygiene. The Resident Nursing Instructions (Resident Care Plan-RCP) documented Resident #1 required 2-person total assistance for bed mobility and one-person physical assistance for personal hygiene. The Nursing Progress Notes (NPN) dated [DATE] at 1:29 PM documented the resident was out of the facility to hospital ER at 11 AM secondary to fall with [MEDICAL CONDITION]. The NPN dated [DATE] at 3:10 PM documented the Registered Nurse Clinical Care Coordinator (CCC) was called to resident's room by CNA to assess patient status [REDACTED]. Resident had a laceration to left eyebrow approximately ½ inches to ¾ inches and bleeding. The NPN dated [DATE] at 7:40 PM documented that the resident was admitted to the hospital at 7:00 PM with [DIAGNOSES REDACTED]. The facility's Investigative Summary (undated) documented on [DATE] at 10:40 AM, the RN was called to evaluate Resident #1 since he was witnessed falling out of bed. Upon the RN's arrival to the room, the resident was lying on his left side, next to his bed and floor mat. According to the aide attending to the resident, she had just completed care on the resident and was attempting to place Hoyer pad under his body and he rolled off the air mattress and fell in between the bed and the floor mat. Resident #1 sustained a laceration to his left eyebrow and he was transferred to the hospital. The facility investigative summary also documented that the Certified Nursing Assistant (CNA) was interviewed and ascertained the resident required an assist of two for bed mobility and transfer per plan of care and resident care profile. The caregiver was suspended pending investigation due to the break in resident's plan of care. The CNA was given an in-service on the need to follow the comprehensive care plan and resident care profile and need to use an assist of 2 when placing on Hoyer pad. The CCC was interviewed on [DATE] at 11:37 AM and stated Resident #1 required total assistance of two persons for bed mobility (boosting and turning). On [DATE] around 10:30 AM CNA #1 came to her and told her that Resident #1 fell . Upon assessment Resident #1 was found to have a small laceration to his left eyebrow and was bleeding. He was non-verbal, awake and conscious. CNA #1 told the CCC that she was placing the Hoyer pad underneath Resident #1 and he rolled off the bed. The CCC stated that placing the Hoyer pad underneath a resident was considered bed mobility, CNA #1 was expected to have another person to assist for placing a Hoyer pad underneath Resident #1. CNA #2, CNA #4, CNA #5 were interviewed on [DATE] at 12:37 PM. The CNAs stated they provided care with Resident #1 at times but were not assigned to Resident #1 on [DATE]. They stated when placing a pad underneath Resident #1, two persons assistance was required. They stated that CNA #1 did not ask for their assistance for Resident #1's care on [DATE]. LPN #2 was interviewed on [DATE] at 1:30 PM and stated Resident #1 was not on her assignment. She was administering treatment with another resident when the CNA (name not recalled) called her name and told her that the CCC needed her in Resident #1's room. Upon entering Resident #1's room she observed Resident #1 laying on the floor with small amount of blood on the floor. She assisted the CCC and transferred Resident #1 back to bed. LPN #2 called the MD (physician). LPN #2 stated that CNA #1 did not ask for her assistance with Resident #1 prior to the fall. The Director of Nursing (DON) was interviewed on [DATE] at 3:49 PM. The DON stated that the staff including CNA #1 were in-serviced and had demonstrated proper procedures regarding Hoyer lift transfers on [DATE]. The DON stated that he was notified of the incident on [DATE]. Upon investigation the facility concluded that the plan of care for Resident #1 was not followed by CNA #1. The DON stated that during reenactment of the incident CNA #1 placed the Hoyer pad underneath Resident #1 by herself. The DON stated CNA #1 was aware that Resident #1 required 2 persons assistance with bed mobility and transfers. The DON stated that CNA #1 did not follow the plan of care and was suspended and was going to be terminated. CNA #1 stated to the DON that she did not believe she needed two persons assistance because she was not transferring the resident but was placing the Hoyer sling under Resident #1. The DON stated the Hoyer lift competency that was completed on [DATE] documented that when placing sling under a resident, 2 persons assistance was required. The competency record was signed by CNA #1. 415.4 (b)

Based on observation, interview and record review during an abbreviated survey, the facility did not ensure that safe and effective assistance devices were provided to each resident to prevent accidents. Specifically, one of three residents reviewed for accidents (Resident #1) fell during a transfer from bed to the shower chair with a mechanical lift utilizing a shower sling on 9/22/16 resulting in a 6 inch laceration to the right side of his head. Subsequently, Resident #1 was sent to the hospital. Resident #1 returned to the facility with three staples to the right side of his forehead on 9/28/16.The facility did not ensure that the care instructions and maintenance of the mechanical lift sling were followed in accordance with the manufacturer's recommendations. Complaint ID #: NY 759 The findings are: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Comprehensive Care Plan (CCP) titled ADLs and dated 9/8/16 documented ADL Functional/Rehabilitation potential for the resident as non ambulatory. Interventions included to mechanically lift with assist of two. The CCP titled Falls/Injury and dated 9/8/16 documented that the resident was at risk for falls/injury related to history of falls, impaired balance, pain and impaired gait. Interventions included instruct/reinforce safety measures that is transfer technique. The Minimum Data Set 3.0 (MDS- an assessment tool) dated 9/15/16 identified that Resident #1 was cognitively intact and required the total assistance of two persons for transferring. An Accident and Incident Report dated 9/22/16 documented that the resident was on the floor next to the bed with blood. Resident stated that the Mechanical lift sling broke. The Nursing Progress note dated 9/22/16 at 4:40 PM, documented that the resident was noted on the floor next to the bed, head at the head of bed, and feet pointing downward. Blood was noted with an opening to the back of the right side of the head. Resident denied any pain. Physician notified ordered to transfer resident to the hospital for further evaluation. The Undated Facility Investigation summary documented that, on 9/22/16 at approximately 3:30 PM, while CNAs (Certified Nursing Assistants) were transferring the resident from his bed to the shower chair via mechanical lift, the mesh shower sling ripped bilaterally from the base of the sling on the right side. This resulted in the resident falling from the sling on to the mechanical lift and hitting his head on the bed. He sustained an approximate 6 inch laceration to the right side of his head. Registered Nurse Supervisor (RNS) and man power were called immediately. Resident was assessed by the nurse, he had no complaint of pain, and had a moderate amount of bleeding from his head. Neuro (neurological) checks were within normal limits. Physician was called and an order obtained to transfer resident to hospital for further evaluation. The area of the sling where the tear occurred showed no signs of ill repair and the rip was clean. No jagged area noted. Interview with both the staff and resident after the occurrence confirmed that there was no indication during the transfer procedure that something could occur. Both CNAs deemed competent on mechanical lift transfer within the last 4 months. The investigation has revealed that there is no cause to believe any alleged abuse, mistreatment or neglect regarding this resident occurred. Upon return from the hospital it was noted that area (injury) was only 3 centimeter in length. The Mechanical lift sling that was involved with the incident was unavailable at the facility for visual inspection during the onsite portion of the survey. The facility Policy titled Hoyer and Shower Pad Inspection dated 6/4/13 documented that all mechanical lift slings are numbered, housekeeping floor men inspect for usable condition prior to taking any sling for distribution to a nursing unit. The inspection consists of a visual assessment and a pull of each strap on a sling as a check for its intactness and readiness for use. Any sling which is deemed unsafe is immediately removed form circulation and placed in a bin identified as exclusively for removed Mechanical lift and Shower slings. Documentation of the inspection, its outcome and the unit to receive, if deemed safe is written on a daily log book. Log sheets are kept in the laundry storage room for one week at a time and stored, subsequently, in a binder with the Director of Housekeeping Services. The Full Body Patient Sling Care Instructions for the product dated 2006 (provided by the facility) documented to inspect patient slings for wear prior to each use. If signs of tearing, fraying or wear are found, discard the sling immediately; worn out slings are not safe for use and may result in injury or death. Washing instructions: hand wash only in water temperature of not more than 120 degrees Fahrenheit. Do not use bleach; bleach will damage the integrity of the sling and strap materials which may result in failure causing injury or death to the patient and/or caregiver. Air dry only. An updated Full Body Patient Sling Care Instruction sheet dated 2016, revised on 1/15/16, and not available at the facility, documented washing instructions: machine wash in warm or cold water. Maximum water temperature 105 degree Fahrenheit. Air Dry, or tumble dry at cool or very low temperature. Do not tumble dry at high temperature. During an interview with the Director of Maintenance (DOM) on 10/11/16 at 11:39 AM, the DOM stated that the incident with Resident #1 was non-equipment related (not related to the lift device). The mechanical lift sling that was involved had ripped causing Resident #1 to fall. During an interview with the Housekeeping Director (HD) on 10/11/16 at 12:05 PM, the HD stated that the facility policy called for each mechanical lift sling and shower sling be checked for imperfections, rips and frayed areas. The inspection was supposed to be documented on a log by the housekeeping staff prior to the mechanical lift sling/shower slings being brought to the unit. The HD stated that he was unable to provide the related paperwork (logs) prior to 9/22/16. The HD stated that the facility was having difficulty identifying individual mechanical lift/shower slings as the marking by the permanent markers and the tags used on the slings would come off during the wash. Each mechanical lift sling was supposed to be labeled however the labels would not stay. The facility tried different options but failed; the identifier would come off or it would not work; it would erase because of the heat during washing. The HD stated that it was difficult to log any findings due to lack of identification of the slings. The HD stated that he brought the issue to the former facility Administrator a couple of years ago and was instructed to continue to visually check the mechanical lift/ shower slings. The HD stated that he did not notify anyone else about the issue of not keeping the logs for mechanical lift/shower sling checks. The HD stated that the housekeeping department did visual checks for each mechanical lift and shower sling in the morning prior to bringing them to the units. If any defect such as rips or tear was detected the staff would bring it to the HD's attention and the defective slings were taken out of circulation. On 9/22/16 the Lead Housekeeper (LH) had verbalized to the HD that he had checked the mechanical lift and shower slings that were being brought to unit 2 B (where Resident #1 resided). The HD stated that the LH did not identify any defective slings. The HD stated that he was verbally communicating with his staff on a daily basis. During an interview with the 2nd floor Lead Housekeeper (LH) on 10/11/16 at 12:30 PM, the LH stated that, in the morning, he inspects each mechanical lift and shower sling. The inspection is done by tugging on each strap to make sure it's not ripping apart. The LH stated that he had checked each mechanical lift sling and the shower sling that he brought up to the unit on 9/22/16 and did not find any issue with any of them. The LH stated that a while ago housekeeping staff was checking and documenting the inspection for each sling. Each mechanical lift and shower sling was marked with the marker. The maker washed out and staff were not able to be visualize the marks. The staff had stopped logging as there was no number (identifier) on the individual slings. During an interview with the 7:00 AM-3:00 PM Registered Nurse Supervisor (RNS) on 10/11/16 at 1:15 PM, the RNS stated that Resident #1 required total care with transfer with a mechanical lift but now requires two persons to assist with transferring without a mechanical lift. On 9/22/16 at approximately 3:30-4:00 PM, the RNS stated that she was called to Resident #1's room. Upon entering the room the RNS observed Resident #1 on the floor. The RNS stated that she conducted an assessment and Resident #1 was able to move all extremities. Resident #1 had a laceration to the right side of his head with a moderate amount of bleeding. The RNS stated that she checked the mechanical lift visually and found no issue. The mechanical lift sling (shower sling) had two straps that were ripped right across the base of the sling on the right side. The cut was a clean cut and it did not appear that that the mechanical lift sling (shower sling) was frayed, worn or tattered. Resident #1 was sent to the hospital for further evaluation after the physician was notified. During an interview with the 3:00 PM-11:00 PM Certified Nursing Assistant (CNA #1) on 10/11/16 at 3:30 PM, she stated that she was the Assigned CNA for Resident #1 who required a mechanical lift for transfer. 9/22/16 was a shower day for Resident #1. CNA #1 stated that the mechanical lift sling including mechanical lift shower slings usually came from housekeeping. CNA #1 stated that she picked up the sling from the linen closet. CNA #1 stated that when she checked the sling prior to the transfer there was no indication that the sling was unsafe to be used. Prior to placing the sling, CNA #1 stated that she ensured that the mechanical lift was okay and that the sling was okay. CNA #1 checked the sling for any damage such as torn, tattered or frayed areas. CNA #1 stated that she conducted a visual observation and also tugged at the straps and found no issue with the mechanical lift or the sling. During the process of transferring Resident #1 from the bed to the shower chair, the mechanical lift shower sling was placed under the resident. CNA #1 stated that Resident #1 was properly placed on the sling prior to lifting him. While the resident was being lifted from the bed to be placed on the shower chair the rung (strap) from the base of the mechanical lift sling ripped; it was a clean rip right across both slings on the right side. During an interview with the 3:00 PM-11:00 PM Certified Nursing Assistant (CNA #2) pm 10/11/16 at 4:15 PM, CNA #2 stated that he had assisted with transfer of Resident #1 from bed to the shower chair on 9/22/16. CNA #2 stated that they (CNA #1 and CNA #2) had checked the mechanical lift sling and there were no rips. CNA #2 stated that he checks on every sling prior to placing it under each resident prior to a mechanical lift transfer. During an interview with the Facility Risk Manager (RM) on 10/12/16 at 2:10 PM, the RM stated that Resident #1 sustained injury and the mechanical lift sling had ripped and that is why the incident was reported to the New York State Department of Health (NYSDOH). The RM stated that the manufacturer was not notified of the issue with the mechanical lift shower sling. The RM stated that the idea of reporting the incident to the manufacturer sounded good and she was going to do it. The RM stated that another agency who was investigating the incident/accident had secured the involved mechanical lift shower sling from the facility. During an interview with the Chief Executive Officer (CEO) of the sling supplier company on 10/13/16 at 3:42 PM, the CEO stated that his company supplies mechanical lift slings to the facility that are compatible to the mechanical lift devices used at the facility. The CEO stated that there are specific manufacturer instructions for care of the sling including washing instructions that must be followed by the consumer to avoid any injuries. The CEO stated that if the temperature of the water is not maintained or if bleach is used to wash the slings it may interfere with the integrity of the fabric causing the sling or the strap to rip. During an interview with the manufacturer Technical Support Representative (TSR) on 10/13/16 at 4:07 PM, the TSR stated that the recommendations provided by the manufacturer have to be followed to ensure integrity of the fabric. The TSR stated that slings are not tested for wash above 120 degree Fahrenheit. Not following recommendation provided by the manufacturer may damage the fabric. The TSR stated that there are new updated recommendation provided by the manufacturer indicating use of washing machine. However the water temperature has to be at 105 degree Fahrenheit. During a subsequent interview with the HD on 10/13/16 at 4:00 PM, the HD stated that all mechanical lift slings are machine washed at a temperature of 220 degrees Fahrenheit and all the slings are machine dried. The HD stated that he was not sure of the temperature of the dryer. The HD stated that the recommendation by the manufacturer is 120 degree water temperature which would not kill the bacteria. During an observation of the mechanical lift sling involved with Resident #1's incident at the off site location where it was secured on 10/14/16 at 3:18 PM, the sling was noted to be frayed, worn and tattered. Both right side straps were disconnected from the sling. The middle loop of one of the disconnected strap was completely torn. The left strap was observed to be attached to the sling however one of the loops (middle loop) was frayed. The fabric on the sling's periphery was compromised. Additionally there was no label on the sling indicating type, model or the manufacturing date of the sling. During a follow up interview with the Manufacturer on 10/20/16 at 1:21 PM, TSR #2 stated that there was a new manual dated January 2016 with updated instructions indicating use of the washing machine with water temperature of 105 degree Fahrenheit. TSR #2 stated that the manual prior to January 2016 indicated to hand wash the slings. TSR #2 stated that the slings that were bought by the facility prior to 2016 should be hand washed as the sling may have a different material and could be compromised by machine washing. TSR #2 stated that it would be safe to follow washing instructions provided in the manual dated 2006 for older slings. During an interview with the HD on 10/24/16 at 10:34 AM, the HD stated that he would not be able to state the date of purchase or date of manufacture of the sling that was involved with the incident. The HD stated that prior to the incident the facility was not tagging or identifying the slings that were being used. The HD stated that the facility is currently utilizing care instruction from the manual (2006) however, laundering practices in the facility were not consistent with manufacturer instructions for slings produced prior or subsequent to 2016. 415.12(h)(1)(2)

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 a system in place to ensure that residents dependent on continuous oxygen therapy were assessed and had an effective plan for potential emergencies while on a recreational trips outside of the facility. Specifically, the Administration failed to ensure that policies and procedures for Community Trip Preparation and Community trip emergencies were implemented; failed to develop policies and procedures for monitoring of oxygen tanks for oxygen dependent residents and residents utilizing supplemental oxygen source when out on community recreational trips. Additionally the administration failed to ensure that the facility staff were provided education related to monitoring of oxygen tanks, handling oxygen concentrators and identifying emergencies during community recreational trips. Complaint ID# NY 383 Cross Reference: F 328- Special Needs The findings are: The Facility Policy titled, COMMUNITY TRIP PREPARATION, dated July 28, 2014 documented: if residents with respiratory insufficiency are going on a trip, the nursing Supervisor of the Respiratory Units, Respiratory Care and Wheelchair shop, will be requested to provide appropriate equipment and staffing to care for needs of this population. One Certified Nursing Assistant per 6-10 residents / 1 to 2 TR (Activity Recreation Therapy) staff per 6-10 Residents / Respiratory Therapist or other staff as needed. The facility policy lacked documented instructions/guidance regarding oxygen dependent residents utilizing oxygen tanks. The Facility Policy titled, COMMUNITY TRIP EMERGENCY PROCEDURES, dated July 28, 2014, documented: Therapeutic Recreation staff will monitor residents while on a community trip and communicate with appropriate Facility Personal and outside Authorities when an emergency occurs. The Therapeutic Recreation Director and/or ADON (Assistant Director of Nursing) or Nursing Director will be responsible to direct and instruct Therapists/staff on proper emergency procedures to follow. If illness or injury is severe (i.e. [MEDICAL CONDITION], stroke, suspected fracture, laceration, etc.) notify Emergency Medical Services immediately by calling 911 or go to the nearest hospital, then notify the Therapeutic Recreation Director, manager or on site supervisor, who would then notify the Medical and Administrative staff. If a resident's illness or injury is relatively mild, the Recreational Manager, Trip Coordinator or on-site Supervisor should be called. He/she would then call the Charge/Head Nurse to apprise him or her of resident's symptoms, problems and concerns, requesting advice or assistance. A physician would be called by the nurse to request suggested treatment regimen. The medical staff would be consulted as to the appropriateness of the treatment location. The facility lacked documented evidence of staff education related to monitoring of oxygen tanks, handling oxygen concentrators and identifying emergencies during community trips. The Undated Facility Investigative Summary documented concern: on 8/30/16 during a facility community trip to a restaurant, an unusual incident occurred involving residents (Resident #1 and #2). Due to unanticipated delays leaving the facility with the Transportation Company and further delay at the restaurant related to meal services contributed to the depletion of each of the two residents' oxygen tanks along with the staff having difficulty implementing the oxygen concentrator which seemed to be working intermittently. Resident #1 was sent to the hospital via 911 due to increased anxiety and complaint. The investigation concluded that an unanticipated delay in leaving the facility for the planned trip and additional delay in serving of food at the restaurant resulted in depletion of oxygen tanks for two residents on the trip. One resident with history of anxiety and continued complaints was sent to ER via 911. The other resident was returned to the facility. The plan to prevent reoccurrence documented that Resident (#1) was returned to the facility in stable condition; the policy and procedure on recreation trip will be reviewed and revised; all staff involved in recreation trip procedure will be in serviced on the policy; all staff members involved in and out of the facility trip will be in serviced on how to implement a portable oxygen concentrator in the event of an emergency and on how to read the oxygen gauge on the portable oxygen tank; and staff will use an audit tool to ensure that the policy and procedure on recreational trip is being followed. During an interview with the Director of Recreation Therapy (DRT) on 9/15/16, she stated that the facility's policy on community trips was very vague and did not have clear directives for staff related to responsibilities regarding monitoring of the oxygen tanks for oxygen supply. The DRT stated that her staff (recreation staff) and nursing should have checked the tank for sufficient oxygen supply in the oxygen tanks. The DRT stated that on 8/30/16 the trip was scheduled for 10:30 AM. Residents left the facility at approximately 12 noon. The DRT stated that the restaurant was at least 15 minutes away from the facility. The DRT stated that she received a call at approximately 2:15 PM from the ART stating Resident #1 ran out of oxygen and that the facility staff used a portable concentrator for Resident #1. The DRT stated that she was also told that Resident #2 also ran out of oxygen. The DRT stated that she had instructed the ART to return back to the facility as soon as possible and that the oxygen tanks would be available at the facility door when they will arrive and also to use her judgement to call 911. The DRT stated that she also notified the Assistant Director of Nursing (ADON) that Resident #1 ran out of oxygen and the staff was instructed to come back to the facility and also to use their judgement to call 911. The DRT stated that the ADON agreed with the directions provided. The DRT stated that at approximately 3:00 PM (don't recall exact time) she received a text message from ART stating that Resident #1 was sent to the hospital via 911. The DRT stated that the recreation staff was not trained to recognize distress symptoms. The DRT stated that she was not sure if the recreation staff was allowed to change the oxygen source from oxygen tank to concentrators. The DRT stated that she was not sure of recreation staff's scope of practice related to oxygen usage. During a subsequent interview with the DRT on 9/16/16 at 5:30 PM, the DRT stated that she was not trained medically; on 8/30/16 she told her staff to make a judgement and if they felt it was an emergency then call 911. During an interview with the Director of Respiratory Therapy (RT #2) on 9/16/16 at 5:15 PM, RT #2 stated that he did not know if the residents go on community trips on oxygen tanks or just the concentrator. During a subsequent interview on 09/19/2016 at 04:49 PM with the RT #2, he stated that the nurses are responsible for the Oxygen tanks and tubing for residents using nasal oxygen via nasal cannula. RT #2 stated that the Respiratory Therapy department is responsible for issuing oxygen concentrators to residents on continuous oxygen and will troubleshoot if there is a problem with the concentrator. RT #2 stated that the Respiratory Therapy department is not involved in the daily functioning of the concentrators and is not involved in checking the gauges on oxygen tanks. However, weekly rounds are made to verify the concentrators are working. RT #2 stated that he was not aware that Resident #1 was going out on pass on 08/30/2016, and that his department did not receive a list of residents going out on recreation trips. During an interview with the Assistant Director of Nursing (ADON)/Risk Manager on 9/16/16 at 4:44 PM, the ADON stated that she did not know why the trip on 8/30/16 was delayed, she believed that the scheduled aide for the trip was not available and the facility had to find another aide to accompany residents on the trip. The ADON stated that the concentrator that was brought to the trip was deemed as an emergency concentrator, however, the nurse (LPN #8) thought it was specifically assigned for Resident #2. The ADON stated that the DRT had called and notified her that Resident #1's tank ran out of oxygen and of the instructions that she provided to the staff on the trip. The ADON stated that she was in agreement with the instructions provided by the DRT. The ADON stated that the tanks were made available and waiting at the facility door for when the residents were to arrive at the facility. During a subsequent interview with the ADON on 9/19/16 at 10:52 PM, the ADON stated how do you always be 100% prepared, it was an unforeseen situation, we learn things by mistakes. The ADON stated that she was not aware of Resident #2 also running out of oxygen in her tank. If the ADON knew, she would have gone to the restaurant with an oxygen concentrator to assess the situation and to calm everything. The restaurant was right up the road. During an interview with the Medical Director (MD) on 9/19/16 at 11:25 AM, the MD stated that staff is supposed to be checking the oxygen tank every hour to ensure oxygen supply is available to the resident utilizing an oxygen tank. The MD stated that there were no policies related to monitoring of oxygen tanks. During an interview with the Director of Nursing (DON) on 9/19/16 at 11:35 AM, the DON stated that the recreation staff was responsible for the residents on a community trip. On 8/30/16 the recreation therapist was responsible for making an evaluation of the resident (Resident #1). The DON stated that recreation therapists are trained on handling emergency situations, on a community trip. CNAs get a general ventilator class which include overview of the oxygen equipment and instructions to check that residents' nasal cannula are in place if the resident is using oxygen. CNAs are expected to notify a nurse if the needle on the oxygen cylinder gauge is on the red zone (refill), however CNAs are not in serviced on oxygen concentrators and normally the nurse is responsible to switch the oxygen tank to the concentrator. The DON stated that because it was an emergency on 8/30/16 CNA #1 took the responsibility of switching the oxygen source. The DON stated that she thought that CNA #1 did the right thing for the welfare of the resident. All CNAs get training that in an emergency they are to call a nurse and the respiratory therapist, therefore she (CNA #1) did what she was supposed to do. The DON stated that there is no policy on monitoring of oxygen tanks. During an interview with the Quality Assurance Director (QAD) on 9/19/16 at 12:20 PM, the QAD stated that the CNAs get orientation about the general overview of the oxygen that includes to check the Oxygen tank and if it is empty, to call the nurse. The QAD stated that in her opinion on 8/30/16 the failure was that the recreation staff did not bring Resident #1 to the nurse to check her oxygen tank. During an interview with the Facility Administrator on 9/19/16 at 1:31 PM, the Administrator stated that he was made aware of the incident on the same day (8/30/16). The expectation from the staff in hindsight, is that the staff need to be familiar with the equipment. The Administrator stated CNA #1 was familiar with some equipment, however the concentrator was newer and the CNA was not aware how to use it. 415.26

Based on observation, interview and record review during an abbreviated survey, the facility failed to have a system in place to ensure that 2 of 6 residents dependent on continuous oxygen therapy were assessed and had an effective plan for potential emergencies while on recreational trips outside of the facility. Specifically, during an outing, with six residents (2 oxygen dependent-Resident #1 and Resident #2) and 3 staff members (1 Activity Recreation Therapist-ART, 1 Recreation Aide-RA, and 1 Certified Nursing Assistant-CNA) facility staff became aware that Resident #1's oxygen tank was empty and the resident reported the inability to breathe. Provision of oxygen to the resident from a concentrator device (a portable device used to provide oxygen therapy to patients at greater oxygen concentrations than the levels of room air) available as a backup oxygen source was delayed secondary to lack of staff knowledge on operation of the equipment. Oxygen delivery to the resident was interrupted again when the backup oxygen source was diverted to a second oxygen-dependent resident (Resident #2), who reported lack of flow from her oxygen tank which was then noted to be empty. Failure to provide prompt treatment resulted in complaint by Resident #1, of inability to breathe. Staff noted the resident's lips were blue and called 911. The resident was transferred to a hospital emergency department and treated for [REDACTED]. This resulted in Immediate Jeopardy. The Immediate Jeopardy was removed on September 9, 2016, prior to the onsite Abbreviated Survey, when the facility developed policies and procedures and provided staff training to ensure that qualified and knowledgeable staff would be available for oxygen-dependent residents to monitor adequate oxygen delivery, assess respiratory status and promptly respond to emergencies while on outings. Complaint ID#: NY 383 The Findings include: The Facility Policy titled, COMMUNITY TRIP PREPARATION, dated July 28, 2014, documented: if residents with respiratory insufficiency are going on a trip, the nursing Supervisor of the Respiratory Units, Respiratory Care and Wheelchair shop, will be requested to provide appropriate equipment and staffing to care for needs of this population. One Certified Nursing Assistant per 6-10 residents / 1 to 2 TR (ART) staff per 6-10 Residents / Respiratory Therapist or other staff as needed. The facility policy lacked documented instructions / guidance regarding oxygen dependent residents utilizing oxygen tanks. The Facility Policy titled, COMMUNITY TRIP EMERGENCY PROCEDURES, dated July 28, 2014, documented: Therapeutic Recreation staff will monitor residents while on a community trip and communicate with appropriate Facility Personal and outside Authorities when an emergency occurs. The Therapeutic Recreation Director and/or ADON (Assistant Director of Nursing) or Nursing Director will be responsible to direct and instruct Therapists/staff on proper emergency procedures to follow. If illness or injury is severe (i.e. [MEDICAL CONDITION], stroke, suspected fracture, laceration, etc.) notify Emergency Medical Services immediately by calling 911 or go to the nearest hospital, then notify the Therapeutic Recreation Director, manager or on site supervisor, who would then notify the Medical and Administrative staff. If a resident's illness or injury is relatively mild, the Recreational Manager, Trip Coordinator or on-site Supervisor should be called. He/she would then call the Charge/Head Nurse to apprise him or her of resident's symptoms, problems and concerns, requesting advice or assistance. A physician would be called by the nurse to request suggested treatment regimen. The medical staff would be consulted as to the appropriateness of the treatment location. The facility lacked documented evidence of staff education related to monitoring of oxygen tanks, handling oxygen concentrators and identifying emergencies during community trips. 1) Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS- an assessment tool) dated 6/16/16 documented Resident #1 as cognitively intact and utilizing oxygen while a resident at the facility. The Comprehensive Care Plan (CCP) dated 10/13/15 titled Diagnosis: [REDACTED]. Interventions included oxygen via nasal cannula as per physician order [REDACTED]. The Medical Progress Note dated 4/18/16 documented resident wants to go around the facility and socialize. She needs oxygen. Patient can go downstairs, however she needs oxygen as she becomes hypoxic (condition in which the body is deprived of oxygen at the tissue level) due to exertion. The Monthly physician order [REDACTED]. The Nursing Progress Note Dated 8/30/16 at 5:41 PM documented received report from off-going supervisor that resident was sent to hospital for respiratory distress from a recreation event at the restaurant. The Undated Facility Investigative Summary documented concern: on 8/30/16 during a facility community trip to a restaurant an unusual incident occurred involving residents (Resident #1 and #2). Due to unanticipated delays leaving the facility with the Transportation Company and further delay at the restaurant related to meal services contributed to the depletion of each of the two residents' Oxygen tanks along with the staff having difficulty implementing the Oxygen concentrator which seemed to be working intermittently. Resident #1 was sent to the hospital via 911 due to increased anxiety and complaint and staff concerns for safety of the resident. The investigation concluded that an unanticipated delay in leaving the facility for the planned trip and additional delay in serving of food at the restaurant resulted in depletion of Oxygen tank for two resident on the trip. One resident with history of anxiety and continued complaints was sent to ER via 911. The other resident was returned to the facility. The plan to prevent reoccurrence documented that Resident (#1) was returned to the facility in stable condition; the policy and procedure on recreation trip will be reviewed and revised; all staff involved in recreation trip procedure will be in serviced on the policy; all staff members involved in and out of the facility trip will be in serviced on how to implement a portable oxygen concentrator in the event of an emergency and on how to read the oxygen gauge on the portable oxygen tank; and staff will use an audit tool to ensure that the policy and procedure on recreational trip is being followed. The Emergency Medical Service Record dated 8/30/16 documented Resident #1 with cyanotic lips and shallow labored breathing. The hospital emergency room (ER) Attending Note dated 8/30/16 documented Diagnosis: [REDACTED]. During an interview with the 7:00 AM-3:00 PM Certified Nursing Assistant (CNA #1) on 9/15/16 at 11:40 AM, CNA #1 stated that she usually didn't go on recreational trips. On 8/30/16 she was asked by the Registered Nurse Supervisor (RNS #1) (don't recall time) to go with the residents on a trip. CNA #1 stated that she just wanted to eat at the restaurant, the facility was paying so she decided to go. The residents had been waiting for 1½ hour outside the facility in the Ambulette for a CNA to accompany them on the trip. Approximately an hour after being at the restaurant, Resident #1 complained that she was not receiving any Oxygen or air. CNA #1 stated that the Oxygen tank was empty. CNA #1 called the facility, and notified RNS #1 that Resident #1 ran out of oxygen in her oxygen tank, RNS #1 instructed her to call the Ambulette to bring Resident #1 back to the facility. CNA #1 stated that Resident #2 had a portable concentrator aside from an Oxygen tank. CNA #1 stated that she borrowed the concentrator from Resident #2 and gave it to Resident #1. CNA #1 stated that initially she was unable to turn the concentrator on as she was not familiar with that particular concentrator. CNA #1 stated that she called the facility again and spoke with a Licensed Practical Nurse (LPN #8) and informed her that the concentrator was being used for Resident #1 and that she was having difficulty starting the concentrator. LPN #8 connected CNA #1 to the Respiratory therapist (don't recall name) who instructed CNA #1, over the phone, on how to turn the concentrator on. CNA #1 stated that not too long after Resident #1 was using the concentrator, Resident #2's Oxygen tank also ran out of Oxygen. Resident #2 insisted that her concentrator be given back to her. CNA #1 stated that she took the concentrator from Resident #1 and gave it to Resident #2. Resident #1 was okay and was not in any distress after the concentrator was taken away from her. After approximately 20-40 minutes Resident #1 became more agitated and kept verbalizing that she couldn't breathe and needed Oxygen/air. CNA #1 stated that Resident #1 did not appear in any respiratory distress and was not using her accessory muscles for respiration. Resident #1 did not have any change in color. CNA #1 stated that the ART called 911. CNA #1 also stated that she was not aware of policies related to community trips. During an interview with the RA on 9/15/16 at 12:21 PM, the RA stated that prior to her going on the trip to the restaurant on 8/30/16 she was not aware of the policy related to the community trip. The RA stated that the trip to the restaurant was initially scheduled for 10:30 AM however, the bus (Ambulette) did not leave the facility until 11:50 AM. The RA stated that while at the restaurant, Resident #1 ran out of oxygen in her tank and started to act differently: shaking a little, slumped over in her chair and not responding when I called her name. CNA #1 checked the tank and it was empty. The concentrator from Resident #2 was given to Resident #1. After the concentrator was applied, Resident #1 was still not eating and kept saying she couldn't breathe. CNA #1 checked the concentrator, she was having tough time starting the concentrator. The RA stated that CNA #1 had to call the facility to get instruction on how to start the concentrator. The RA stated that she herself did not know how to handle a concentrator or an Oxygen tank. The RA stated that she was not even aware what she was supposed to look for if a resident was using Oxygen tanks. RA further stated that half way through lunch (specific time unknown) Resident #2's tank ran out of Oxygen and she wanted her concentrator back from Resident #1. The concentrator was taken off of Resident #1 and was applied to Resident #2 by CNA #1. Resident #1 was now without oxygen and stayed without Oxygen for approximately 25-30 minutes. In the meantime the Ambulette was called twice by the ART. The RA stated that CNA #1 told her not to call 911 until Resident's lips turn blue. The ART called 911 as Resident #1 kept saying she couldn't breathe and needed air. Resident #1 was panicking, tapping on things, moving her chair and kept saying she couldn't breathe and needed air. Resident #1's lips were looking blue. The Restaurant's manager kept coming out and asking if 911 was called. The 911 responders came, placed Resident #1 on oxygen and took her to the hospital. The RA stated that she did not get education regarding trip policy until after the trip. During an interview with the ART on 9/15/16 at 1:09 PM, the ART stated that she had accompanied the trip to the restaurant on 8/30/16. On 8/29/16, the ART had instructed each nursing unit to have their resident ready to go at 10:30 AM on 8/30/16. The ART stated that on 8/30/16 the bus came at 10:00 AM and the bus driver was getting upset because of the confusion about the time of the trip (as per ART the trip was scheduled at 10:30 AM). The ART stated that she tried to get all residents down as quickly as possible. The ART stated that she brought Resident #1 down at 10:30 AM and told a male nurse (couldn't recall name) that she was taking Resident #1 for the trip. The ART stated that no one on the unit looked at Resident #1's tank at that time to check the amount of Oxygen. The ART stated that she was not instructed to look at the tank. The ART had checked the Oxygen tanks for Oxygen level previously, on occasion, with an understanding that she was doing a favor for the nurses. The ART stated that she did not check on Resident #1's tank on 8/30/16 as the bus driver was rushing her and was very irritable. The ART stated that she was never instructed to take a spare Oxygen source on community trips prior to the incident on 8/30/16. The ART stated that she was never in-serviced on monitoring of Oxygen tanks during a community recreational trip. The ART stated that she did know if the needle was in red zone it indicated that the tank was empty. The ART stated that she did not know anything about the concentrator and had never received education related to same. The ART stated that while at the restaurant Resident #1's tank ran out of Oxygen and the ART suggested to use concentrator from Resident #2. The ART stated that CNA #1 tried to place the concentrator, but it would not turn on. The ART stated that she called the Director of Recreation Therapy (DRT) as soon as it was discovered that Resident #1 ran out of Oxygen (don't recall time). The DRT instructed her to return to the facility as soon as possible and full oxygen tanks will be available at the facility door when Resident #1 arrived at the facility. The DRT also instructed the ART to use her judgment to call 911. The ART stated that Resident #1 kept saying she needed air after the concentrator was taken away from her to give to Resident #2 as she (Resident #2) also ran out of Oxygen and wanted her concentrator. Resident #1 was then without any oxygen source (couldn't recall how long). During that time Resident #1 kept pleading she needed Oxygen and ART didn't know what to do. ART stated that she did not recall noticing any changes in the color of Resident #1's face or lips. The ART stated I felt very helpless, scared and nervous so I decided to call 911. During a subsequent interview with the ART on 9/16/16 at 9:43 AM, the ART stated that before she had called the DRT she had contacted the Ambulette Company and was told that it would take the Ambulette at least 30 minutes to get to the restaurant. The ART stated that the restaurant was at least 15 minutes away from the facility. The ART stated that while Resident #1 was using the portable concentrator, Resident #2 asked that her oxygen tank be checked as she could not feel the air. CNA #1 checked Resident #2's tank and found it empty. The ART stated that she did not know Resident #2's condition after her tank was found empty. The ART stated that everything went wrong that day (8/30/16), they didn't have an aide to go on the trip, nursing was trying to get an aide, I want to impress upon you that because everything else was going wrong I didn't even think of looking at the tanks and I was suspended for that. During an interview with the DRT on 9/15/16, she stated that the facility's policy on community trips was very vague and did not have clear directives for staff related to responsibilities regarding monitoring of the Oxygen tanks for Oxygen supply. The DRT stated that her staff (recreation staff) and nursing should have checked the tank for sufficient oxygen supply. The DRT stated that on 8/30/16 the trip was scheduled for 10:30 AM. Residents left the facility at approximately 12 noon. The DRT stated that the restaurant was at least 15 minutes away from the facility. The DRT stated that she received a call at approximately 2:15 PM from the ART stating Resident #1 ran out of Oxygen and that the facility staff used a portable concentrator for Resident #1. The DRT stated that she was also told that Resident #2 also ran out of Oxygen. The DRT stated that she had instructed the ART to return to the facility as soon as possible and that the oxygen tanks would be available at the facility door when they will arrive and also to use her judgement to call 911. The DRT stated that she also notified the ADON that Resident #1 ran out of oxygen and the staff was instructed to come back to the facility and also to use their judgement to call 911. The DRT stated that the ADON agreed with the directions provided. The DRT stated that at approximately 3:00 PM (don't recall exact time) she received a text message from ART stating that Resident #1 was sent to the hospital via 911. The DRT stated that the recreation staff was not trained to recognize distress symptoms. The DRT stated that she was not sure if the recreation staff was allowed to change the oxygen source from Oxygen tank to concentrators. The DRT stated that she was not sure of recreation staff's scope of practice related to Oxygen usage. During a subsequent interview with the DRT on 9/16/16 at 5:30 PM, the DRT stated that she was not trained medically; on 8/30/16 she told her staff to make a judgement and if they felt it was an emergency then call 911. During an interview with the Respiratory Therapist (RT #1) on 9/16/16, she stated that she works at the facility as a per diem staff. RT #1 stated that LPN #8 came down with a request for a portable concentrator on the morning of 8/30/16. RT #1 stated that prior to giving the concentrator to LPN #8, she had checked the concentrator for functionality and found no issues. RT #1 stated that she was not aware Resident #1 or Resident #2 were going out on a community trip. RT #1 stated that she received a call from CNA #1 (could not recall time) stating that the portable Oxygen concentrator was not working. RT #1 stated that she gave instructions to CNA #1 on how to start the portable concentrator. RT #1 stated that she was not made aware that Resident #1's or Resident #2's tank ran out of Oxygen. During an interview with the 7:00 AM-3:00 PM Registered Nurse Supervisor (RNS #1) on 9/16/16 at 12:46 PM, RNS #1 stated that she was not aware that Resident #1 or #2, who were going out on a community trip, were utilizing Oxygen via Oxygen tanks. RNS #1 stated that she received a call from CNA #1, approximately after lunch (couldn't recall time), stating that Resident #1 did not have any Oxygen in her tank. RNS #1 stated that she had instructed CNA #1 to return back to the facility if the restaurant was close by. RNS #1 stated that she also advised CNA #1 to look at Resident #1 and if she was in distress then call 911. CNA #1 stated that Resident #1 was not in any distress. Later (couldn't recall time) CNA #1 called back to notify RNS that 911 was called and Resident #1 was sent to the hospital. RNS #1 stated that she did not communicate her conversation with CNA #1 to anyone at the facility because they were already aware of it as when I came down to the nursing office the ADON mentioned it to me. RNS #1 stated that at 2 liters flow rate, the Oxygen tank is good for four hours. RNS #1 further stated that the CNAs are not supposed to be changing the Oxygen source or adjusting the flow rate of Oxygen as it is not in their scope of practice, however, CNAs are knowledgeable enough to change the Oxygen source and the flow rate in an emergency. During a subsequent interview with RNS #1 on 9/21/16 at 12:28 PM, she stated that she did not notify the Primary Care Physician about the incident. During an interview with the General Manager (GM) of the Restaurant on 9/16/16 at 3:00 PM, the GM stated that the Residents arrived at the restaurant at approximately 11:30 AM-12:00 Noon. There were six residents and 3 aides. Two residents were on Oxygen. They both ran out of Oxygen and complained about having difficulty breathing. The facility staff did not have a backup Oxygen source. The GM stated that he asked the aide (CNA #1) if the oxygen was checked before residents were brought to the restaurant. CNA #1 stated that it was not her job to check on Oxygen; she was there for the lunch. The GM stated that lunch was done at approximately 2:20 PM and the GM had expedited the payment. After that residents and staff waited at the restaurant for 30-35 minutes after paying the bill for the bus. During that time Resident #1 kept saying that she needed air and wanted to leave. The GM stated that no one from the restaurant called 911. During an interview with the Director of Respiratory Therapy (RT #2) on 9/16/16 at 5:15 PM, RT #2 stated that he did not know if the residents go on community trips on Oxygen tanks or just the concentrator. During a subsequent interview on 9/19/2016 at 04:49 PM with the RT #2, he stated that the nurses are responsible for the Oxygen tanks and tubing for residents using nasal Oxygen via nasal cannula. RT #2 stated that the Respiratory Therapy department is responsible for issuing oxygen concentrators to residents on continuous Oxygen and will troubleshoot if there is a problem with the concentrator. RT #2 stated that the Respiratory Therapy department is not involved in the daily functioning of the concentrators and is not involved in checking the gauges on Oxygen tanks. However, weekly rounds are made to verify the concentrators are working. RT #2 stated that he was not aware that Resident #1 was going out on pass on 8/30/2016, and that his department did not receive a list of residents going out on recreation trips. During an interview with the ADON/Risk Manager on 9/16/16 at 4:44 PM, the ADON stated that she did not know why the trip on 8/30/16 was delayed, she believed that the scheduled aide for the trip was not available and the facility had to find another aide to accompany residents on the trip. The ADON stated that the concentrator that was brought to the trip was deemed as an emergency concentrator, however, the nurse (LPN #8) thought it was specifically assigned for Resident #2. The ADON stated that the DRT had called and notified her that Resident #1's tank ran out of Oxygen and of the instructions that she provided to the staff on the trip. The ADON stated that she was in agreement with the instructions provided by the DRT. The ADON stated that the tanks were made available and waiting at the facility door for when the residents were to arrive at the facility. During a subsequent interview with the ADON on 9/19/16 at 10:52 PM, the ADON stated how do you always be 100% prepared, it was an unforeseen situation, we learn things by mistakes. The ADON stated that she was not aware of Resident #2 also running out of Oxygen in her tank. If the ADON knew, she would have gone to the restaurant with an Oxygen concentrator to assess the situation and to calm everything. The restaurant was right up the road. During an interview on 09/19/2016 at 11:01 AM with the 7:00 AM - 3:00 PM LPN #8, she stated that she was Resident #2's assigned nurse on 08/30/2016, and checked the Resident #2's Oxygen tank before the Recreation staff came to take the resident off the unit. LPN #8 stated that the Recreation staff member brought Resident #2 to her and she put a full Oxygen tank on the back of Resident #2's wheelchair. Then she (LPN #8), the recreation staff member and Resident #2 went downstairs to the Respiratory Therapy office to pick up the portable concentrator that was being taken on the trip for Resident #2. The RT (RT #1) had set the flow rate for Resident #2. LPN #8 stated that CNA #1 called her later from the restaurant and said Resident #2's Oxygen tank was almost empty, and she told CNA #1 to put the resident on the concentrator and she instructed CNA #1 on how to turn on the concentrator. The resident was saying she was not getting enough Oxygen. LPN #8 stated that she then had the RT (unable to recall name) speak with CNA #1 to verify that CNA #1 turned the concentrator on properly. LPN #8 stated that she called CNA #1 back and she said that Resident #2 was fine. CNA #1 had not reported that the concentrator was being used by any other resident. If CNA #1 reported that the concentrator was not working she would have told CNA #1 to call 911. During an interview with the Medical Director (MD) on 9/19/16 at 11:25 AM, the MD stated that staff is supposed to be checking the Oxygen tank every hour to ensure oxygen supply is available to the resident utilizing an Oxygen tank. The MD stated that the [MEDICAL CONDITION] residents have the ability to tolerate Oxygen saturation as low as 60 to 70%. The MD stated that if a resident has blue lips that in itself does not indicate any distress it has to be associated with other symptoms. The MD stated it depends on who is assessing the resident, he would question the credibility of person assessing the resident if someone has 'blue lips' what does that really mean. The MD stated that if the resident had blue lips and was complaining of not being able to breathe he cannot say if it was distress, however he would have advised the staff to call 911. The MD stated that he was not aware that Resident #1 had verbalized that she was not able to breathe. The MD stated that there were no policies related to monitoring of oxygen tanks. During an interview with the Director of Nursing (DON) on 9/19/16 at 11:35 AM, the DON stated that the recreation staff was responsible for the residents on a community trip. On 8/30/16 the recreation therapist was responsible for making an evaluation of the resident (Resident #1). The DON stated that recreation therapists are trained on handling emergency situations, on a community trip. CNAs get a general ventilator class which include overview of the oxygen equipment and instructions to check that residents' nasal cannula are in place if the resident is using oxygen. CNAs are expected to notify a nurse if the needle on the Oxygen cylinder gauge is on the red zone (refill), however CNAs are not in serviced on Oxygen concentrators and normally the nurse is responsible to switch the Oxygen tank to the concentrator. The DON stated that because it was an emergency on 8/30/16 CNA #1 took the responsibility of switching the Oxygen source. The DON stated that she thought that CNA #1 did the right thing for the welfare of the resident. All CNAs get training that in an emergency they are to call a nurse and the respiratory therapist, therefore she (CNA #1) did what she was supposed to do. The DON stated that there is no policy on monitoring of Oxygen tanks. During an interview with the Quality Assurance Director (QAD) on 9/19/16 at 12:20 PM, the QAD stated that the CNAs get orientation about the general overview of the Oxygen that includes to check the Oxygen tank and if it is empty, to call the nurse. The QAD stated that in her opinion on 8/30/16 the failure was that the recreation staff did not bring Resident #1 to the nurse to check her Oxygen tank. During an interview with the Facility Administrator on 9/19/16 at 1:31 PM, the Administrator stated that he was made aware of the incident on the same day (8/30/16). The expectation from the staff in hindsight, is that the staff need to be familiar with the equipment. The Administrator stated CNA #1 was familiar with some equipment, however the concentrator was newer and the CNA was not aware how to use it. On 09/19/2016 at 6:22 PM Resident #1 was observed in her room sitting in a wheelchair next to her bed having just finished her dinner meal. Resident #1 was alert, oriented, well groomed, and very hard of hearing. Resident #1 recalled going out on a trip to the restaurant and stated that the trip was terrible, the lobster was under cooked, and she ran out of Oxygen and the girl didn't know how to turn on the machine (the concentrator). Resident #1 stated I couldn't breathe; hold your breath for 5 minutes and see how that feels. Resident #1 stated that the ambulance came and got her on Oxygen right away and about 5 minutes later she started to feel better, and was taken to the hospital. 2) Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS- an assessment tool) dated 7/27/16 documented Resident #2 as cognitively intact and utilizing oxygen while a resident at the facility. The Comprehensive Care Plan (CCP) dated 8/9/16 titled Respiratory/[MEDICAL CONDITION]/Asthma documented interventions to monitor signs and symptoms of respiratory distress that is dyspnea, congestion, shortness of breath, wheezing and cyanosis. Oxygen via nasal cannula as per physician's orders [REDACTED].>The Monthly Physician order [REDACTED]. The Monthly Physician order [REDACTED]. The Treatment Administration Record (TAR) for the month of August 2016 signed for administration of Oxygen via nasal cannula at 2 liter per minute continuously. During an interview with the 7:00 AM-3:00 PM Certified Nursing Assistant (CNA #1) on 9/15/16 at 11:40 AM, CNA #1 stated that she usually didn't go on recreational trips. On 8/30/16 she was asked by the Registered Nurse Supervisor (RNS #1) (don't recall time) to go with the residents on a trip. CNA #1 stated that she just wanted to eat at the restaurant, the facility was paying so she decided to go. The residents had been waiting for 1½ hour outside the facility in the Ambulette for a CNA to accompany them on the trip. Approximately an hour after being at the restaurant, Resident #1 complained that she was not receiving any oxygen or air. CNA #1 stated that the Oxygen tank was empty. CNA #1 called the facility, and notified RNS #1 that Resident #1 ran out of Oxygen in her Oxygen tank, RNS #1 instructed her to call the Ambulette to bring Resident #1 back to the facility. CNA #1 stated that Resident #2 had a portable concentrator aside from an Oxygen tank. CNA #1 stated that she borrowed the concentrator from Resident #2 and gave it to Resident #1. CNA #1 stated that initially she was unable to turn the concentrator on as she was not familiar with that particular concentrator. CNA #1 stated that she called the facility again and spoke with a Licensed Practical Nurse (LPN #8) and informed her that the concentrator was being used for Resident #1 and that she was having difficulty starting the concentrator. LPN #8 connected CNA #1 to the Respiratory therapist (don't recall name) who instructed CNA #1, over the phone, on how to turn the concentrator on. CNA #1 stated that not too long after Resident #1 was using the concentrator, Resident #2's Oxygen tank also ran out of Oxygen. Resident #2 insisted that her concentrator be given back to her. CNA #1 stated that she took the concentrator from Resident #1 and gave it to Resident #2. Resident #1 was okay and was not in any distress after the concentrator was taken away from her. After approximately 20-40 minutes Resident #1 became more agitated and kept verbalizing that she couldn't breathe and needed oxygen/air. CNA #1 stated that Resident #1 did not appear in any respiratory distress and was not using her accessory muscles for respiration. Resident #1 did not have any change in color. CNA #1 stated that the ART called 911. CNA #1 also stated that she was not aware of policies related to community trips. During an interview with the Recreational Aide (RA) on 9/15/16 at 12:21 PM, the RA stated that prior to her going on the trip to the restaurant on 8/30/16 she was not aware of the policy related to the community trip. The RA stated that the trip to the restaurant was initially scheduled for 10:30 AM however, the bus (Ambulette) did not leave from facility until 11:50 AM. The RA stated that while at the restaurant, Resident #1 ran out of Oxygen in her tank and started to act differently: shaking a little, slumped over in her chair and not responding when I ca

Based on record review and staff interviews during an abbreviated and partial extended survey, the facility failed to ensure that residents received proper respiratory care and treatment. The facility failed to effectively implement its system for prompt response to ventilator alarms. Specifically, one (Resident #1) of 4 ventilator dependent residents' ventilator triggered alarms on [DATE] between 6:31 PM-6:51 PM to which staff did not respond. The alarm logs documented that the alarms were sounding and the pager logs documented that pagers were activated during this time frame. The video surveillance camera showed that facility staff did not enter Resident #1's room during the time frame. The individual charged with monitoring the alarm screen at the nurses' station did not recall if she used a walkie-talkie to alert staff that the alarms were triggering, individuals designated to respond did not do so when their pagers activated, and 11 staff members reported that the walkie-talkies were not functional. Subsequently, Resident #1 became unresponsive, without pulse or respirations and had to be resuscitated. This is actual harm with the potential for widespread serious harm for 28 ventilator dependent residents that is Immediate Jeopardy and Substandard Quality of Care. This is a repeat deficiency from the [DATE] abbreviated survey (Immediate Jeopardy). Complaint Number: NY 722 The findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Comprehensive Care Plan for Potential Breathing Problems related to Permanent [MEDICAL CONDITION] dated [DATE], and updated [DATE], documented that the resident was at risk for breathing problems due to [MEDICAL CONDITION]. Interventions included to monitor the resident for increased congestion, monitor respiratory status every shift, suction as needed to maintain a patent airway, and observe color, amount and consistency of secretions. The facility's Policy and Procedure for Ventilator Alarm Monitor System Response dated ,[DATE], and revised [DATE], documented that staff assigned to care for ventilator dependent residents will respond to ventilator alarms, and after a 6 second delay if the ventilator alarm continues to sound it is transmitted both as an audible alarm and as a visual display that will appear at the designated workstations and pagers. The Minimum Data Set (MDS - a clinical assessment tool) dated [DATE] documented Resident#1's cognitive status as being severely impaired and functional status as being totally dependent for all aspects of activities of daily living. The Log of Events (alarms log) dated [DATE] documented that High Inspiratory Pressure and/or Low VT (tidal volume) alarms sounded every minute from 6:31 PM - 6:51 PM. The Log of Remote Alerts (pager logs) dated [DATE] documented that pages were sent to Pager 101 on 14 occasions between 6:31 PM - 6:51 PM on [DATE]. Review of Resident #1's medical record lacked documented evidence of a Respiratory Flow Sheet with a respiratory assessment for the 7:00 AM - 7:00 PM shift on [DATE]. The Nursing Progress Note (NPN) dated [DATE] at 11:02 PM documented Resident #1 was received in bed,[MEDICAL CONDITION] vent maintained, alert and nonverbal. It was reported by Respiratory Therapist (RT#2) that the resident was nonresponsive at approximately 8:15 PM. At that time the Licensed Practical Nurse (LPN) #1 (LPN#1) entered the room and the resident was noted with no pulse, and was pale in color. A Rapid Response was called, and CPR (Cardio-Pulmonary Resuscitation) was initiated by LPN#1. The Progress Note by Respiratory Therapy (RT#2) dated [DATE] at 11:56 PM documented that at approximately 8:00 PM RT#2 went to see Resident #1 in her room because the High Pressure alarm was sounding. RT#2 suctioned, lavaged, and gave a hand held nebulizer treatment to the resident. While in the room the resident became unresponsive and a Rapid Response was initiated. After this event the resident was sent to the hospital for evaluation. The facility's Summary of Findings dated [DATE] concluded that Resident #1's alarms were going off on [DATE] from 6:31 PM - 8:03 PM with intermittent multiple short periods when the alarm was not going off for approximately 1 - 3 minutes. However, despite these short periods of self- resolution the resident's respiratory status did not resolve as it had between 6:09 PM - 6:31 PM, after staff intervention. Once the intermittent alarming began again at 6:32 PM, there appears to be no staff intervention until 8:03 PM, and subsequently the resident required CPR. The Hospital Transfer Summary dated [DATE] at 2:12 PM documented that on [DATE] Resident#1 was sent from the facility after a brief period of unresponsiveness with pulseless electrical activity requiring CPR, and also was noted to have copious respiratory secretions. The discharge [DIAGNOSES REDACTED]. During an interview with Administrator #1 (ADM#1) on [DATE] at 11:44 AM, he stated that you couldn't put more systems in place and still what should have happened, didn't happen. ADM #1 stated that it was felt that there was not resolution even though the resident was able to clear herself; the alarms did continue to go off. ADM #1 stated that residents' ventilator alarms only go out to two nurses and one respiratory therapist according to which side of the unit they are working, but announcements made over the walkie-talkies go out to all the staff on the unit regardless of which side they are working. During an interview with the Director of Respiratory Therapy (DRT) on [DATE] at 3:40 PM, the DRT stated that he participated in the investigation of the incident on [DATE] to some extent. The DRT stated that Resident #1 had a High Pressure alarm which meant that there was an occlusion or obstruction (occurs when the resident exceeds the set respiratory rate or can mean there is an occlusion or obstruction), after which the resident alarmed Low VT (low tidal volume) (which occurs when a resident does not meet the expected set volume, or can also be caused by a leak, coughing or talking) and High Rate (which occurs when a resident exceeds the set respiratory rate). The DRT stated that all alarms are audible and go to the Ventilator Monitoring System. The High Pressure and I-time (Inspiratory) Too Long are both high priority alarms and I would have expected someone to go into the room to check the alarms. The DRT stated that at 6:55 PM the alarm was silenced and reset, and that alarms commonly are silenced by someone physically going into the resident's room, but that there is no evidence any interventions were done or that any hyper- Oxygenation was given. During an interview with the 7:00 AM - 7:00 PM shift Licensed Practical Nurse (LPN #2) on [DATE] at 1:07 PM, LPN#2 stated that she was assigned to the Low Side of the unit on [DATE], but was not assigned to Resident#1. LPN #2 stated that she carried a pager which would receive all resident ventilator alarms on the Low Side. LPN #2 stated that she did not hear any alarms paged to her pager for Resident #1. A review of the Unit 1C Low Side Camera #4 surveillance video was conducted with the Director of Nursing (DON) and the Director of Plant Operations on [DATE] at 1:58 PM and revealed that no facility staff entered the resident's room between 6:31 PM - 6:51 PM on [DATE]. During an interview with the 7:00 AM - 7:00 PM shift RT #1 on [DATE] at 3:17 PM, RT#1 stated that on [DATE], Resident#1 had a lot of secretions and needed to be suctioned a lot. RT#1 stated that Resident #1's tidal volume was running low which meant Resident #1 was not getting enough air into her lungs. RT #1 stated that she had to change her walkie-talkie three times during her shift because the batteries in the walkie-talkies kept dying, and that only one staff member had a functional walkie-talkie. RT #1 stated that she did not recall getting any alarms for Resident #1 on her pager. During an interview with the 7:00 PM - 7:00 AM shift LPN#1 on [DATE] at 11:02 AM, LPN #1 stated that she did not see any alarms paged on her pager for Resident #1 on [DATE] and that there had been issues with the pagers, such as the alarms do not always go through to the pagers. LPN #1 stated that on [DATE] she did not have a walkie-talkie on her person from 7:00 PM - 9:00 PM, but the supervisor brought her one. LPN #1 stated that everyone knows that they (the walkie-talkies) are never charged, that there have been issues with the walkie-talkies, and that she told the administrator in the past but could not recall when. During an interview with the 7:00 PM - 7:00 AM shift Registered Nurse (RN#3) on [DATE] at 12:29 PM, RN#3 stated that she had a walkie-talkie on her person a few weeks ago that did not charge, and that she had placed it on the charger and didn't know until 10 minutes later that the walkie-talkie was not charging. RN #3 stated that if she has not heard her walkie-talkie go off for a while, she goes and changes walkie-talkies. RN #3 stated that on [DATE] she was assigned to the Low Side of the unit (with LPN#1), that her walkie-talkie was working and she did not recall receiving any calls regarding Resident #1 over the walkie-talkie. During an interview with the 3:00 PM - 11:00 PM shift Certified Nursing Assistant (CNA#5) on [DATE] at 1:21 PM, CNA#5 stated that she was assigned to monitor the Ventilator Monitoring System screen on [DATE]. CNA#5 stated that she was unable to recall if Resident #1 had alarms going off or if she paged any alarms over the walkie-talkie. During an interview with the 3:00 PM - 11:00 PM shift CNA #1 on [DATE] at 4:35 PM, CNA#1 stated that a lot of the walkie-talkies were not working on [DATE], even on the day shift. CNA #1 stated that the walkie-talkies would have a full charge when she took one, all the bars were visible, but the walkie-talkies were faulty. I'd take it and it would die. During a subsequent interview with the DRT on [DATE] at 12:08 PM, the DRT stated that new walkie-talkies were ordered on [DATE] because the walkie-talkies being used were inexpensive and the batteries died quicker. The DRT stated that RT #1 should have seen the resident more frequently during her shift based on review of the alarms between 4:00 PM - 7:00 PM on [DATE]. During an interview with the Director of Nursing (DON) on [DATE] at 1:52 PM, the DON stated that she was not aware of any issues with the walkie-talkies prior to [DATE]. The DON stated that complaints about the walkie-talkies are being addressed with new walkie-talkies. During an interview with the 3:00 PM - 11:00 PM shift CNA#10 on [DATE] at 5:15 PM, CNA#10 stated that when she has been assigned to monitor watch, she has used her walkie-talkie to announce alarms and that sometimes it has taken a while before someone responds. CNA#10 stated that when this has occurred she will page on the walkie-talkie will someone answer me please, and if no one responds she picks up the phone and overhead pages an announcement. CNA#10 stated that there have been times when nurses have said that they did not hear any pages on their walkie-talkies, and would then look at their walkie-talkie and it would be dead. During an interview with 11:00 PM - 7:00 PM shift CNA#7 on [DATE] at 10:57 AM, CNA#7 stated that she worked the 3:00 PM - 11:00 PM shift on [DATE] and that she checks her residents continuously because she does not trust the Ventilator Monitoring System, and that the monitor has a delay before alarming. CNA#7 stated that she has heard a resident's ventilator alarm go off when the resident was at the nurses' station, but the alarm did not come up on the Ventilator Monitor screen for 10 - 15 seconds. CNA#7 stated that she gets responses from nurses and respiratory therapists to her walkie-talkie pages because she is persistent about calling them until she gets a response and someone tells her they are in the resident's room. CNA#7stated that there have been issues in the past with the walkie-talkies charging, and that there would be walkie-talkies on the chargers with no charge, and that she told the supervisor at the time, it was months ago. During an interview with the Attending Physician (AP) on [DATE] at 11:24 AM, the AP stated that he reviewed what he could of Resident#1's chart, and that the resident had [MEDICAL CONDITION] and respiratory distress, staff responded and administered a nebulizer treatment, and the resident became unresponsive and a rapid response was called. The AP stated that he spoke to the admitting physician at the hospital who felt that the resident had a mucous plug. The AP stated if a resident has a mucous plug, it can cause [MEDICAL CONDITION] within 15 seconds. The AP stated that if a resident's ventilator is alarming Low VT, High Inspiratory Pressure the staff should respond immediately. During an interview with the Medical Director (MD) on [DATE] at 02:02 PM, the MD stated that he became aware of the incident on [DATE], and was told by either the ADM #1 or DON that a letter was received that said the system in place on the unit for monitoring residents did not take place, and that an investigation would be done, but has not seen the report of the investigation as yet. A subsequent interview was conducted on [DATE] at 2:53 PM with the DRT. The DRT stated that the server for the Ventilator Monitoring System was replaced about 2 weeks ago because the data base was filing up, and that there have been data problems with the system since. The DRT stated that the company was contacted on [DATE], and the Ventilator Monitoring System was down for 4 hours on [DATE]. During an interview with the 7:00 AM - 7:00 PM shift RN#4 on [DATE] at 5:15 PM, RN#4 stated that there have been issues with the walkie-talkies, and that earlier in the year new chargers were received and then the walkie-talkies began not holding their charge. RN#4 stated that she told the supervisor there were problems with the walkie-talkies and there were not enough walkie-talkies for the staff on [DATE], but the supervisor did not bring any additional walkie-talkies to her. RN#4 stated that on [DATE] the Ventilator Monitoring System alarmed a no vent data (indicating the resident is not connected to the ventilator) alarm on a resident and when RN#4 went to check the resident, the resident was connected to the ventilator and was okay. RN#4 stated that some of the ventilator alarms do not reset within the 2 minutes as they should and RN#4 reported this in the past (unable to recall when) to the supervisor and to respiratory therapy, and was told to go to the DRT or Assistant DRT with any problems. RN#4 stated that on [DATE] she told CNA#5 to call out everything (alarms) on the walkie-talkie because the RT told her the Ventilator Monitoring System alarms were delayed going out to the pagers. RN#4 stated that the Ventilator Monitor screen goes white at times ( a condition that has been occurring for a few months) and will stay white usually for more than a minute, and that when this occurs a Ventilator Watch (continuous walking rounds) has to be called. 415.12(k)(6)

br>Based on staff interviews and record review during an abbreviated and partial extended survey, the Administration failed to ensure that each resident reached and maintained the highest practicable physical, mental and psychosocial well-being. Specifically, the Administration failed to implement a system to ensure that staff responded to ventilator alarms and activated pagers promptly. This is actual harm with the potential for widespread harm to 28 ventilator dependent residents that is Immediate Jeopardy and Substandard Quality of Care. This is a repeat deficiency from the 07/30/2014 abbreviated survey (Immediate Jeopardy). Cross Reference: F328- Treatment/Care For Special Needs The findings include: The facility's Policy and Procedure for Ventilator Alarm Monitor System Response dated 03/2009 and revised 09/12/2014 documented that staff assigned to care for ventilator dependent residents will respond to ventilator alarms, and after a 6 second delay if the ventilator alarm continues to sound it is transmitted both as an audible alarm and as a visual display that will appear at the designated workstations and pagers. The Log of Events (alarms log) dated 08/15/2015 documented that High Inspiratory Pressure and/or Low VT (tidal volume) alarms sounded every minute from 6:31 PM - 6:51 PM. The Log of Remote Alerts (pager logs) dated 08/15/2015 documented that pages were sent to Pager 101 on 14 occasions between 6:31 PM - 6:51 PM on 08/15/2015. During an interview with Administrator #1 (ADM#1) on 08/21/2015 at 11:44 AM, he stated that you couldn't put more systems in place and still what should have happened, didn't happen. ADM#1 stated that it was felt that there was not resolution even though the resident was able to clear herself; the alarms did continue to go off. ADM#1 stated that residents' ventilator alarms only go out to two nurses and one respiratory therapist according to which side of the unit they are working, but announcements made over the walkie-talkies go out to all the staff on the unit regardless of which side they are working. During an interview with the Director of Respiratory Therapy (DRT) on 08/21/2015 at 3:40 PM, the DRT stated that he participated in the investigation of the incident on 08/15/2015 to some extent. The DRT stated that Resident#1 had a High Pressure alarm which meant that there was an occlusion or obstruction (occurs when the resident exceeds the set respiratory rate or can mean there is an occlusion or obstruction), after which the resident alarmed Low VT (low tidal volume) (which occurs when a resident does not meet the expected set volume, or can also be caused by a leak, coughing or talking) and High Rate (which occurs when a resident exceeds the set respiratory rate). The DRT stated that all alarms are audible and go to the Ventilator Monitoring System. The High Pressure and I-time (Inspiratory) Too Long are both high priority alarms and I would have expected someone to go into the room to check the alarms. The DRT stated that at 6:55 PM the alarm was silenced and reset, and that alarms commonly are silenced by someone physically going into the resident's room, but that there is no evidence any interventions were done or that any hyper-Oxygenation was given. A review of the Unit 1C Low Side Camera #4 surveillance video was conducted with the Director of Nursing (DON) and the Director of Plant Operations on 08/24/2015 at 1:58 PM and revealed that no facility staff entered the resident's room between 6:31 PM - 6:51 PM on 08/15/2015. 415.26

Based on staff interviews and record review during an abbreviated survey the facility did not ensure that each resident's physician was immediately consulted regarding a significant change in a resident's physical, mental or psychosocial status in order to commence a new form of treatment. Specifically, one (Resident #1) of four residents reviewed for notification of changes was assessed by the nursing supervisor to have a physical change in condition, unable to stand and in pain. The physician was notified, however the complete Registered Nurse (RN) assessment was not relayed to the physician. Subsequently, the resident was left in prolonged pain before being transferred to the hospital two days later. This resulted in actual harm that is not Immediate Jeopardy. Complaint Number: NY 999 The findings are: The Policy and Procedure on Notification of Change in Resident Condition dated 4/2009 documented that the attending physician will be notified when there is a significant change in the condition of the resident. Any deviation from the resident's baseline medical condition which in the opinion of the charge nurse and nursing supervisor constitutes an abnormal condition will be reported to the physician. When a resident becomes ill, her/his condition deteriorates, or any other condition arises of which the attending physician should be aware, the charge nurse and/or supervisor will call the physician. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (an assessment tool) dated 8/21/14 documented that Resident #1's cognition was severely impaired. The Care Plan Activity Report (CPAR) effective 10/8/13 documented Resident #1's potential risk for injury. Interventions included checking the resident for unmet needs and address them including but not limited to pain. The CPAR effective 10/8/13 documented Resident #1's risk for pain/discomfort with interventions to observe for signs and symptoms of pain including but not limited to verbal, facial grimacing, moaning. The Pain Screen Form (PSF) dated 11/26/14 documented that Resident #1 does not complain of pain or have evidence of pain. The PSF documented that the resident does not have any [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The physician's orders [REDACTED]. The physician's orders [REDACTED]. The Rehabilitation Screen/Referral Form dated 12/9/14 documented that Resident #1's range of motion is within functional limits; no pain; no [MEDICAL CONDITION]. The resident is able to ambulate 40 feet with rolling walker with min/mod assist of one; more independent in ambulation with merry walker as he can self-ambulate without any assistance ad lib. The Nursing Progress Notes (NPN) dated 12/20/14 at 12:30 PM documented that Resident #1 was alert, responsive, noted diaphoretic, weakness, not able to get up out of bed. Grimace noted to face secondary to pain. Tylenol given as per MD (medical doctor) standing order with little effect. Nursing supervisor called to come assess; needed three nurses to transfer to wheelchair. Called doctor; ordered urine culture. The NPN dated 12/20/14 at 1:03 PM documented that the RNS was notified by unit nurse of resident with a change in status. Assessed resident alert, responsive to tactile stimuli; ROM (range of motion) bilateral knees limited; unable to stand, normally is limited assist of one with transfers. Facial grimacing noted; received standard dose of Tylenol by unit nurse with poor effect; vital signs WNL (within normal limits); placed resident in wheelchair to transport utilizing two person assist. Call placed to MD; new order obtained for UA/C&S (urinalysis/culture & sensitivity). The Resident Medication Administration Record [REDACTED]. The RMAR lacked documented evidence of pre- and post- assessment for pain. The Resident Treatment Administration Record (RTAR) dated 12/20/14 and 12/21/14 documented that the physician's standing order for Icy Hot Patch was administered during the 7:00 AM to 3:00 PM nursing shift. The RTAR lacked documented evidence of pre- and post- assessment for pain. The Investigation Timeline Summary dated 1/11/15 documented that, on 12/20/14, the resident had a sudden onset change in transfer ability. He was assessed for pain and given medication for same. The physician ordered urine be collected for testing, investigating whether an infection may have led to a change in mental status and resultant change in transfer status. With no report of a fall and no sign of injury, a medical etiology is reasonable to be suspected and prudent to be pursued. An interview was conducted with the 12/20/14 charge LPN #4 on 1/8/15 at 2:12 PM. LPN #4 stated that, on 12/20/14 before 8:00 AM, an aide called her to see Resident #1, who was not able to stand. LPN #4 stated that she called for the supervisor to assess the resident. LPN #4 stated that she did not stay with the supervisor during her assessment. LPN #4 stated that, when the supervisor finished with the resident, "she (supervisor) told me he just had arthritis so it might be why he can't stand. She told me to give him (resident) whatever he was supposed to get for pain, so I gave him Tylenol that was a standing order. I'm not sure what it (Tylenol) was for." The supervisor did not call the doctor. LPN #4 stated that the supervisor told her to call the doctor, so she called the doctor and told the doctor Resident #1's vital signs and that the resident wouldn't get into his merry walker. She did not tell the doctor about Resident #1's transfer status or facial grimacing. The doctor ordered a UA/C&S. An interview was conducted with the 12/20/14 7:00 AM to 3:00 PM RNS #1 on 1/8/15 at 2:40 PM. RNS #1 stated that, on 12/20/14 around 8:00 AM, an unrecalled nurse called her to see Resident #1 because the resident was having trouble transferring. RNS #1 stated that the resident normally was able to stand and walk with a merry walker independently. RNS #1 stated that she had the resident transferred to a transport wheelchair and assessed him in the transport chair. Resident #1 had guarding on the lower extremities with limited range of motion. RNS #1 stated, "I thought he (Resident #1) could bear weight but couldn't stand up. I thought he just might be in pain and didn't want to get up, so I told the nurse to give him Tylenol. He had facial grimacing but he didn't verbalize pain." She was unable to say whether or not Resident #1 was usually capable of verbalizing pain. RNS #1 stated that she did not speak to the doctor but told an unrecalled nurse to call the doctor; RNS #1 did not give any special instructions to tell the doctor. RNS #1 stated that, later that morning, the unrecalled nurse told her that the Tylenol had a poor effect on Resident #1; "I'm not sure what happened after that." RNS #1 stated that she did not pass on any further information about the resident to the next nursing shift; "Since they already had orders from my shift I didn't see any reason to." She stated that she was back on duty on Sunday 12/21/14 at 7:00 AM but did not follow-up with the resident. An interview was conducted with the Attending Physician (AP) on 1/12/15 at 10:11 AM. The AP stated that he did receive a call on the morning of 12/20/14 from the charge nurse regarding Resident #1. The AP stated that he was told that the resident was not acting like himself with no further description or concern, so the AP ordered a UA/C&S to see if the resident had a UTI (urinary tract infection). The AP stated that the nurse did not provide him any description of a physical change in transfer or ambulation status, did not describe any change in range of motion and did not advise him of the resident having pain. The AP stated that, if he had been provided with that type of description, he would have provided other orders, including x-rays and pain medication. The AP stated that he admitted Resident #1 to the hospital on [DATE] with multiple trauma including pelvic, right humerus and rib fractures. An interview was conducted with the Director of Nursing (DON) on 1/12/15 at 1:05 PM. The DON further stated that the physician needs to be called whenever there is a change in a resident's status and be provided with the full assessment in order to give appropriate orders to treat the resident. During a subsequent interview with LPN #4 on 1/12/15 at 1:15 PM LPN #4 stated that the Tylenol given to Resident #1 "didn't seem to do anything. He (Resident #1) still looked in pain but I didn't know what was bothering him, because he can't voice that something is bothering him." She did not call the doctor again and was unable to give any further explanation of how to monitor if a resident is having pain. During an interview with the Administrator on 1/12/15 at 1:45 PM the Administrator stated that he prepared the Investigation Timeline Summary based on review of the medical record. The Administrator stated that he was unaware that the AP was not accurately notified of Resident #1's significant change in condition on 12/20/14. 415.3(e)(2)(ii)(b)

Based on staff interviews and record review during an abbreviated survey the facility did not ensure that the necessary care and services to attain and maintain the highest practicable physical, mental and psychosocial well-being were provided to one (Resident #1) of four residents reviewed for quality of care. Specifically, Resident #1 ambulated independently with a merry walker (a tubular walker/chair combination device). On 12/20/14 the resident (with severe cognition impairment and unable to verbalize pain) was assessed with [REDACTED]. The facility staff did not implement interventions nor reassess the resident's pain needs. The resident subsequently was left in prolonged pain before being transferred to the hospital on [DATE] where he was admitted for multiple fractures. This resulted in actual harm that is not Immediate Jeopardy. Complaint Number: NY 999 The findings are: The Policy and Procedure on Pain Management Program dated 6/18/08 documented that each resident will be screened for the presence of pain, including its origin, location, severity, alleviating and exacerbating factors and current treatment and response to treatment. Pain screening involves both the nurse and the resident and will occur, at a minimum, at a suitable interval after pharmacologic or non-pharmacologic intervention (e.g., 15 to 30 minutes after parental drug therapy and one hour after oral administration of pain medication). The licensed nurse identifies interventions for pain and, using the pain management flow sheet, evaluates the effectiveness of the interventions; documents also on the Medication Administration Record [REDACTED] The Policy and Procedure on Documentation: Twenty-Four Hour Condition Report dated 11/5/08 documented that nursing staff will provide accurate and complete resident care by continuous communication on a twenty-four hour basis to all resident care personnel. Change of shift report must be given to incoming nurses. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (an assessment tool) dated 8/21/14 documented that Resident #1's cognition was severely impaired. The Care Plan Activity Report (CPAR) effective 10/8/13 documented Resident #1's potential risk for injury. Interventions included checking the resident for unmet needs and address them including but not limited to pain. The CPAR effective 10/8/13 documented Resident #1's risk for pain/discomfort with interventions to observe for signs and symptoms of pain including but not limited to verbal, facial grimacing, moaning. The Resident Nursing Instructions effective 7/18/14 documented that Resident #1 can ambulate ad lib once set up in merry walker. The Pain Screen Form (PSF) dated 11/26/14 documented that Resident #1 does not complain of pain or have evidence of pain. The PSF documented that the resident does not have any [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The physician's orders [REDACTED]. The physician's orders [REDACTED]. The Rehabilitation Screen/Referral Form dated 12/9/14 documented that Resident #1's range of motion is within functional limits; no pain; no [MEDICAL CONDITION]. The resident is able to ambulate 40 feet with rolling walker with min/mod assist of one; more independent in ambulation with merry walker as he can self-ambulate without any assistance ad lib. The Nursing Progress Notes (NPN) dated 12/20/14 at 12:30 PM documented that Resident #1 was alert, responsive, noted diaphoretic, weakness, not able to get up out of bed. Grimace noted to face secondary to pain. Tylenol given as per MD (medical doctor) standing order with little effect. Nursing supervisor called to come assess; needed three nurses to transfer to wheelchair. Called doctor; ordered urine culture. Nursing will continue to monitor. Temperature: 97.8; Blood Pressure: 118/76; Pulse: 93; Respirations: 16; Blood Sugars: 165. The NPN dated 12/20/14 at 1:03 PM documented that the RNS was notified by unit nurse of resident with a change in status. Assessed resident alert, responsive to tactile stimuli; ROM (range of motion) bilateral knees limited; unable to stand, normally is limited assist of one with transfers. Facial grimacing noted; received standard dose of Tylenol by unit nurse with poor effect; vital signs WNL (within normal limits); placed resident in wheelchair to transport utilizing two person assist. Call placed to MD; new order obtained for UA/C&S (urinalysis/culture & sensitivity). Nursing to monitor. The 24 Hour Report dated 12/20/14 documented verbatim the above-stated NPNs. (The 24 Hour Report is directly linked to the electronic medical record.) The Resident Medication Administration Record [REDACTED]. The RMAR lacked documented evidence of pre- and post- assessment for pain. The Resident Treatment Administration Record (RTAR) dated 12/20/14 and 12/21/14 documented that the physician's standing order for Icy Hot Patch was administered during the 7:00 AM to 3:00 PM nursing shift. The RTAR lacked documented evidence of pre- and post- assessment for pain. The medical record lacked documented evidence of any further assessment or interventions after identifying the ineffectiveness of the administration of Tylenol. The NPN dated 12/21/14 at 4:38 AM documented that a UA/C&S to be obtained as per MD order due to change in status, weakness. Resident slept well through the night; no grimacing noted. The NPN dated 12/22/14 at 10:08 AM documented that, during morning care, CNA (Certified Nursing Assistant) reported that resident had discolorations to right inner arm and right elbow; grimacing during any attempts of ROM to right arm and right leg; unable to weight bear; possible external rotation observed. (NP) Nurse Practitioner in to evaluate; ordered x-rays of right shoulder, elbow, hip and knee. The Radiology Results dated 12/22/14 documented that an x-ray of the right shoulder/humerus revealed [MEDICAL CONDITION]; severely displaced fracture right humeral neck. The NPN dated 12/22/14 at 2:15 PM documented that x-rays were taken and verbal report from portable x-ray received. NP ordered transfer to the hospital for evaluation. The NPN dated 12/22/14 at 11:23 PM documented that the resident was admitted to the hospital with [REDACTED]. The Hospital Radiology Results Report (HRRR) dated 12/22/14 documented that a CT (computed tomography) without contrast of the abdomen/pelvis was performed. Fractures of the right superior and inferior pubic rami; fractures of the right acetabulum extending into the iliac wing with adjacent hematoma. Impression: multiple right pelvic fractures. The HRRR dated 12/22/14 documented that a chest x-ray was performed. Right humeral neck fracture is seen. There is also evidence of non-displaced right posterior 5th rib fracture. Impression: right humeral neck fracture; non-displaced right posterior 5th rib fracture. The Investigation Timeline Summary dated 1/11/15 documented that, on 12/20/14, the resident had a sudden onset change in transfer ability. He was assessed for pain and given medication for same. The physician ordered urine be collected for testing, investigating whether an infection may have led to a change in mental status and resultant change in transfer status. With no report of a fall and no sign of injury, a medical etiology is reasonable to be suspected and prudent to be pursued. An interview was conducted with the 12/19/14 7:00 AM to 3:00 PM CNA #1 on 1/8/15 at 11:36 AM. CNA #1 stated that Resident #1 walks around the unit ad lib in his merry walker and never shows any sign of being in pain; he feeds himself and loves ice cream. When CNA #1 left at 3:00 PM on 12/19/14 the resident was his usual self. CNA #1 stated that, when she returned to work on Monday, 12/22/14 at 7:00 AM, the only report she received was that Resident #1 was now in a wheelchair because he couldn't get up on Saturday morning. CNA #1 went to do morning care with the resident and noticed a bruise to his right elbow. CNA #1 stated that the resident's face was grimacing and he could not move. She stated she went to tell the nurse; "I know him (Resident #1); something's wrong. He's not moving." An interview was conducted with the 12/19/14 7:00 AM to 3:00 PM charge Licensed Practical Nurse (LPN #1) on 1/8/15 at 11:56 AM. LPN #1 stated that, on 12/19/14, Resident #1 was his usual self, unintelligibly singing, ambulating without assistance in his merry walker throughout the unit; the resident ate well by feeding himself. The resident had a standing order for Tylenol but rarely, if ever, showed any sign of pain. LPN #1 stated that, when she returned to work on the morning of 12/22/14, she received verbal report that the resident was having weakness over the weekend and had to be put into a wheelchair. There was no report of pain. LPN #1 stated that CNA #1 called her to the room to see the resident; the resident was in a lot of pain, had discoloration down the inner arm and swelling to the upper & outer arm. LPN #1 stated that the NP came to do an assessment and ordered x-rays, which were done very quickly. The x-ray report came back with a [MEDICAL CONDITION] shoulder and the resident was sent to the hospital. An interview was conducted with the 12/20/14 7:00 AM to 3:00 PM and 3:00 PM to 11:00 PM CNA #2 on 1/8/15 at 12:11 PM. CNA #2 stated that, when she came on duty at 7:00 AM on 12/20/14, there was nothing new reported about Resident #1. When CNA #2 went to the resident somewhere between 7:30 AM and 8:00 AM, Resident #1 was not normal; he was not making eye contact and would not get up. CNA #2 got LPN #4, who took the resident's vitals, said everything was okay and left the room. CNA #2 stated that she tried to transfer the resident but he was dead weight and couldn't stand. She called LPN #4, who then called for the supervisor. CNA #2 stated that the supervisor wanted to transfer Resident #1 to a regular wheelchair and the only wheelchair CNA #2 could think of was the transport chair in the lobby, so CNA #2 went to get it and it took two to transfer the resident into the chair. CNA #2 stated that the supervisor assessed Resident #1 and said that, since it was raining outside and the resident has a history of arthritis, it was probably the bad weather affecting him. CNA #2 stated that she told the supervisor that she never saw the resident be affected by weather. CNA #2 stated that Resident #1 was totally different all day and seemed like he was hurting. CNA #2 explained, "His facial expression was like very severe; "she looked around the table, saw a pain scale and pointed at it stating, "He (Resident #1) looked like this all day, number 4" (she pointed at a Pain Screen face showing 'very severe'). CNA #2 stated that Resident #1 usually fed himself but the rest of the day on 12/20/14 "he didn't want to eat or even open his mouth so I could feed him. He loves ice cream and wouldn't even eat that." She further stated, "The nurses knew. His behavior is usually singing and happy but he wasn't like that. He had a face like he was in pain all day." CNA #2 stated that she worked the next day, 12/21/14, and, although the resident was not on her assignment, she saw the resident frowning/grimacing his eyebrows; "He still wasn't the same as his usual self but they (nurses) didn't say that anything was wrong with him." An interview was conducted with the 12/20/14 11:00 PM to 7:00 AM and 12/21/14 7:00 AM to 3:00 PM LPN #3 on 1/8/15 at 1:59 PM. LPN #3 stated that, when she came on duty at 11:00 PM on 12/20/14, there was nothing on report for Resident #1 except that a urine sample was needed for a UA/C&S which she couldn't obtain. LPN #3 stated that she didn't know anything about the resident having any pain or being unable to stand. LPN #3 stated that the resident was in a transport chair during the day on 12/21/14 and needed two staff members to transfer him but "I didn't know anything was wrong. I usually work nights when he sleeps. He (Resident #1) can't say if he's in pain." LPN #3 was unable to say if Resident #1 was having pain on 12/21/14 and could not give any further explanation on how to monitor if a resident is having pain. An interview was conducted with the 12/20/14 charge LPN #4 on 1/8/15 at 2:12 PM. LPN #4 stated that, on 12/20/14 before 8:00 AM, an aide called her to see Resident #1, who was not able to stand. LPN #4 stated that she called for the supervisor to assess the resident. LPN #4 stated that she did not stay with the supervisor during her assessment. LPN #4 stated that, when the supervisor finished with the resident, "she (supervisor) told me he just had arthritis so it might be why he can't stand. She told me to give him (resident) whatever he was supposed to get for pain, so I gave him Tylenol that was a standing order. I'm not sure what it (Tylenol) was for." The supervisor did not call the doctor. LPN #4 stated that the supervisor told her to call the doctor, so she called the doctor and told the doctor Resident #1's vital signs and that the resident wouldn't get into his merry walker. The doctor ordered a UA/C&S. An interview was conducted with the 12/20/14 7:00 AM to 3:00 PM RNS #1 on 1/8/15 at 2:40 PM. RNS #1 stated that, on 12/20/14 around 8:00 AM, an unrecalled nurse called her to see Resident #1 because the resident was having trouble transferring. RNS #1 stated that the resident normally was able to stand and walk with a merry walker independently. RNS #1 stated that she had the resident transferred to a transport wheelchair and assessed him in the transport chair. Resident #1 had guarding on the lower extremities with limited range of motion. RNS #1 stated, "I thought he (Resident #1) could bear weight but couldn't stand up. I thought he just might be in pain and didn't want to get up, so I told the nurse to give him Tylenol. He had facial grimacing but he didn't verbalize pain." She was unable to say whether or not Resident #1 was usually capable of verbalizing pain. RNS #1 stated that she did not speak to the doctor but told an unrecalled nurse to call the doctor; RNS #1 did not give any special instructions to tell the doctor. RNS #1 stated that, later that morning, the unrecalled nurse told her that the Tylenol had a poor effect on Resident #1; "I'm not sure what happened after that." RNS #1 stated that she did not pass on any further information about the resident to the next nursing shift; "Since they already had orders from my shift I didn't see any reason to." She stated that she was back on duty on Sunday 12/21/14 at 7:00 AM but did not follow-up with the resident. During a subsequent interview with RNS #1 on 1/9/15 at 5:08 PM RNS #1 stated that, when she assessed Resident #1 on 12/20/14, "I have no idea what was causing him pain. My impression is that he didn't want to ambulate." She further stated, "I don't know if the nurse gave Tylenol. I don't know if I reassessed him (Resident #1)." An interview was conducted with the 12/19/14 3:00 PM to 11:00 PM CNA #3 on 1/8/15 3:15 PM. CNA #3 stated that, on 12/19/14, Resident #1 was walking fine as usual by himself in the merry walker. CNA #3 helped the resident to bed without an incident. CNA #3 stated that she returned to work on Sunday morning, 12/21/14, at 7:00 AM and "there was a big change in him (resident)." CNA #3 stated that she was not told of any change with the resident during report but, when she went to the resident, Resident #1 "could barely stand, very weak. I put the walker in front of him at the edge of the bed as usual and his whole top body was like floppy." She went to the nurse who told her that the resident was in a wheelchair since the previous day but was unable to give a reason; CNA #3 was not provided any specific instructions for care of the resident. She stated, "All I know is he wasn't happy singing like he usually is. He was weak and hurting. He wouldn't eat. He loves ice cream but wouldn't eat it. That's something he eats everyday no matter what." CNA #3 further stated that the resident's facial expression was grimacing; "He can't tell you what's wrong. You have to know him and watch him. There was definitely something wrong." CNA #3 stated that she worked on the evening of 12/21/14. She was not assigned to the resident during this shift but the resident needed two staff members to transfer him, so CNA #3 helped to transfer him; "He was so weak." An interview was conducted with the daily 7:00 AM to 3:00 PM RNS #2 on 1/9/15 at 12:54 PM. RNS #2 stated that, on 12/19/14, there was no report of any concern with Resident #1. RNS #2 stated that, when she returned to work on Monday, 12/22/14, she was very confused about the resident's status. She stated, "I don't know why they were all concerned about collecting urine. When he (Resident #1) had such a physical change, I don't know why they wouldn't do more." RNS #2 further stated, "I looked at the progress notes and it said the pain medication wasn't working but nothing else was done. It wasn't a great assessment." An interview was conducted with the Risk Manager (RM) on 1/9/14 at 1:19 PM. The RM stated that she conducted an investigation into the origin of Resident #1's injuries as discovered on 12/22/14 which remain inconclusive. The RM stated that, during her investigation, she did not interview the nurses involved with the resident's change of status on 12/20/14 but did review same on record review. The RM stated that she thought that the doctor's order did not really match the assessment recorded by RNS #1. The RM stated that, although this triggered as inconsistent, she did not question or investigate it any further. The RM stated, "If I were the nurse and told a doctor the same assessment I read in (Resident #1's) chart, I would expect more of an order than just getting a urine. But, I wasn't the nurse." An interview was conducted with the 12/20/14 and 12/21/14 3:00 PM to 11:00 PM LPN #5 on 1/9/15 at 1:49 PM. LPN #5 stated that, when she came on duty on 12/20/14, there was no report about a significant change in Resident #1. However, when LPN #5 saw the resident in a wheelchair, she knew there was an obvious change yet she was never told the reason. LPN #5 stated she started asking other staff and some said that the resident probably had a mental status change. LPN #5 stated that Resident #1 had a very sad face but she doesn't know if was having any pain. She further stated, "I don't know how you would know if a pain med is effective if they (residents) don't tell you." LPN #5 stated that Resident #1 is not able to say what he needs. An interview was conducted with the Director of Rehabilitation (DR) on 1/12/14 at 9:40 AM. The DR stated that, prior to 12/20/14, Resident #1's range of motion upper and lower extremities were within normal limits and there had been no recent status changes. The DR reported that he first heard of the resident's change in status on Monday, 12/22/14 during morning report. The DR further stated that he was surprised that he had not been called on 12/20/14 when the resident was not able to stand; "Rehab is in the building on the weekends and I personally was here on that day." An interview was conducted with the Attending Physician (AP) on 1/12/15 at 10:11 AM. The AP stated that he did receive a call on the morning of 12/20/14 from the charge nurse regarding Resident #1. The AP stated that he was told that the resident was not acting like himself with no further description or concern, so the AP ordered a UA/C&S to see if the resident had a UTI (urinary tract infection). The AP stated that the nurse did not provide him any description of a physical change in transfer or ambulation status, did not describe any change in range of motion and did not advise him of the resident having pain. The AP stated that, if he had been provided with that type of description, he would have provided other orders, including x-rays and pain medication. The AP stated that he admitted Resident #1 to the hospital on [DATE] with multiple trauma including pelvic, right humerus and rib fractures. An interview was conducted with the Assistant Director of Nursing (ADON) on 1/12/15 at 10:57 AM. The ADON stated that "unresolved pain must be addressed and re-assessed." The ADON stated, "If there's a change in a resident's status, the pain medication needs to be re-evaluated and assessed after being administered even if it is a standing medication." She stated that the policy on pain doesn't address the need to assess a resident prior to and after administering pain medication; "The policy on pain is outdated. It doesn't include this and obviously needs to be updated." She further stated that a nurse would have to open a specific drop-down screen in the RMAR/RTAR of the electronic medical record to do a reassessment of a resident's pain but this was never done with regard to Resident #1. An interview was conducted with the Director of Nursing (DON) on 1/12/15 at 1:05 PM. The DON stated that the policy on pain management needs revision. The DON stated that a resident should always be assessed for pain and especially immediately after a resident expresses pain verbally or by physical change. She stated that all nurses should know what type of pain they are medicating a resident for and assess the effectiveness of the medication after administering it whether it is a standing order or PRN (as needed) order. The DON further stated that the physician needs to be called whenever there is a change in a resident's status and be provided with the full assessment in order to give appropriate orders to treat the resident. During a subsequent interview with LPN #4 on 1/12/15 at 1:15 PM LPN #4 stated that the Tylenol given to Resident #1 "didn't seem to do anything. He (Resident #1) still looked in pain but I didn't know what was bothering him, because he can't voice that something is bothering him." LPN #4 was unable to give any further explanation of how to monitor if a resident is having pain. 415.12

Based on record review and interviews during an abbreviated survey, the facility did not ensure that each resident received adequate supervision and that each resident's environment was as free from accident hazards as is possible. Specifically, four of seven (Resident #2, #5, #6, #3) residents reviewed for accidents, was at risk for falls, did not receive adequate supervision and fell . Residents #2 and #5 sustained injury. Resident#2 was left unsupervised in a TV room with other residents. Resident #2 was found on the floor upside down with the wheelchair on top of her sustaining a hematoma above her right eye. The facility's video surveillance recorded staff members entering and exiting the TV room prior to the floor and no one noticed that the residents were unsupervised. Resident #5 was admitted to the facility with a history of falls, assessed as being at moderate risk for falls, was observed attempting to ambulate on her own and the care plan was not updated to address safety concerns. The resident subsequently fell , transferred to hospital and was found to have an acute right displaced impacted intra-articular distal radial metaphyseal fracture status [REDACTED]. Resident #6 had a history of [REDACTED]. Resident#3 was left unsupervised in a TV room, slid out of the chair and sustained an abrasion to the right knee. Additionally one of seven (#4) residents' reviewed for accidents, physical environment was not free from accident hazards. Resident#4's diaper was being changed in the bathroom when she fell on to brackets that were set into the bathroom wall tiles sustaining facial injury. The brackets were moved after the incident. This resulted in actual harm that is not Immediate Jeopardy. ACTS ID Numbers: 258, 594, 957, 316, 538 The findings are: 1) Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The policy and procedure for Dining Room Supervision dated 6/1/2002 documented that the resident dining rooms will be supervised at all times when residents are present in the dining room. The procedure included that the Nurse Manager assures that the Certified Nursing Assistant (CNA) is assigned to the dining room during use hours. Additionally, CNAs are to provide continuous, conscientious surveillance of residents entering, within and exiting the dining room. The Comprehensive Care Plan (CCP) for falls dated 4/23/12 and updated 7/13/13 documented interventions including bed alarm, low bed, encourage resident to ask for assistance as needed, toileting schedule every 2 hours (7/13/13). The care plan lacked interventions specific to monitoring/supervision of resident. The Care Plan Activity Report documented falls for Resident #2 including: On 4/23/2012, the resident was observed on floor in room. The resident stated she was attempting to close her bedroom door and fell . Body assessment done, resident complained of pain to right hip. The resident was transferred to the hospital and admitted with a medical [DIAGNOSES REDACTED]. On 5/20/12 the resident slid forward out of wheelchair while attempting to stand today. No injury noted on assessment. On 9/23/12, the resident was found on the floor on the right side, near the bathroom. The resident was on the floor with moderate amount of blood to 3 cm laceration to posterior head. The resident was alert and responsive, B/P 160/80, HR 80, spO2 98% on r/a, resp (respirations) 18. The resident was sent to the hospital secondary to 3cm laceration and head trauma for treatment. The CCP for behaviors: Potential Risk for Injury due to cognitive impairments of self and others inability to comprehend personal boundaries and poor impulse control dated 6/8/12 lacked documented interventions to monitor or supervise resident. The Progress Notes dated 1/14/13 at 7:41 PM documented that at approximately 2:50 PM on evening rounds, the resident was found on the floor in the TV room. The resident had fallen from wheelchair and was face down on the floor with wheel chair tilted upwards. The resident had a large hematoma over the right eye, positive range of motion (ROM) to all extremities. The resident was assisted back to the wheelchair. The Resident Nursing Instructions (CNA accountability) for Monitoring safety documented interventions to include monitoring closely (no specific monitoring documented, dated 5/23/12). Review of the facility's investigation summary dated 1/14/13 documented that the time stamped camera showed the Certified Nursing Assistant (CNA#2) assigned to supervise the TV room, exited the room without handing off to another CNA to ensure the safety of the residents. Additionally nursing/ recreation staff exited and entered the TV room several times failing to recognize that residents (including Resident #2) were unsupervised. During a telephone interview with 7AM-3PM Licensed Practical Nurse (LPN#1) medication nurse on 3/14/14 at 12:44 PM, she stated that at approximately 2:45 PM on 1/14/13 she went into the TV room to fill a water pitcher and did not realize that the residents were not supervised. She was not thinking about it. CNA#2 left the room and did not ensure coverage and did not tell the nurse. CNA#2 should have notified LPN #1 if the other CNA did not relieve her or stayed in the room. The nurses on the unit are responsible to ensure CNAs fulfill their assignments. LPN#1 stated that at the time of the incident, staff were transferring residents in and out of the dining room. During a subsequent telephone interview with 7AM-3PM LPN#1 on 3/18/14 at 12:54 PM, she stated that she did not recall asking CNA#1 to weigh a patient at the time the CNA should have been covering the TV room. LPN#1 stated that she was in the hall when the supervisor yelled for help. The resident was on the floor and bleeding. LPN#1 could not recall where or what position Resident#2 was found and could not recall who assisted resident back to chair. During a telephone interview with Recreation staff #1 on 3/14/14 at 3:14 PM, she stated that she was taking residents to program when she noticed Resident #2 trying to take her shirt off. She went to get help from CNA#3. CNA#3 came into room and Recreation Staff #1 left and continued to bring residents out of the TV room for program. While doing program she heard (could not say how) that Resident #2 fell . She did not recall seeing the residents in the TV room alone and nothing was brought to her attention about resident's being left alone in a TV room. During a telephone interview with Recreation staff #2 on 3/14/14 at 3:53 PM, she stated that she did not recall any incident with Resident #2 falling after being left unsupervised in any room. No one in Administration spoke with her about leaving residents alone. During a telephone interview with CNA#3 on 3/18/14 at 3 PM, she stated that she was at the computer by the nurse's station when a staff member from recreation or rehab asked for assistance because a resident was trying to take off her shirt. CNA#3 went to assist, it was Resident #2, and left the room. She does not recall if the residents were alone because she was not paying attention to her surroundings. She went back to the nurse's station and at some point heard the supervisor yelling for help. She glanced inside and there were staff members present. She did not go into the room. During a telephone interview with 7AM-3PM Registered Nurse Supervisor (RNS#1) on 3/19/14 at 12:30 PM she stated on 1/14/13 she was performing end of shift rounds when she noticed resident on the TV room floor turned upside down with wheelchair on top of her (she was passing in the hall). RNS#1 went to the resident and called for help. Staff members responded and the resident was lifted up with chair (could not recall who assisted) and assessed. The resident had a hematoma above her right eye. There were no staff members in the room when RNS found the resident. RNS#1 stated that all CNAs participate in the surveillance assignment; given different times. They are expected to engage and face the residents to monitor what's going on. 2) Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Risk Fall assessment dated [DATE] documented the score as 13 (moderate risk). The Nursing Admission Assessment/Initial Care Plan dated 1/16/13 for falls documented interventions including reduce environmental hazards, call bell within reach, monitor for changes in ADLs, cognition, behavior, medications, monitor resident's activity. The assessment portion of the form was not completed. The nursing Progress Notes dated 1/16/13 at 10:17 PM documented that the resident was admitted with Right Greater Trochanter Fracture and Dementia. The resident had multiple ecchymotic areas to the left forearm, multiple ecchymotic areas to arm and forearm, and large ecchymotic area on forearm 5x6 cm. The resident was alert x1 to person. On 1/17/13 at 8:02 AM sutures were noted to the right hand between fourth and fifth digit. Right hip fracture. The Nursing Progress Notes dated 1/20/13 at 11:28 PM documented that the nurse noted the resident sitting on the side of her bed; attempting to walk herself to the toilet. This nurse recommended a bed alarm for this resident, Supervision aware. The nursing progress note dated 1/23/13 at 7:16 AM documented that the resident was found in the hallway on the floor. The resident had confusion and was unable to give a rational answer as to why she was walking out of room. The physician was made aware at 8:30 AM and ordered an x-ray of the right hip and right shoulder secondary to fall. At 9:23 AM it is documented that the RN responded to call to unit regarding resident on the floor at approximately 7 AM. Resident found on the floor lying supine on the high side hall, bilateral LE orientation noted to be pointing toward opposite room. Assessment done which revealed the following: resident is alert and responsive to both verbal and tactile stimuli, no visible injury noted related to fall, no open skin, no swelling noted, able to move bilateral upper extremities actively without difficulty but verbally complaining of pain in right forearm. No external or internal rotation noted, no palpable crepitus noted to hip and bilateral lower extremities. ROM to left LE done which revealed WNL and no complaint of pain. The resident was transferred to wheelchair and was assisted by unit nurse. On 1/23/13 at 9:27 am, the designated representative arrived at approximately 8:15 AM yelling and screaming that resident fell and demanded that resident be released immediately to them. After discussion with family, family in agreement to have resident transferred to hospital via ambulance. Resident was transferred at 9:10 AM. At 11:32 PM, the resident was admitted to the hospital at 7:14 PM with right hip fracture and right wrist fracture. Supervisor made aware. The Investigation Report for 1/23/13 documented that on 1/16/13 an initial fall/safety care plan implemented per facility policy via nursing admission assessment. On 1/20/13, the resident was observed sitting on edge of bed attempting to walk herself to the bathroom. Nursing staff noted the need for bed alarm and notified RNS. On 1/21/13, additional nursing care plans initiated by NCC. On 1/23/13 at approximately 6:28 AM, the resident was found on floor of hallway across from the room. RNS assessed resident with no apparent injury noted, however resident was sent to the hospital ER for further evaluation secondary to recent fall with hip fracture. The final determination documented that the resident was assessed by the 3-11 admitting RNS and scored a 13 on the Fall Risk assessment and initial care fall/safety care plan was implemented, resident nursing care plans were initiated within 5 days of admission, the RN staff who recognized the need for a bed alarm for resident safety and reported it to the oncoming supervisor did not update the fall/safety care plan and ensure the new safety intervention was put in place prior to leaving at the end of his shift, and the RNS notified of need for intervention did not follow up to ensure the care plan was updated, the bed alarm was in place, or initiate any other type of intervention. The hospital record (History and Physical) dated 1/23/13 documented a history of a previous Right hip fracture and being told that the fracture would heal on its own and did not require intervention aside from rehab. The history of the present illness was that the resident was found to have acute right displaced impacted intra-articular distal radial metaphyseal fracture status [REDACTED]. During an interview with Licensed Practical Nurse (LPN#9) on 1/31/13 at 2:30 PM, the LPN stated that she found the resident lying on the floor in front of the room in the hallway. She called for assistance and then the resident was sent out. The LPN did not recall seeing the resident try to get up, however, the resident was confused. She asked the resident where she was going and the resident stated that she was trying to go to bed. The resident was capable of moving her extremities. During an interview with Registered Nurse (RN#11) on 1/31/13 at 3 PM, stated that he was on the unit from 7-11PM on the evening of 1/20/13. RN#11 stated that he was not familiar with this resident. He saw her sitting on the edge of her bed attempting to get up and he called the CNA to toilet her. RN further stated that he told the Supervisor that he thinks this resident needs a bed alarm. The RN stated that he was disciplined because he should have ensured that she got a bed alarm. During an interview with the RN Risk Manager on 1/31/13, she stated that the nurse had the resident toileted when he saw her trying to get up but that he also should have ensured that the resident got a bed alarm kept in the Supervisor's office. The RN informed the Supervisor, that he felt the resident should have an alarm. The resident was found on the other side of the hallway opposite her room, after she got out of bed and walked out of her room. The bed alarm would not have prevented her fall, however, it may have called alerted the staff that she was out of bed. The incident occurred almost the end of the 11-7 shift. During an interview with Administrator #1 on 1/31/13 at 2 PM, the Administrator stated that after the fall on 1/23/13 the family wanted to take the resident home AMA, but they were advised by the nurse to take her to the hospital. He further stated that if the hospital thought it was a new fracture they may not be aware that the resident had already been diagnosed with [REDACTED]. We did not report it because we felt that the injury was due to the fall previously. He also stated that if the resident was not observed trying to get up we would not have put the bed alarm in place. The resident was assessed and had a fall care plan on 1/21/13 but the supervisor failed to put a new plan in place. He admitted that it took three days before the resident got a bed alarm.The x-ray at the hospital revealed the fracture, but we do not know if they were aware that the resident had already been diagnosed with [REDACTED]. The resident was assessed as moderate risk for falls from the beginning, but a bed alarm was not part of the original interventions. During a telephone interview with the Registered Nurse (RN#1) Unit Manager on 1/23/14 at 3 PM, the RN stated that when she came in the next morning after the incident on 1/20/13, it was not reported to her that the resident had fallen on the previous night. She also did not know that the care plan was not updated. During a telephone interview with RN#12, Supervisor on 1/27/14 at 3 PM, the RN stated that a bed alarm should have been initiated when the resident was noted to be attempting to get out of bed (1/20/13). The procedure should be to place a bed alarm, to put the resident on report and to monitor. A bed alarm should be available in the Supervisor's office. She did not remember the circumstances regarding the incident. During a telephone interview with RN#3 on 1/23/14 at 12 PM, she did the initial assessment when the resident was admitted . RN was asked why the resident did not have an alarm after she was identified as a moderate risk for falls with a score of 13. She could not answer if it was not on the report. 3) Resident#6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had a history of [REDACTED]. The Physical Therapy screen dated 8/17/12 documented that the resident was at risk for falls, distance supervision on unit adlib without assistive device, and Physical Therapy was not indicated. There are no further documented physical therapy screens or evaluations between 8/17/12 and 2/21/13. The fall risk assessment dated [DATE] documented a score of 13 (moderate risk). The Minimum (MDS) data set [DATE] documented the resident's cognition status as moderately impaired and locomotion on unit was with supervision/set up. The Fall Care Plan dated 8/20/12 documented interventions including encourage use of glasses, reduce environmental hazards, i.e. clutter, keep floors dry and clear, call bell within reach, instruct/reinforce safety measures, i.e., transfer techniques, proper footwear, locking wheelchair, PT and OT as per plan, monitor for changes in ADL's, cognition, behavior, mood, medications, staff to ensure resident to have a clear path to walk in hall way and wrap around area (10/4/12). The ADL Walking Care Plan dated 8/20/12 documented that the goal was distant supervision for walking in room and corridor. The interventions included PT as per plan, assist/encourage resident in maximal self-performance observe/report for changes in ability i.e. unsteady gait, decrease balance, fatigue, dyspnea, and decreased distance; provide/assist teaching/assurance in safety techniques i.e. proper footwear, balance techniques, and use of assistive devices. The Progress Notes and Accident/Incident reports documented the following falls: On 9/24/12 at 6:59 PM, the RN supervisor was called to the unit to assess the resident who was found lying on the floor on her back in the hallway by nursing station at approximately 4 PM. Another resident's family member saw Resident#6 trip over the wheelchair anti-tippers of another resident. Resident#6 was checked and noted with a small abrasion to the right knee, no active bleeding, denied pain or discomfort and was able to move all extremities without difficulty. The resident was ambulating on the unit with no complaints of pain or discomfort. Continue on one to one supervision due to a prior inappropriate peer to peer interaction. The Patient Accident/Incident Report dated 9/24/12 documented that another resident's family member witnessed the resident trip over the anti-tippers of a resident's wheelchair. The resident was found on the floor. The resident stated that she tripped. The assigned Certified Nursing Assistant (CNA) statement dated 9/24/12 documented that she was giving care to another resident. The A/I lacked documented evidence that the one to one was present during the time of the fall. The Final summary and determination documented that the resident is out of bed to a standard chair with supervision and the resident ambulates on unit with distant supervision. The resident was observed on the floor in hallway. The resident was ambulating on hallway and tripped on peer's anti-tippers. PT to evaluate for gait and balance or possible use of wheelchair secondary to unsteady gait. There is no documented evidence that a Physical Therapy evaluation was initiated after this incident. On 10/4/12 at 7:57 PM, the RN supervisor documented that she was called to the unit and observed the resident sitting on the floor around wrap around area. The CNA stated that the resident was walking in between wheelchairs that were positioned in the middle of the wrap around area and fell . A full body check was done and the resident didn't have any complaints of pain or discomfort. The MD and designated representative were notified. The resident was to continue on every 10 minute checks. The Patient Accident/Incident Report dated 10/4/12 documented that the resident was unable to state her version of Accident/Incident due to dementia. The investigation lacked documented evidence of a statement from the CNA who reported the fall to the unit nurse. The Final summary and determination documented that the resident was ambulating, lost balance and fell . Staff in serviced to ensure to not place resident in the middle of the room and ensure that there is a clear path for resident to walk in wrap around. On 11/28/12 at 2:26 PM (at approximately 11:15 AM) the unit nurse was called to the wrap around by staff and reported the resident was on the floor. Positive range of motion to bilateral upper extremity/bilateral lower extremity. Denied any pain or discomfort. The staff reported witnessing the resident trip over sitting chair leg and then fell on floor. The Patient Accident/Incident Report dated 11/28/12 documented that the resident tripped over sitting chair and fell to floor. The Final Summary and Determination documented that the resident was ambulating on the wrap around and observed by staff tripping on stationary chair and fell to the floor. On 1/4/13 at 7:08 PM the resident was found on the floor, in the door way of a room (not the resident's room). Review of video revealed that the resident was in room for approximately 20 while another resident walked in and out multiple times, the last exit at 3:38 shows the other resident exiting then turning back and bending down at which point a CNA arrives and the other staff is called to the scene. The resident is alert with confusion. The Patient Accident/Incident Report dated 1/4/13 documented that the resident was unaware of the incident. The Final Summary and Determination documented that the resident was in another resident's room and another resident was entering and exiting the room when the other resident was noted bending over attempting to assist the resident off the floor. The fall was not witnessed by staff and residents were unable to give an account of the incident. It was unknown at the time what caused the resident to fall. On 1/5/13 at 5:58 PM (approximately 5:15 PM) the resident was found lying on the side in a room (not her room) with head resting on pillow. The LPN, CNA, and 3 other peers were present. The resident denied pain, no visible signs/symptoms of injuries noted with positive range of motion to all extremities without difficulties. The resident stated that someone was in the way. IDR (interdepartmental memo) to PT for evaluation (a copy of the IDR was noted and documented that the resident was FOF (found on floor) 2 days in a row (1/4/13 and 1/5/13). The Resident Accident and Incident Report dated 1/5/13 documented that the resident was on the floor in a room. The Final Summary and Determination documented that the resident was alert with a history of wandering. The resident ambulated with supervision. The resident is on a dementia unit, ambulated ad lib through the unit with supervision and history of wandering in and out of rooms most likely bumped into another resident accidentally causing her to fall as another resident was in the way as per the resident's statements. The Progress Notes dated 2/21/13 at 6:13 PM documented that the supervisor was called to the unit to assess a fall at 4:42 PM. Upon arrival the resident was found lying on her back head up close to the wall and at the end of the hallway on the high side. The resident was wearing a pair of sneakers at the time. Staff assisted resident to the wheelchair and range of motion, pain assessment and body check completed. A slight bruise 0.5 x 2.0 cm noted in mid back vertebrae, slight redness, and no blood observed. The resident complained of pain to the head and the designated representative was notified. The resident was transferred to the hospital for evaluation. The resident was readmitted to the facility on [DATE] at 11:20 PM. The Resident Accident and Incident Report for 2/21/13 documented that the resident currently ambulates ad lib with distant supervision. On 2/21/13 a visitor witnessed the resident fall to floor and called for the nurse. The LPN responded and assessed. There are no injuries noted, resident unable to make statement due to cognitive deficit. The witness stated that she heard the resident hit her head. The nursing supervisor was notified and noted a small bruise to back, MD notified, and resident sent to the hospital for CT scan. The investigation concluded that the resident fell during ambulation due to abnormal body movement. The investigation revealed that there is no reasonable cause to believe any alleged abuse, mistreatment, or neglect regarding this resident has occurred. The investigator observed the resident ambulating freely on Unit on 3/6/13. Resident appropriately groomed. Resident is noted walking with upper body outward posture (slant) without device. Resident is non interviewable. During a telephone interview with 7-3 RN supervisor (RN#9) on 5/6/14 at 12:54 PM she stated a risk score of 13 indicates that the resident is at risk for falls but not a high risk; a fall injury care plan is initiated. Distance supervision for ambulation means that you would have to see a resident ambulating in the hallway but does not require contact guard. Have to see a resident at any given time in the hallways. During a subsequent telephone interview on 5/7/14 at 3:35 PM, RN#9 stated that PT was not indicated because the resident did not have any decline. She was not seeing objects as she was ambulating. On the unit, the resident's pathways were kept clear. She could not say what happened to 1:1 on 9/24/12 when the resident had her fall, which was in place at the time. During a telephone interview with 7-3 RN supervisor (RN#1) on 5/6/14 at 1:43 PM, she stated distant supervision would be keeping an eye on the resident as she is ambulating. During a subsequent interview with RN#1 on 5/7/14 at 1:40 PM, she stated that on 11/28/12 Resident#6 was walking in the wrap around area. The resident walked with her head up, was not aware of surroundings and would walk into things. She tripped over a chair that might have been moved by a resident. Staff should have been present to supervise area. RN#1 was not aware of the prior fall. Interventions put in place at this time was that the area would be clear of clutter. Resident Anderson fell again on 1/5/13 and a PT evaluation request was sent and as per nursing notes was performed. During a telephone interview with the Director of Physical Therapy on 5/6/14 at 3:34 PM, he stated that he did not have any record of a PT evaluation being performed for Resident#6 between 9/24/12 and 2/21/13. During a subsequent telephone interview with the Director of Physical Therapy on 5/7/14 at 4:30 PM he stated that RN#1 told him about the nursing progress note that documented a PT evaluation was done and wheelchair recommended but he could not find the actual PT evaluation. During a subsequent telephone interview with the Director of Physical Therapy on 5/21/14 at 10:16 AM, he stated that distant supervision means visual supervision as the resident is ambulating on unit. It is a dementia unit so staff is to ensure that the patient does not wander into areas they should not be in alone or in and out of other residents' rooms. 4) Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documented the resident's cognition status as severely impaired. The Fall Risk assessment dated [DATE] documented the resident as a moderate risk for falls. The Nursing Assessment/Initial Care Plan dated 5/3/12 documented interventions including to reduce environment, call bell within reach, monitor for changes in ADLs/cognition/behavior/mood/medications, attempt alternatives to prevent use of restraints, diversional activities/devices, monitor resident's activity, and floor mats for both sides. The Progress notes dated 5/5/12 at 2:09 PM documented that the RN was called to the unit where the resident was observed in the room on the floor next to Geri chair. On assessment, Passive Range of Motion to bilateral upper and lower extremities as tolerated without any signs or symptoms of discomfort. No signs or symptoms of any pain or discomfort noted at this time. The physician also examined the resident. The Comprehensive Care Plan (CCP) for falls dated 5/6/12 documented interventions including to be supervised in common area while out of bed and Rehab to evaluate resident for appropriate Geri chair. The Resident Nursing Instructions (CNA accountability) for safety dated 5/6/12 documented resident to be in a common area when out of bed. The Progress notes dated 5/23/12 at 2:31 PM documented that the RN was called to assess the resident observed on the floor in the TV room. The resident was assisted back to the wheelchair. Range of motion to all extremities with same limitations. The resident was alert, awake with no evidence of pain or acute distress. The vital signs were 120/80, P 92, R 16 and pulse oximetry of 96% on room air. The Accident/ Incident report: Final summary and determination for 1/23/14 documented that the resident was noted with an abrasion to the right knee. The resident had just finished lunch and staff transported the resident to the TV room. The resident attempted to get up and fell to the floor. Staff was disciplined for leaving the resident unattended. During a telephone interview with the Administrator on 11/22/13 at 11 AM, he stated that there was a miscommunication between two aides, each thought the other was covering and he is not sure who actually left the DR last. The CNAs were transporting residents out of the dining room for it to be cleaned so we don ' t know who was last. We identified a number of issues. There was also conflicting directions from the Supervisor. It was an honest communication error, the resident did not get hurt. During an interview with 7 AM-3 PM CNA#10 on 6/24/14 at 10:20 AM, she stated that on 5/23/12, there was a CNA assigned to do surveillance all day but could not recall her name. Surveillance took place in a TV lounge. When the assigned CNA took her breaks, the CNAs on the unit had to cover the surveillance. Surveillance means someone is always with the residents especially fall risks to ensure they are attended to. Right after lunch, there are a few minutes that residents are being transferred from dining room to TV lounge. On the assignment sheet, CNA#10 was to cover a particular time (but could not recall the time). She thought surveillance was present in the TV lounge. CNA#10 was in the dining room transporting residents. She stated that the CNA who was covering all day was also present in the dining room but she did not know if that CNA was on her break. She added that the TV room is not covered until after lunch is over. The first person to take a resident to the dining room is to stay with the resident until surveillance arrives. She could not recall who was in the TV room but stated that someone had to transport the resident there. During an interview with 7 AM-3 PM RN supervisor#13, on 6/24/14 at 11 AM, she stated that she could not specifically recall who notified her of the fall on 5/23/12 but she observed the resident on the floor in the TV room. A

Based on staff interviews and record review during an abbreviated survey, the facility did not ensure that each resident's medical care was supervised by a physician. Specifically, the attending physician did not monitor changes in the medical status for one (Resident#2) of 12 residents reviewed for physician services. Resident#2 has a physician order [REDACTED]. The resident was placed on a 100% oxygen non re-breather mask (treatment modality used in emergency situations to increase oxygenation) for approximately 3 hours while waiting for a return call from the physician. Subsequently, the resident was transferred to the hospital secondary to inability to maintain oxygen saturation. This resulted in actual harm that is not Immediate Jeopardy. Complaint#NY 076 The finding is: Resident#2 was admitted to the facility with [DIAGNOSES REDACTED]. The Facility policy titled Use of Non-Rebreathing mask during an emergency situation dated 3/09 documented the use of non-rebreathing mask is restricted to imminent life threatening situations or acute care situations in which an ambulance has been called or will be called to transport the resident to the hospital. The Minimum Data Set 3.0 ((MDS) dated [DATE] documented brief interview for mental status (BIMS) score of 15 indicating resident cognitively intact. The Admission Physician order [REDACTED]. The Admission Physician order [REDACTED]. The Interim physician order [REDACTED]. The Interim physician order [REDACTED]. The Interim Physician order [REDACTED]. The Interim Physician order [REDACTED]. The CCP dated 7/14/14 documented [DIAGNOSES REDACTED]. Interventions including monitor signs and symptoms of respiratory distress that is dyspnea (difficulty breathing), congestion, shortness of breath, wheezing and cyanosis, monitor for fatigue, encourage rest period as needed and medications as per physician's orders [REDACTED]. The Respiratory Care Flow Sheet dated 7/21/14 documented on 7/21/14 at 10:45AM, 7/21/14 at 3:41PM and 7/22/14 at 1:07PM oxygen device mode: Non re-breather at 100% oxygen. Resident on Non re-breather mask all morning due to desaturation, numbers bounce from high 100% to low 60%. Attempted nasal cannula a few times during day but resident de-saturated back to Non re-breather. Resident placed on [MEDICAL CONDITION] machine at 11:30PM saturation 67%-43%, placed back on Non re-breather mask tolerated well. The Nursing Progress Note (NPN) dated 7/21/14 at 5:46PM documented resident assessed for lethargy, noted by staff. Resident awake on Non re-breather at the time of assessment; oxygen saturation of 95%, bilateral lung fields clear on auscultation. Physician made aware of resident's condition, no new orders at this time. The NPN dated 7/21/14 at 5:53PM documented abnormal lab results reviewed with physician sputum culture and sensitivity with [MEDICAL CONDITION] Resistant Staphylococcus Aurous (MRSA), orders received to start [MEDICATION NAME] 100 mg orally every 12 hours for 7 days. The NPN dated 7/22/14 at 3:41AM documented resident alert and responsive to both verbal and tactile stimuli, resident currently on non re-breather on 15 liter per minute. Respiratory rate of 20/minute and oxygen saturation of 99%, not in respiratory distress at this time. Physician aware of current situation and ordered resident to be transferred to hospital for further evaluation. The NPN dated 7/22/14 at 5:19AM documented at approximately 9:39PM (7/21/14) resident was on Non re-breather mask, resident oxygen saturation noted to fluctuate from 75%-93% when resident removes oxygen mask. At approximately 11:00PM (on 7/21/14) resident placed on Bi-PAP, by 11:45PM (on 7/21/14) noted to have de-saturated. Respiratory was aware and provided resident with breathing treatments. This nurse called the designated representative to make aware of resident's condition and possible transfer to the hospital secondary to resident's inability to maintain a normal oxygen saturation, voice mail message left. Physician called, message left on voicemail. Desaturation continued even when oxygen mask left in place. Physician called again and made aware of resident's condition and ordered to send resident to hospital secondary to resident's inability to maintain normal oxygen saturation. Resident left to hospital at 3:30AM. The Patient Transfer/Intake Form dated 7/22/14 at 3:07AM documented transfer reason Resident unable to maintain normal oxygen level. The Respiratory Therapy Progress Note dated 7/22/14 at 3:51AM documented that at 11:15PM resident placed on [MEDICAL CONDITION], resident's oxygen saturation decreased to 67% to 43%. After two attempts respiratory treatments given and nasal cannula connected. Oxygen saturation 90% and 88%, resident placed back on Non re-breather at 15 liter per minute oxygen tolerated well with no acute respiratory distress noted. The hospital emergency department physician's note dated 7/23/14 at 00:15 documented that the resident presented in respiratory distress, markedly hypoxic, distressed and anxious. The resident had gradual response to nebs and [MEDICAL CONDITION], lung exam notable for decreased breath sounds at left base and inspiratory rales right lung and midfield left lung. CXR and BNP c/w acute [MEDICAL CONDITIONS]. The patient received IV [MEDICATION NAME], MICU consulted for inability to tolerate coming off [MEDICAL CONDITION]. During an interview with 7:00AM-7:00PM Registered Nurse (RN#1) on 7/23/14 at 12:15PM, RN#1 stated that the respiratory department is responsible for respiratory issues including [MEDICAL CONDITION]. A specific order is required for Non re-breather unless used in an emergency. RN#1 was not sure regarding use of [MEDICAL CONDITION]. A subsequent interview with RN#1 was conducted on 8/7/14 at 10:30AM, RN#1 stated that a Non re-breather was used for Resident#2 for a short period of time during her shift; RN#1 could not clarify short period. She spoke with the primary care physician (PCP) on 7/21/4 and notified him of Resident#2's lethargy and respiratory issues of drop in oxygen saturation. RN#2 could not recall if she specifically notified physician of Resident#2 using the Non re-breather to maintain the oxygen saturation. During an interview with the Respiratory Therapist (RT#1) 7:00PM-7:00AM on 7/28/14 at 1:26PM, RT#1 stated that Resident#2 kept on de-saturating to 43% on [MEDICAL CONDITION] on maximum available oxygen. She had to be placed on 100% Non re-breather. The Non re-breather was kept on Resident#2 for approximately 3-4 hours. Physician was notified at approximately 11:00-12:00AM, RT#2 could not recall if the physician gave any new orders. RT#2 further stated that a physician's orders [REDACTED]. During an interview with the Primary Care Physician (PCP) on 8/4/14 at 11:50AM, the PCP stated that the Nurse Practitioner (NP) was on call and he believed that the facility staff was in contact with the NP. The PCP further stated that 100% Non re-breather is for emergency use and should not be used as a long standing treatment modality. During an interview with the NP on 8/4/14 at 12:50PM, the NP stated that the Non re-breather should be used in emergency, it was not appropriate to use a Non re-breather for 3-4 hours. She did not recall receiving any call from the facility staff on 7/21/14 or 7/22/14 regarding use of Non re-breather. The NP stated that if she would have received a call she would have sent the resident out to a higher level of care for evaluation as Resident#2 was not on comfort care. During an interview with the Registered Nurse Supervisor (RNS) on 8/6/14 at 10AM, the RNS stated that Resident#2 had an order for [REDACTED]. All options were exhausted prior to using the Non re-breather. The RNS stated that the Non re-breather should not be used for a long time as a treatment modality, he further stated that he was not aware as to how long Resident#2 was on 100% Non re-breather mask. During an interview with the Acting Director of Respiratory Therapy (ADRT) on 8/6/14 at 12:30PM, the ADRT stated that a Non re-breather could be used as a temporary resource for oxygenation until resident reaches a desired level of oxygen saturation. Non re-breather mask was used for Resident#2 for couple of minutes. Three to four hours on a Non re-breather is a long time, the ADRT further stated that the physician should have been called and resident should have been sent out to the hospital for evaluation if she needed the Non re-breather mask for 3-4 hours. 415.15(b)(1)(i)(ii)

Based on staff interviews and record review during an abbreviated and partial extended survey the Medical Director failed to ensure that the facility provided proper respiratory treatment and care. Specifically, the Medical Director failed to ensure the coordination of medical care related to staff competency for ventilator alarm response. Additionally, the Medical Director failed to ensure that policies and procedures were implemented related to ventilator maintenance This resulted in the potential for widespread harm that is Immediate Jeopardy. Complaint Number: NY 936 Cross References: F328 - Special Needs F490 - Administration F520 - Quality Assessment and Assurance The findings are: The Policy and Procedure on Ventilator Equipment Maintenance dated 4/6/09 documented that it is the policy of the facility that all mechanical ventilators are maintained in proper working order and a master list of ventilators including serial number and next scheduled preventative maintenance date is maintained by the Director of Respiratory Therapy. If a ventilator is removed from service the Respiratory Therapist updates the Ventilator Tracking Log listing the resident's name, room number and ventilator serial number. There was no documented evidence of consistent ventilator tracking. The Policy and Procedure on Ventilator Alarm Monitor System Response dated 8/10 documented that, after a six second delay, if the ventilator alarm continues to sound it is transmitted both as an audible alarm and visual display that will appear at the designated workstations and pagers. The Policy and Procedure on Communication System Protocol via Walkie Talkie Radios dated 8/10 documented that Nurses and Respiratory therapists are encouraged to communicate with each other via walkie talkie radio regarding their availability or unavailability to respond to a specific alarm. The Policy and Procedure on Alarm System and Peripherals dated 10/11 documented that it is the responsibility of the Respiratory and Nursing Staff assigned to respond to the alarms to investigate the cause and implement corrective action when necessary. An interview was conducted with the Medical Director (MD) on 7/29/14 at 2:04 PM. The MD stated that he is not a pulmonologist and cannot answer regarding the meaning of certain alarms on the vent unit. The MD further stated that there has been no QA regarding respiratory/ventilator issues and no new policy or policy revisions regarding respiratory/ventilator issues. The MD phoned back minutes later to say that there is a new policy for tracking ventilators and communicating this with the Administrator. 415.15 (a)

Based on observation, staff interviews and record review during an abbreviated and partial extended survey the facility failed to ensure that residents received proper respiratory treatment and care. The facility failed to effectively implement its system for prompt response to ventilator alarms. Specifically, one (Resident #1) of 11 ventilator-dependent residents reviewed was triggering several ventilator alarms to which staff did not respond. The individual charged with monitoring the panel at the nurses' station did not transmit the alarm to staff over the walkie-talkies and the individuals designated to respond did not do so when their pagers activated. Facility response was initiated only after a Respiratory Therapist (RT) happened by a hall monitor, noticed the visual alarm and intervened. The resident subsequently became unresponsive, was unable to be revived and died . The facility further failed to have a system in place to identify, monitor and track ventilator maintenance. This resulted in actual harm to Resident #1 and the potential for widespread serious harm that is Immediate Jeopardy and Substandard Quality of Care. Complaint Number: NY 936 The findings are: The Policy and Procedure on Ventilator Equipment Maintenance dated [DATE] documented that it is the policy of the facility that all mechanical ventilators are maintained in proper working order and a master list of ventilators including serial number and next scheduled preventative maintenance date is maintained by the Director of Respiratory Therapy. If a ventilator is removed from service the Respiratory Therapist updates the Ventilator Tracking Log listing with the resident's name, room number and ventilator serial number. There was no documented evidence of consistent ventilator tracking. The Policy and Procedure on Alarm Equipment Maintenance dated ,[DATE] documented that audibility of alarms on all laptop monitors are to be audible at all times. The Policy and Procedure on Ventilator Alarm Monitor System Response dated ,[DATE] documented that, after a six second delay, if the ventilator alarm continues to sound it is transmitted both as an audible alarm and visual display that will appear at the designated workstations and pagers. The Policy and Procedure on Communication System Protocol via Walkie Talkie Radios dated ,[DATE] documented that Nurses and Respiratory therapists are encouraged to communicate with each other via walkie talkie radio regarding their availability or unavailability to respond to a specific alarm. The Policy and Procedure on Alarm System and Peripherals dated ,[DATE] documented that it is the responsibility of the Respiratory and Nursing Staff assigned to respond to the alarms to investigate the cause and implement corrective action when necessary. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (an assessment tool) dated [DATE] documented that Resident #1's cognition was severely impaired. The Alarm List Settings dated [DATE] documented that a High Inspiratory Pressure alarm is audible to the workstation and no pager alert is sent. The Ventilator Company Customer Service Report (VCCSR) dated [DATE] documented that, on [DATE], Resident #1's ventilator failed annual preventative maintenance; exhalation flow sensor replaced. The Comprehensive Care Plan (CCP) for Ventilator Disconnect effective [DATE] documented that Resident #1 was at risk for ventilator disconnect. The CCP for Respiratory effective [DATE] documented that Resident #1 would be free from signs/symptoms of respiratory distress by monitoring for signs/symptoms of respiratory distress; i.e. dyspnea, congestions, shortness of breath, wheezing, cyanosis. The unsigned VCCSR dated [DATE] documented that, on [DATE], Resident #1's ventilator shut down and restarted multiple times. Customer reported problem cannot be duplicated; Replaced CPU (central processing unit) as a preventive measure. The unsigned VCCSR dated [DATE] documented that, on [DATE], Resident #1's ventilator was in clinical use and kept shutting down; corrective maintenance was performed. The Respiratory Cardex/Care Plan dated [DATE] and updated [DATE] documented to maintain Resident #1's current ventilator settings. The Alarm Log of Events Report (ALER) dated [DATE] documented that High Inspiratory Pressure alarms were sounded at 3:22:28 PM, 3:23:08 PM, 3:25:38 PM and 3:44:48 PM. The ALER dated [DATE] documented that "The Displayed Data for Esprit - CB32 is not current" alarms sounded at 3:46:08 PM, 3:46:38 PM, 3:47:08 PM and 3:47:38 PM. The Pager Alert Log dated [DATE] documented that pages were sent to Pager 101 and Pager 102 at 3:46:08 PM, 3:46:38 PM, 3:47:08 PM, 3:47:38 PM, 3:47:39 PM, 3:48:08 PM, 3:48:09 PM and 3:48:25 PM. The Daily CNA (Certified Nursing Assistant) Assignment dated [DATE] documented that RN #3 was assigned to the alarm monitor from 3:30 PM to 7:00 PM. The 30 Minute Safety Rounds Form for 3:00 PM to 11:00 PM dated [DATE] documented that the 3:30 PM rounds were done at 3:00 PM for Resident #1, who was in her chair. The Nursing Progress Notes (NPN) dated [DATE] (written by a Registered Nurse (RN)) documented that Resident #1 was found with no current vent data. RT responded to call and found patient in respiratory distress. RNS made aware. I was told to call a rapid response which I did and all nursing staff responded to room [ROOM NUMBER]. Doctor notified and he notified designated representative of expiration. The NPN dated [DATE] (written by a RN) documented that RN #4 responded to a rapid response called at 3:47 PM. The resident was being manually ventilated by the RT. It was noted that the resident is a DNR (Do Not Resuscitate). I was unable to determine a pulse; unable to determine the blood pressure. RNS arrived. I waited for the EMTs (Emergency Medical Technician) to arrive while trying to retake the vital signs. The NPN dated [DATE] (written by a Registered Nurse Supervisor (RNS)) documented that this nurse responded to rapid response at 3:45 PM. Resident appeared bluish grey but regained pink color after a short while, eyes open and small amount of foam at the mouth. Doctor notified, order received to transfer resident to hospital; 911 called. Order transfer cancelled as Wishes for Care in place - no hospitalization , DNR in place. Resident asystole at 4:48 PM. RT disconnected the vent. The Respiratory Therapy Notes (RTN) dated [DATE] (written by a RT) documented that, while RT #4 was at the nurse's station at about 3:45 PM, RT #3 called her into the resident's room. I went immediately and found (RT #3) ambuing resident who was cyanotic. I checked for a pulse and could feel nothing. I called a rapid response. We continued to ambu but resident never regained consciousness. EMS (Emergency Medical Services) was called. EMS did have a slow pulse and low sat on their monitor. They stayed until she had no more pulse. Meanwhile I switched out the vent because she did have a pulse and put her on her settings. The RTN dated [DATE] (written by a RT) documented a late entry for [DATE] that RT #3 responded to "No Current Vent Data" alarm in resident's room. Upon entering the room, I found the resident cyanotic, verbally responsive yelling "Help me." I also found the vent not functioning with the words "vent inop" on the ventilator screen. I immediately called for another respiratory therapist, suctioned the resident and started ambuing on 100% O2 (oxygen). The resident appeared to gain some color back as another respiratory therapist was in the process of switching out her vent. The resident again went cyanotic and unresponsive and a rapid response was called. Nursing could not palpate a pulse or obtain a BP (blood pressure). The resident was a DNR. When EMS arrived, I left the room to respond to a call for another resident. The Certificate of Death dated [DATE] documented that Resident #1 was pronounced at 4:48 PM with an immediate cause of death as [MEDICAL CONDITION] and an unknown interval between onset and death. The Investigation Report dated [DATE] documented that all evidence indicates staff followed facility policy and procedure in alarm monitoring, response to alarms and rapid response. The investigation revealed that there is insufficient evidence to determine that abuse, neglect or mistreatment has occurred. During an observation of the Unit 1C nursing station alarm monitor on [DATE] at 10:54 AM a High Inspiratory Pressure alarm sounded and visually lit up in red four consecutive times for room [ROOM NUMBER]. The concierge assigned to view the monitor did not announce the alarms. An observation of room [ROOM NUMBER] revealed that no staff was in the room attending to the residents. An interview was conducted with the Unit 1 C Concierge #1 on [DATE] at 10:55 AM. Concierge #1 stated that, when an alarm shows on the monitor for about ten seconds, she will announce the alarm over the walkie talkie. If the alarm keeps coming up on the monitor, it should definitely be announced. Concierge #1 was unable to say why she did not announce the four High Inspiratory Pressure alarms for room [ROOM NUMBER]. An interview was conducted with an 11:00 PM to 7:00 AM Registered Nurse Supervisor (RNS #1) on [DATE] at 11:16 AM. RNS #1 stated that, if any alarm appears on the monitor at the nursing station, it should be immediately announced by the concierge. RNS #1 stated that an alarm that repeats itself means that "there is a problem with a resident and, if it keeps on repeating, a resident probably needs to be suctioned." RNS #1 further stated that she cannot remember the last time staff was in-serviced regarding ventilator or respiratory issues. An interview was conducted with a 7:00 AM to 7:00 PM Respiratory Therapist (RT #3) on [DATE] at 12:25 PM. RT #3 stated that she was not the assigned RT to Resident #1 but, after finishing care for another resident on [DATE] around 3:45 PM, RT #3 came out of another room, glanced at the hallway monitor outside room [ROOM NUMBER] and saw "No Current Vent Data" for Resident #1's room. RT #3 stated that there were no alarms sounding and she had not heard a page to her beeper or on the walkie talkie. RT #3 stated that she went to the resident's room and, upon entering the room, Resident #1 was yelling, "Help Me." She heard a "buzzing from the vent; it's the sound a vent makes when it's shutting down." RT #3 stated that "Vent InOp" was on the screen of the vent, meaning vent inoperable. Resident #1 was cyanotic and RT #3 started to ambu the resident and called for RT #4, who responded and went out of the room to get another ventilator. When RT #4 returned with another ventilator, the resident cringed, turned cyanotic again and went completely unresponsive. RT #4 called out for a Rapid Response over her walkie talkie and 911 arrived a few minutes later. RT #3 left the room when 911 arrived to respond to another resident. RT #3 stated that she is not aware of any previous problems with Resident #1's ventilator; "vents are switched in and out of rooms all the time for maintenance. I'm not made aware of any issue." RT #3 further stated that, if any alarm for a resident is repeated, the alarm should be announced so a resident could be assessed. "We don't get High Pressure alarms to our beepers. We used to but a couple of years ago the facility stopped that." During a subsequent interview with RT #3 on [DATE] at 2:06 PM RT #3 stated that, on [DATE], she first noticed a "No Current Vent Data" alarm on the hallway monitor. "I didn't hear any pages. I saw it first on the monitor and then, when I got to the room, the vent itself was buzzing. Buzzing only makes that noise when the vent shuts down. It's not an alarm." An interview was conducted with the 7:00 AM to 7:00 PM charge RN #3 on [DATE] at 3:11 PM. RN #3 stated that, on [DATE], she was alone at the nursing desk due to a staff shortage on the unit and was covering watching the alarm monitor as well as her charge nurse duties. RN #3 stated that, sometime around 3:45 PM, she heard someone saying, 'Someone call Rapid Response.' RN #3 stated that she looked at the alarm monitor and announced a 'Rapid Response' and 'No Current Vent Data' simultaneously to Resident #1's room. She remained at the nursing desk and was not able to go to the room until after 911 arrived. RN #3 stated that the resident was a DNR (Do Not Resuscitate) so CPR (Cardiopulmonary Resuscitation) was not done. RN #3 stated that, if an alarm stays on the monitor over 30 seconds, she will announce the alarm via walkie talkie. RN #3 stated that there is not always a way to know if staff has responded to an announced alarm because "they don't all tell that they're going (to respond)." RN #3 further stated that she is not aware of any prior issue or concern regarding Resident #1's ventilator; "I wouldn't know. If there's an issue, Respiratory takes care of it." During a subsequent interview with RN #3 on [DATE] at 3:00 PM RN #3 stated that, on [DATE], she announced a 'Rapid Response' and 'No Current Vent Data' to Resident #1's room; "both of those were simultaneous." RN #3 stated that she did not hear, see or announce any alarms prior to that. RN #3 further stated that she was the charge nurse that afternoon and there was a shortage of CNAs, so RN #3 had to watch the alarm monitor as well as tending to charge nurse duties including CNA assignments, physician's orders [REDACTED]. An interview was conducted with a 3:00 PM to 11:00 PM CNA #1 on [DATE] at 4:09 PM. CNA #1 stated that, on [DATE], she did the 3:30 PM 30-minute safety rounds early, shortly after 3:00 PM and did not see Resident #1 again until after the Rapid Response. CNA #1 stated that there is no specific staff that must do 30-minute safety rounds; "we kind of just do it-whoever is available, whoever is free." CNA #1 stated that she sometimes covers the alarm monitor at the nursing desk and her job is to call out an alarm on the walkie talkie if it is beeping more than 30 seconds. An interview was conducted with the assigned 7:00 AM to 7:00 PM RT #4 on [DATE] at 10:16 AM. RT #4 stated that she was near the nursing desk when she heard RT #3 call her to Resident #1's room. When RT #4 entered the room, RT #3 was ambuing Resident #1, who looked blue. RT #4 stated that she could not obtain a pulse and called for a Rapid Response. RT #4 went to get another ventilator. The resident was a DNR. 911 arrived and was picking up an electrical reading on their monitor, so the resident was hooked up to the new ventilator; 911 remained with the resident until she flatlined and was pronounced. RT #4 stated that she did not hear any pages to her beeper or announcements regarding Resident #1 until RT #3 called her to the resident ' s room. RT #4 stated that, when she called for a Rapid Response, an announcement over the walkie talkie came at the same time for 'Rapid Response' and 'No Current Vent Data.' RT #4 stated that she will rely on the beeper only if it starts beeping a lot, because "when you look at the beeper, you have so many pages that you don't really know exactly which got beeped. I rely more on the person announcing and the screen; if you look at the beeper constantly, you wouldn't get anything done." RT #4 further stated that she believes all alarms go to the beeper as well as being announced from the nursing desk. RT #4 stated that she couldn't say whether or not Resident #1's ventilator had previous issues because "I don't notice which vent fails. I believe the head of the department keeps track of that." An interview was conducted with a 7:00 AM to 7:00 PM RN #4 on [DATE] at 11:01 AM. RN #4 stated that he was at the nursing station in the back room on [DATE] at the time the Rapid Response for Resident #1 was called. RN #4 stated that he had his walkie talkie with him and no pages were made until the Rapid Response to which RN #4 responded. RN #4 stated that he tried to obtain a pulse and blood pressure but could not; Resident #1 became unresponsive and EMS arrived. RN #4 stated that he would not have received any beeper pages because Resident #1 was not in his district but RN #4 receives every other page over the walkie talkie. RN #4 further stated that he receives High Inspiratory Pressure alarms to his beeper and, if one of his residents had this alarm, he would have to check on that resident to see if there were any secretions. An interview was conducted with the assigned 7:00 AM to 7:00 PM RN #5 on [DATE] at 11:37 AM. RN #5 stated that, around 3:30 PM on [DATE], she was doing a treatment [MEDICAL CONDITION] on another resident. As she finished, RN #5 heard a 'No Current Vent Data' and 'Rapid Response' at the same time paged on the walkie talkie. RN #5 stated that she had not heard any pages prior to this and did not hear a page to her beeper, but, after the Rapid Response was over, RN #5 saw a page of 'No Current Vent Data' on her beeper. RN #5 stated that she had never heard any alarms prior to the Rapid Response. RN #5 stated that she would not know of any prior issues with a resident's ventilator because Respiratory takes care of ventilator issues. RN #5 stated that Resident #1 sometimes triggered a High Inspiratory Pressure alarm when she would be talking but "it (High Inspiratory Pressure alarm) could also mean she needed suctioning." RN #5 stated that High Inspiratory Pressure alarms go to her beeper but she waits to receive a second beep and then will go in to check on a resident. An interview was conducted with the Alarm Company Chief Technical Officer (ACCTO) on [DATE] at 1:06 PM. The ACCTO stated the facility has chosen not to have High Inspiratory Pressure alarms go to the pagers, so there is no High Inspiratory Pressure alarms in the pager log. The ACCTO stated that, according to the alarm log, Resident #1's ventilator alarm was going on and off a few times prior to losing current vent data. An interview was conducted with the Ventilator Company Service Specialist (VCSS) on [DATE] at 2:35 PM. The VCSS stated that there is no point when the company will say that a ventilator should come out of service since this decision is up to the facility. The VCSS stated that Resident #1's ventilator is no longer in production but parts are available until 2016. The VCSS stated that the company provides annual maintenance on the ventilators and any interim maintenance the facility reports. During an observation of the video surveillance for [DATE] Unit 1C nursing desk (server #2) on [DATE] at 3:00 PM the Director of Plant Operations stated that server #2 shows the accurate time. The Director of Nursing identified staff in the video. The video records the following: -From 3:22 PM to 3:25 PM RN #3, LPN #1 and RN #7 are behind the nursing desk; no staff is observed to use the walkie talkie or phone to make an announcement. (The Alarm Log of Events dated [DATE] documents that High Inspiratory Pressure alarms sounded for Resident #1 at 3:22:28 PM, 3:23:08 PM and 3:25:38 PM.) -From 3:44 PM to 3:45 PM RN #3 is sitting behind the nursing desk in front of the alarm monitor with head down writing. (The Alarm Log of Events dated [DATE] documents that a High Inspiratory Pressure alarm sounded for Resident #1 at 3:44:48 PM.) -From 3:46 PM to 3:49 PM RN #3 is sitting behind the nursing desk with head down writing. (The Alarm Log of Events dated [DATE] documents that 'The Displayed Data for Esprit-CB32 is not current' alarms sounded for Resident #1 at 3:46:08 PM, 3:46:38 PM, 3:47:08 PM, 3:47:38 PM, 3:47:39 PM, 3:48:08 PM and 3:48:09 PM.) (The Alarm Log of Events dated [DATE] documents that a 'No Current Vent Data' alarm sounded for Resident #1 at 3:48:26 PM.) -At 3:52 PM RN #3 is seen using the walkie talkie. The Director of Nursing stated that this is when RN #3 is calling a Rapid Response. An interview was conducted with the Acting Director of Respiratory Therapy (ADRT) on [DATE] on 4:01 PM. The ADRT stated that she does not call the ventilator company for maintenance and relies on the company to call her. "We don't keep a log of which vents were failing. The company was coming; that was their responsibility." The ADRT stated that she doesn't ever remember keeping a tracking log of the ventilators whether in service or not. The company sends a service report; "I have to admit, I'm so busy I really don't read them." The ADRT stated that she is not aware of any policy regarding what to do when a ventilator is not functioning properly. The ADRT stated that she does not know who decided what alarms should go to the pagers. She stated that the most important alarms to announce is when a resident is disconnected from a ventilator, if there is no vent data or if the vent data is not current because "you don't know what's going on; the patient should be assessed instantly. A High Inspiratory Pressure alarm means the patient may need to be suctioned." The ADRT stated that Respiratory in-services new staff to the unit but there is no ongoing in-services. An interview was conducted with the assigned 3:00 PM to 11:00 PM CNA #2 on [DATE] at 5:00 PM. CNA #2 stated that, on [DATE], she last saw Resident #1 around 3:07 PM sitting in her chair. The next time she saw the resident was after a Rapid Response was called. CNA #2 stated, "Prior to the Rapid Response, I didn't hear any alarms or page for her (Resident #1)." CNA #2 stated that all residents on unit 1C are on 30-minute rounds and "anybody that works on the floor does it; if you're free, you just do it. It's not like it's anything specific." CNA #2 further stated that she covers the nursing desk alarm monitor at times and is supposed to call a page on the walkie talkie if an alarm comes up on the monitor; "it depends on the person (staff) sometimes. We have up to 30 seconds or a minute, but, if it (alarm) keeps coming up, then you page." An interview was conducted with the 3:00 PM to 11:00 PM RNS #2 on [DATE] at 5:58 PM. RNS #2 stated that, on [DATE], she responded to a Rapid Response to Resident #1's room and was told by staff that the resident ' s ventilator went inoperable. The resident was a DNR and 911 stayed with the resident until she expired; RNS #2 pronounced the resident at 4:48 PM. RNS #2 stated that all residents on "30-minute monitoring rounds have to stay with the patient physically at all times or the patient should be moved to a central area where they can be watched and then you just keep logging it." RNS #2 stated that every nurse carries a beeper and "any alarm that comes on the screen (monitor) gets a page on the beeper." RNS #2 stated that a staff member is constantly looking at the alarm monitor at the nursing desk. RNS #2 insisted that, on [DATE], unit 1C was fully staffed with six CNAs. She left the interview and returned to say, "I was mistaken. We were short-staffed." An interview was conducted with the Risk Manager (RM) on [DATE] at 9:50 AM. The RM stated that she completed the investigation into the incident of [DATE] with Resident #1 but the investigation is still ongoing. The RM stated that Resident #1's ventilator "should have been taken out of circulation long before this event. I don ' t know any purpose for moving residents from vent to vent. They shouldn't even for infection control issues." The RM stated that she did not use video surveillance for her investigation of the [DATE] incident and approximated times on the investigation based on assumptions. The RM further stated that there has been no QA (quality assurance) that she can remember regarding respiratory and ventilator issues. An interview was conducted with the Attending Physician (AP) on [DATE] at 10:36 AM. The AP stated that a High Inspiratory Pressure alarm signifies a respiratory abnormality to which staff should go and check on a patient. The AP further stated that he coordinates the medical and clinical care but is never informed about any technical issues regarding ventilators. An interview was conducted with the Medical Director (MD) on [DATE] at 2:04 PM. The MD stated that he is not a pulmonologist and cannot answer regarding the meaning of certain alarms on the vent unit. The MD further stated that there has been no QA regarding respiratory/ventilator issues and no new policy or policy revisions regarding respiratory/ventilator issues. The MD phoned back minutes later to say that there is a new policy for tracking ventilators and communicating this with the Administrator. An interview was conducted with the Director of Nursing (DON) on [DATE] at 4:13 PM. The DON stated that she was made aware of Resident #1's death and inoperable ventilator on the evening of [DATE] by RNS #2. The DON stated that, on [DATE], RN #3 was alone at the desk to monitor alarms but also had other charge nurse duties. The DON stated that Respiratory decides when not to use a ventilator and she believes only a one-time problem with a ventilator is enough to take it out of circulation, but there has been no tracking of the ventilators. The DON stated that she is not aware of who sets alarms to go to pagers and has never had any contact with the alarm company. The DON further stated that she is not aware of any issue regarding 30-minute safety monitoring. During an observation of Unit 1C on [DATE] at 9:50 AM the low side hallway alarm monitor by room [ROOM NUMBER] was not audible while alarms were observed on the monitor. An interview was conducted with the 7:00 AM to 7:00 PM charge RN #6 on [DATE] at 10:00 AM. RN #6 stated that he does not know why the low side hallway monitor is not audible, because "all monitors are supposed to be audible." An interview was conducted with the Administrator on [DATE] at 12:00 Noon. The Administrator stated that he became aware of the incident with Resident #1 and an inoperable ventilator on [DATE]. The Administrator stated that there had been no consistent tracking of ventilators among residents; he created a tracking record for ventilator serial numbers assigned to each resident. The Administrator stated that Respiratory is responsible for logging ventilator service records and he counts on the ventilator company to ensure that a ventilator has been serviced. The Administrator further stated that certain alerts such as the High Inspiratory Pressure alarm were removed from the pager several years ago to free up space for other alerts to be communicated faster. 415.12(k)(6)

Based on staff interviews and record review during an abbreviated and partial extended survey it was determined that the administration failed to ensure that each resident reached and maintained the highest practicable physical, mental and psychosocial well-being. Specifically, the Administration failed to effectively implement a system and ensure staff competency for prompt ventilator alarm response; failed to have a system in place to identify, monitor and track ventilator maintenance. Additionally, the Administration failed to conduct a thorough investigation to determine the root cause of an incident. This resulted in actual harm to Resident #1 and the potential for widespread serious harm that is Immediate Jeopardy. Complaint Number: NY 936 Cross References: F328 - Special Needs F501 - Medical Director F520 - Quality Assessment and Assurance The findings are: The Policy and Procedure on Ventilator Equipment Maintenance dated 4/6/09 documented that it is the policy of the facility that all mechanical ventilators are maintained in proper working order and a master list of ventilators including serial number and next scheduled preventative maintenance date is maintained by the Director of Respiratory Therapy. If a ventilator is removed from service the Respiratory Therapist updates the Ventilator Tracking Log listing the resident's name, room number and ventilator serial number. There was no documented evidence of consistent ventilator tracking. The Policy and Procedure on Ventilator Alarm Monitor System Response dated 8/10 documented that, after a six second delay, if the ventilator alarm continues to sound it is transmitted both as an audible alarm and visual display that will appear at the designated workstations and pagers. The Policy and Procedure on Alarm System and Peripherals dated 10/11 documented that it is the responsibility of the Respiratory and Nursing Staff assigned to respond to the alarms to investigate the cause and implement corrective action when necessary. The Ventilator Company Customer Service Report (VCCSR) dated 2/18/14 documented that, on 2/17/14, Resident #1's ventilator failed annual preventative maintenance; exhalation flow sensor replaced. The unsigned VCCSR dated 5/7/14 documented that, on 5/5/14, Resident #1's ventilator shut down and restarted multiple times. Customer reported problem cannot be duplicated; Replaced CPU (central processing unit) as a preventive measure. The unsigned VCCSR dated 7/11/14 documented that, on 7/9/14, Resident #1's ventilator was in clinical use and kept shutting down; corrective maintenance was performed. An interview was conducted with the Acting Director of Respiratory Therapy (ADRT) on 7/25/14 on 4:01 PM. The ADRT stated that she does not call the ventilator company for maintenance and relies on the company to call her. "We don't keep a log of which vents were failing. The company was coming; that was their responsibility." The ADRT stated that she doesn't ever remember keeping a tracking log of the ventilators whether in service or not. The company sends a service report; "I have to admit, I'm so busy I really don't read them." The ADRT stated that she is not aware of any policy regarding what to do when a ventilator is not functioning properly. The ADRT stated that she does not know who decided what alarms should go to the pagers. The ADRT further stated that Respiratory in-services new staff to the unit but there is no ongoing in-services. An interview was conducted with the Risk Manager (RM) on 7/29/14 at 9:50 AM. The RM stated that she completed the investigation into the incident of 7/20/14 with Resident #1 but the investigation is still ongoing. The RM stated that Resident #1's ventilator "should have been taken out of circulation long before this event. I don ' t know any purpose for moving residents from vent to vent. They shouldn't even for infection control issues." The RM stated that she did not use video surveillance for her investigation of the 7/20/14 incident and approximated times on the investigation based on assumptions. The RM further stated that there has been no QA (quality assurance) that she can remember regarding respiratory and ventilator issues. An interview was conducted with the Medical Director (MD) on 7/29/14 at 2:04 PM. The MD stated that he is not a pulmonologist and cannot answer regarding the meaning of certain alarms on the vent unit. The MD further stated that there has been no QA regarding respiratory/ventilator issues and no new policy or policy revisions regarding respiratory/ventilator issues. The MD phoned back minutes later to say that there is a new policy for tracking ventilators and communicating this with the Administrator. An interview was conducted with the Director of Nursing (DON) on 7/29/14 at 4:13 PM. The DON stated that she was made aware of Resident #1's death and inoperable ventilator on the evening of 7/20/14 by RNS #2. The DON stated that, on 7/20/14, RN #3 was alone at the desk to monitor alarms but also had other charge nurse duties. The DON stated that Respiratory decides when not to use a ventilator and she believes only a one-time problem with a ventilator is enough to take it out of circulation, but there has been no tracking of the ventilators. The DON stated that she is not aware of who sets alarms to go to pagers and has never had any contact with the alarm company. The DON further stated that she is not aware of any issue regarding 30-minute safety monitoring. An interview was conducted with the Administrator on 7/30/14 at 12:00 Noon. The Administrator stated that he became aware of the incident with Resident #1 and an inoperable ventilator on 7/20/14. The Administrator stated that there had been no consistent tracking of ventilators among residents; he created a tracking record for ventilator serial numbers assigned to each resident after the incident. The Administrator stated that Respiratory is responsible for logging ventilator service records and he counts on the ventilator company to ensure that a ventilator has been serviced. The Administrator further stated that certain alerts such as the High Inspiratory Pressure alarm were removed from the pager several years ago to free up space for other alerts to be communicated faster. 415.26

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 identified system failures pertaining to ventilator maintenance and prompt response by designated staff to ventilator alarms. Specifically, the Quality Assessment and Assurance (QAA) Committee failed to thoroughly review and evaluate the sequence of events preceding the death of Resident #1 to identify system failures. This resulted in the potential for widespread harm that is Immediate Jeopardy. Complaint Number: NY 936 Cross References: F328 - Special Needs F490 - Administration F501 - Medical Director The findings are: The Policy and Procedure on Ventilator Equipment Maintenance dated 4/6/09 documented that it is the policy of the facility that all mechanical ventilators are maintained in proper working order and a master list of ventilators including serial number and next scheduled preventative maintenance date is maintained by the Director of Respiratory Therapy. If a ventilator is removed from service the Respiratory Therapist updates the Ventilator Tracking Log listing the resident's name, room number and ventilator serial number. There was no documented evidence of consistent ventilator tracking. The Policy and Procedure on Alarm Equipment Maintenance dated 8/10 documented that audibility of alarms on all laptop monitors are to be audible at all times. The Policy and Procedure on Ventilator Alarm Monitor System Response dated 8/10 documented that, after a six second delay, if the ventilator alarm continues to sound it is transmitted both as an audible alarm and visual display that will appear at the designated workstations and pagers. The Policy and Procedure on Communication System Protocol via Walkie Talkie Radios dated 8/10 documented that Nurses and Respiratory therapists are encouraged to communicate with each other via walkie talkie radio regarding their availability or unavailability to respond to a specific alarm. The Policy and Procedure on Alarm System and Peripherals dated 10/11 documented that it is the responsibility of the Respiratory and Nursing Staff assigned to respond to the alarms to investigate the cause and implement corrective action when necessary. An interview was conducted with the Acting Director of Respiratory Therapy (ADRT) on 7/25/14 on 4:01 PM. The ADRT stated that she does not call the ventilator company for maintenance and relies on the company to call her. "We don't keep a log of which vents were failing. The company was coming; that was their responsibility." The ADRT stated that she doesn't ever remember keeping a tracking log of the ventilators whether in service or not. The company sends a service report; "I have to admit, I'm so busy I really don't read them." The ADRT stated that she is not aware of any policy regarding what to do when a ventilator is not functioning properly. The ADRT stated that she does not know who decided what alarms should go to the pagers. The ADRT stated that Respiratory in-services new staff to the unit but there is no ongoing in-services. An interview was conducted with the Risk Manager (RM), who was involved in the Quality Assurance team, on 7/29/14 at 9:50 AM. The RM stated that she completed the investigation into the incident of 7/20/14 with Resident #1 but the investigation is still ongoing. The RM stated that Resident #1's ventilator "should have been taken out of circulation long before this event. I don't know any purpose for moving residents from vent to vent. They shouldn't even for infection control issues." The RM stated that she did not use video surveillance for her investigation of the 7/20/14 incident and approximated times on the investigation based on assumptions. The RM further stated that there has been no QA (quality assurance) that she can remember regarding respiratory and ventilator issues. An interview was conducted with the Medical Director (MD) on 7/29/14 at 2:04 PM. The MD stated that there has been no QA regarding respiratory/ventilator issues and no new policy or policy revisions regarding respiratory/ventilator issues. The MD phoned back minutes later to say that there is a new policy for tracking ventilators and communicating this with the Administrator. An interview was conducted with the Director of Nursing (DON) on 7/29/14 at 4:13 PM. The DON stated that she was made aware of Resident #1's death and inoperable ventilator on the evening of 7/20/14 by RNS #2. The DON stated that Respiratory decides when not to use a ventilator and she believes only a one-time problem with a ventilator is enough to take it out of circulation, but there has been no tracking of the ventilators. The DON stated that she is not aware of who sets alarms to go to pagers and has never had any contact with the alarm company. An interview was conducted with the Administrator on 7/30/14 at 12:00 Noon. The Administrator stated that he became aware of the incident with Resident #1 and an inoperable ventilator on 7/20/14. The Administrator stated that there had been no consistent tracking of ventilators among residents; he created a tracking record for ventilator serial numbers assigned to each resident. The Administrator stated that Respiratory is responsible for logging ventilator service records and he counts on the ventilator company to ensure that a ventilator has been serviced. The Administrator stated that certain alerts such as the High Inspiratory Pressure alarm were removed from the pager several years ago to free up space for other alerts to be communicated faster. The Administrator further stated that the facility ' s QA has been the scheduled preventative maintenance as well as Respiratory ' s response to any code indicators by switching out the ventilators. 415.27 (a-c)

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 were systems in place to ensure that each resident reached and maintained highest practicable physical, mental and psychological well-being. Specifically, the administration failed to have a system in place to identify, communicate and monitor residents' bowel patterns in order to prevent impaction/obstruction; failed to train staff and ensure staff competency specific to bowel management. This resulted in actual harm to Resident # 1 and potential for widespread serious harm that is immediate jeopardy. Complaint Number: NY 935 Cross References: F 309- Provide Care for Highest Well being F501-Medical Director F520-Quality Assessment & Assurance The findings are: The Policy and Procedure on Bowel Management Regimen effective 4/9/07 documented that nursing staff will record and monitor each resident's bowel habits by observing the frequency and nature of a resident's bowel movements. The Certified Nursing Assistant (CNA) must notify the charge nurse to any changes in a resident's bowel habits and the nurse will review bowel records on all residents daily. If a bowel movement does not occur for two days a bowel regimen protocol will be initiated. An interview was conducted with the Nurse Practitioner (NP) on 7/2/14 at 10:56 AM. The NP stated that, if a resident is consistently having loose stools, a rectal exam is warranted by nursing. "If a resident is consistently having loose stools that means there is leakage given a history of bowel obstruction." The NP stated that he relies on nurses to tell him regarding a resident's bowel records. The NP further stated that he was never made aware of Resident #1 having loose stools. An interview was conducted with the Risk Manager (RM) on 7/2/14 at 1:55 PM. The RM stated that the data entered by a CNA into the electronic medical record will alert a nurse if a resident does not have a bowel movement but will not alert if a resident consistently has abnormal stools; " The only way of knowing this is if it is reported." The RM stated that there is no standard in-servicing on bowel management. She further stated, "When I identify a need for in-servicing I will identify an issue and set the in-service for throughout the facility." An interview was conducted with the Medical Director (MD) on 7/2/14 at 3:42 PM. The MD stated that there have been no recent adjustments to the bowel management policy. The MD stated, "A lack of a bowel movement drives the policy." The MD stated that impaction is something to pay attention to in a resident with loose stools, so this should be communicated and bowel movement documentation should be in its entirety. The MD further stated that a digital rectal exam should be part of an assessment done by RNs. An interview was conducted with the In-Service Coordinator (ISC) on 7/2/14 at 4:02 PM. The ISC stated that, on orientation, CNAs are taught to enter residents' bowel movement types into the electronic medical record. During orientation the bowel protocol is reviewed with the nurses and assessment of bowel sounds is stressed with the Registered Nurses. The ISC stated that nurses have to know a resident's history and, if a resident has a history of obstruction, loose stool is very significant. 415.26

Based on staff interviews and record review during an abbreviated and partial extended survey the Medical Director failed to ensure that the facility provided care to meet the needs of residents. Specifically, the Medical Director failed to ensure that policies and procedures related to bowel management to prevent bowel impaction/obstruction were developed and implemented to ensure coordination of medical care. This failure resulted in the potential for widespread harm that is Immediate Jeopardy. Complaint Number: NY 935 Cross References: F 309- Provide Care for Highest Well being F 490- Administration F 520-Quality Assessment & Assurance The findings are: The Policy and Procedure on Bowel Management Regimen effective 4/9/07 documented that nursing staff will record and monitor each resident's bowel habits by observing the frequency and nature of a resident's bowel movements. The Certified Nursing Assistant (CNA) must notify the charge nurse to any changes in a resident's bowel habits and the nurse will review bowel records on all residents daily. If a bowel movement does not occur for two days a bowel regimen protocol will be initiated. The Clinical Notifications Detail Report/No Bowel Movement (CNDRNBM) from 6/1/14 to 6/25/14 did not identify Resident #1. The CNDRNBM is generated daily by the electronic medical record only for residents who have not had bowel movements for two days. An interview was conducted with the Medical Director (MD) on 7/2/14 at 3:42 PM. The MD stated that there have been no recent adjustments to the bowel management policy. The MD stated, "A lack of a bowel movement drives the policy." The MD stated that impaction is something to pay attention to in a resident with loose stools, so this should be communicated and bowel movement documentation should be in its entirety. The MD further stated that a digital rectal exam should be part of an assessment done by RNs. 415.15 (a)

Based on staff interview and record review during an abbreviated and partial extended survey the facility failed to provide a quality assessment and assurance program that identified residents with potential for bowel impaction/obstruction. Specifically, the Quality Assessment and Assurance (QAA) committee failed to review and evaluate sequence of events preceding hospitalization of Resident #1 for Bowel Obstruction and identify system failure to determine the root cause. The QAA committee failed to ensure the development and implementation of policies and procedures related to bowel management to prevent bowel impaction/obstruction were developed and implemented to ensure coordination of medical care. This failure resulted in the potential for widespread harm that is immediate jeopardy. Complaint Number: NY 935 Cross References: F 309- Provide Care for Highest Well being F 490- Administration F501-Medical Director The findings are: The Policy and Procedure on Bowel Management Regimen effective 4/9/07 documented that nursing staff will record and monitor each resident's bowel habits by observing the frequency and nature of a resident's bowel movements. The Certified Nursing Assistant (CNA) must notify the charge nurse to any changes in a resident's bowel habits and the nurse will review bowel records on all residents daily. If a bowel movement does not occur for two days a bowel regimen protocol will be initiated. An interview was conducted with the Risk Manager (RM) on 7/2/14 at 1:55 PM. The RM stated that there is no standard in-servicing on bowel management. She further stated, "When I identify a need for in-servicing I will identify an issue and set the in-service for throughout the facility." The RM stated that there was no QA or auditing conducted on bowel protocol/bowel management, there have also been no updates on the bowel management policy. An interview was conducted with the Administrator on 7/3/14 at 10:50 AM. The Administrator stated that he became aware of Resident #1's colonic obstruction after the resident was hospitalized . The Administrator stated that his role is to oversee that appropriate policies are in place for all departments. The Administrator further stated that he does not know of any measures taken at this time. The administrator stated that he did not recall any Quality Assurance regarding bowel management that was conducted by the facility. 415.27 (a-c)

Based on staff interviews and record review during an abbreviated and partial extended survey the facility failed to ensure that the necessary care and services to attain and maintain the highest practicable physical, mental and psychosocial well-being were provided to one (Resident #1) of 8 residents reviewed for quality of care. The facility failed to ensure that there was a system in place to identify, communicate and monitor residents' bowel patterns in order to prevent impactions. Specifically, Resident #1 had a history of [REDACTED]. The facility staff did not identify or address a change in bowel pattern and loose stools. The resident subsequently presented with fever and dark brown emesis and was admitted to the hospital with [REDACTED]. The facility failed to train and ensure staff competency specific to bowel management. Key staff rely on the electronic medical record which provides no detail other than whether or not a resident has or has not had a bowel movement. This resulted in actual harm to Resident #1 and the potential for widespread serious harm that is Immediate Jeopardy and Substandard Quality of Care. Complaint Number: NY 935 The findings are: The Policy and Procedure on Bowel Management Regimen effective 4/9/07 documented that nursing staff will record and monitor each resident's bowel habits by observing the frequency and nature of a resident ' s bowel movements. The Certified Nursing Assistant (CNA) must notify the charge nurse to any changes in a resident's bowel habits and the nurse will review bowel records on all residents daily. If a bowel movement does not occur for two days a bowel regimen protocol will be initiated which includes MOM (milk of magnesia) on the morning of day three, ducolax suppository at HS (hour of sleep) on day three, fleets enema at 6:00 AM on day four. Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (an assessment tool) dated 5/8/14 documented that Resident #1's cognition is severely impaired. The resident has no speech and rarely/never understands or understood. The Care Plan Activity Report (CPAR) for constipation effective 4/16/13 documented that Resident #1 is at risk for and/or has a history of constipation. Interventions included monitoring bowel movements daily, stool for consistency, color and size; monitor for signs/symptoms of impaction, including nausea, vomiting, abdominal pain, distention and firm feces on digital exam. The CPAR for activities of daily living effective 4/16/13 documented that Resident #1 is incontinent of bowel. Interventions included observe for abnormal bowel function, including loose stools. The Hospital Transfer Summary dated 5/15/13 documented that Resident #1 was admitted to the hospital from the facility on 5/13/13 for a partial small bowel obstruction, resolved. The resident was transferred back to the facility on [DATE]. The Resident CNA Documentation History Detail from 5/1/14 to 5/31/14 documented that Resident # 1 had soft stools 19 times and loose stools 23 times. The stool consistency was not documented 40 times. The Nursing Progress Notes (NPN) dated 5/11/14 documented that Resident #1 was noted with a large amount of coffee ground emesis and hematuria; abdomen distended, firm. The doctor was notified with orders to start IV (intravenous) fluids for three days. The Resident CNA Documentation History Detail from 6/1/14 - 6/2/14 recognized 12 opportunities for documentation. Of 12 opportunities, Resident #1 had 5 documented bowel movements. The stool consistency was not documented for all 5 times. The NPN dated 6/2/14 at 12:38PM documented abdomen softly distended with positive bowel sounds; will continue to follow up. The Medical Progress Notes (MPN) dated 6/2/14 at 11:15PM documented Resident #1 was seen and examined at the bed side during morning rounds; awake, no abdominal pain, no constipation and no fever. The Resident CNA Documentation History Detail from 6/19/14 - 6/20/14 recognized 12 opportunities for documentation. Of 12 opportunities, Resident #1 had 4 documented bowel movements. The stool consistency was not documented for all 4 times. The NPN dated 6/20/14 at 6:15AM documented an episode of emesis x1; resident is alert and responsive to both verbal and tactile stimuli; abdomen soft, non-tender with positive bowel sounds; will continue to follow up. At 6:45AM, resident noted with non-distended/tender abdomen. The CPAR quarterly review dated 6/21/14 documented that no changes were noted; no use of BM (bowel management) protocol noted; continue with POC (plan of care). The Resident CNA Documentation History Detail from 6/22/14 - 6/23/14 recognized 12 opportunities for documentation. Of 12 opportunities, Resident #1 had 8 documented bowel movements, of which five were documented as loose stools and three had no documented consistency. The NPN dated 6/24/14 at 11:26PM documented Resident #1 with temperature of 100.2, observed with moderate amount of dark brown emesis. The doctor was notified with orders to start IV fluids for three days. The NPN dated 6/25/14 at 5:56AM documented no further emesis noted, gastrostomy feeding back on infusing well, resident in no apparent distress. At 10:59AM Resident seen and evaluated by Physician during rounds, in no apparent distress or discomfort. Abdomen softly distended with bowel sounds present. Physician ordered enema one application, large bowel movement documented on 6/24/14, will continue to follow up. At 2:11PM abdomen remained distended, loose bowel movement noted after enema, non-tender with positive bowel sounds x4. Resident in no apparent distress or discomfort. Physician made aware and ordered abdominal X-ray secondary to abdominal distention. The NPN dated 6/25/14 at 6:24PM documented that preliminary results of abdominal X-Ray shows: massively dilated colon and small bowel. Needs Computed Tomography (CT) of the abdomen to rule out high grade obstruction. Physician ordered to send resident to hospital for CT. The Resident CNA Documentation History Detail from 6/1/14 to 6/25/14 documented that Resident #1 had loose stools 18 times. Stool consistency was not documented 39 times. The Clinical Notifications Detail Report/No Bowel Movement (CNDRNBM) from 6/1/14 to 6/25/14 did not identify Resident #1. The CNDRNBM is generated daily by the electronic medical record only for residents who have not had bowel movements for two days. The NPN dated 6/26/14 documented that Resident #1 was admitted to the hospital at 7:20 PM with colonic obstruction. An interview was conducted with 7:00AM-7:00PM Registered Nurse, Charge Nurse (CN) on 6/30/14 at 3:08PM. The CN stated that she was not aware of Resident #1's history of constipation or bowel obstruction, "can't really memorize history of all residents, I have to do research when I become aware of any issue." The CN denied reviewing Resident #1's medical record at any time to ascertain his clinical history. The CN stated that she did not do care plans for any residents and was not aware of specific interventions for Resident #1 for constipation. She was not aware of him having loose bowel movements. A "bowel" list is generated by the electronic computer system of residents' who did not have any bowel movement for 3 days "I tell the district nurses to check the bowel list." If the residents' are having any abnormal bowel movements usually the CNAs verbally notify the nurses on the unit. The CN denied that any abnormal bowel movements were reported to her by any CNA. The CN further stated that if resident was having consistent loose stool the physician should have been notified. The CN denied contacting the physician related to Resident #1 having loose stools. An interview was conducted with an assigned 7:00 AM to 3:00 PM CNA #1 on 7/1/14 at 12:14 PM. CNA #1 stated that Resident #1 has been having pudding-type, pasty bowel movements for a long time. CNA #1 stated that she doesn't know what kind of bowel movements the resident had on other shifts because she can only see her shift in the electronic medical record; "if he (Resident #1) had something wrong with his stomach, the nurses should tell us." CNA #1 further stated that she has not been in-serviced regarding bowel management or signs of constipation; "the nurse will give an in-service if something happens, if there's an issue." An interview was conducted with an assigned 7:00 AM to 3:00 PM CNA #2 on 7/1/14 at 12:43 PM. CNA #2 stated that, whenever she has cared for the resident, Resident #1 has had loose stools. CNA #2 stated that she would tell the nurse; " I don ' t know what they did. I don ' t recall him (Resident #1) ever being on bowel protocol. " An interview was conducted with the 7:00 AM to 7:00 PM Registered Nurse (RN #1) on 7/1/14 at 1:15 PM. RN #1 stated that she has been caring for Resident #1; "I was not aware of history with bowels or stomach distention." RN #1 stated that CNAs are supposed to document the consistency of residents' bowel movements. She, then, stated, "I can check CNAs content on the screen but I would only check if a patient had a bowel protocol." A bowel protocol is started if a resident does not have a bowel movement for two days. RN #1 further stated that she was not aware of specifics regarding Resident #1's care plan for constipation but RN #1 would not do a rectal exam. An interview was conducted with the 7:00 AM to 7:00 PM Licensed Practical Nurse (LPN #1) on 7/1/14 at 1:47 PM. LPN #1 stated that the night shift nurses run a 48 hour report to check for residents that have not had a bowel movement. LPN #1 stated that monitoring a resident's abnormal bowel movements is "mainly verbal; sometimes they (residents) complain." An interview was conducted with the 7:00 AM to 7:00 PM Licensed Practical Nurse (LPN #2) on 7/1/14 at 2:23 PM. LPN #2 stated that the bowel protocol only reports a resident that does not move one's bowels. LPN #2 stated that, if a resident is on bowel protocol, then she would look at the bowel record if she knew a resident was having issues; "otherwise I don't look at it." LPN #2 stated that in-services are taken on-line through the computer and she has never been trained regarding bowel management; "the supervisors come around and give an in-service if something new is going on." LPN #2 further stated that she is not aware of Resident #1 having loose stools or any issues with his bowels. An interview was conducted with the 7:00 AM to 3:00 PM CNA #3 on 7/1/14 at 2:54 PM. CNA #3 stated that Resident #1's bowel movements " have not been formed, always loose like a melted Hershey bar." CNA #3 stated that he can document in the computer but can't see any other shift's documentation. CNA #3 further stated that he doesn't recall any in-services regarding constipation or bowel management. An interview was conducted with the 7:00 PM to 7:00 AM RN #2 on 7/2/14 at 10:00 AM. RN #2 stated, "I wouldn't know if a resident was having loose stools on other shifts. If a resident is on bowel protocol, it will pop up on the computer." RN #2, then, stated, "I heard he (Resident #1) went out for bowel obstruction. No one ever told me he had loose stools." An interview was conducted with the 11:00 PM to 7:00 AM CNA #4 on 7/2/14 at 10:20 AM. CNA #4 stated that Resident #1's stools are very loose. CNA #4 stated that she doesn't know if Resident #1 had stomach pain or enlarged because "he (Resident #1) doesn't talk so I don't know." CNA #4 further stated, "There's no in-service on bowels. If something happens, we normally do one (in-service)." An interview was conducted with the 7:00 AM to 3:00 PM Registered Nurse Supervisor (RNS #1) on 7/2/14 at 10:46 AM. RNS #1 stated that the electronic medical record triggers a report for bowel protocol and, other than this report, there is no other way of monitoring bowel patterns. RNS #1 stated that, if a resident is having vomiting or distention, an assessment of the resident should be done. She, then, stated, " But, we don't do digital exams." An interview was conducted with the Nurse Practitioner (NP) on 7/2/14 at 10:56 AM. The NP stated that, if a resident is consistently having loose stools, a rectal exam is warranted by nursing. "If a resident is consistently having loose stools that means there is leakage given a history of bowel obstruction." The NP stated that he relies on nurses to tell him regarding a resident's bowel records. The NP further stated that he was never made aware of Resident #1 having loose stools. An interview was conducted with the Director of Nutrition (DN) on 7/2/14 at 11:34 AM. The DN stated that Resident #1 was on a very high fiber formula which should have caused binding to result in formed stool. The DN stated that the bowel protocol only triggers for residents who do not move their bowels; if a resident had consistently loose bowels, the only way of knowing is if a nurse reported it to the team. The DN further stated, "It was never reported that he (Resident #1) had loose bowel movements." An interview was conducted with the Risk Manager (RM) on 7/2/14 at 1:55 PM. The RM stated that the data entered by a CNA into the electronic medical record will alert a nurse if a resident does not have a bowel movement but will not alert if a resident consistently has abnormal stools; "The only way of knowing this is if it is reported." The RM stated that there is no standard in-servicing on bowel management. She further stated, "When I identify a need for in-servicing I will identify an issue and set the in-service for throughout the facility." An interview was conducted with the Medical Director (MD) on 7/2/14 at 3:42 PM. The MD stated that there have been no recent adjustments to the bowel management policy. The MD stated, "A lack of a bowel movement drives the policy." The MD stated that impaction is something to pay attention to in a resident with loose stools, so this should be communicated and bowel movement documentation should be in its entirety. The MD further stated that a digital rectal exam should be part of an assessment done by RNs. An interview was conducted with the In-Service Coordinator (ISC) on 7/2/14 at 4:02 PM. The ISC stated that, on orientation, CNAs are taught to enter residents' bowel movement types into the electronic medical record. The ISC stated that nurses have to know a resident's history and, if a resident has a history of obstruction, loose stool is very significant. An interview was conducted with the Director of Nursing (DON) on 7/3/14 at 9:42 AM. The DON stated that she would expect CNAs to report abnormal bowel movements to the nurse, who should assess the consistency of the stool and do a complete GI (gastrointestinal) assessment including bowel sounds. The DON stated that nurses do not do digital rectal exams and would have to tell the Nurse Practitioner to have a digital exam done. An interview was conducted with the Administrator on 7/3/14 at 10:50 AM. The Administrator stated that he became aware of Resident #1's colonic obstruction after the resident was hospitalized . The Administrator stated that his role is to oversee that appropriate policies are in place for all departments. The Administrator further stated that he does not know of any measures taken at this time. During a subsequent interview with the Administrator on 7/3/14 at 12:30 PM the Administrator stated that monitoring of loose stools is reported verbally by CNAs and communicated to the physician, when indicated. 415.12