Every finding on record at Nassau Rehabilitation & Nursing Center

Based on observation, staff interview and record review during an abbreviated survey (NY00373760), the facility failed to ensure food was prepared in a form designed to meet the resident's needs as documented on a hospital discharge summary for one (1) (Resident #1) of three (3) residents reviewed. Specifically, Resident #1 was admitted with a modified consistency diet of minced moist consistency and thickened liquids. The facility diet order documented chopped consistency with thin liquids. Resident # 1 was found unresponsive in the dining room during breakfast on 09/10/2024. This resulted in Resident #1 being transported to the hospital with upper airway obstruction from food and subsequently expired. This deficient practice has the potential to affect all 102 residents in the facility with a modified consistency diet that is Immediate Jeopardy. The finding is: Facility policy and procedure titled Transmission of Diet Orders for New admission dated 01/01/2024, documented nursing staff will review Patient Review Instrument upon admission for the diet that was provided. The nursing supervisor will enter the resident diet into the electronic medical record. Facility policy and procedure titled Texture and Consistency-Modified Diets dated 08/20/2024, documented as part of the nutrition care process upon admission, all new and readmissions admitted on regular consistency will receive a mechanically altered diet (chopped), pending speech language pathologist evaluation. If hospital record states the resident was receiving a pureed or any other texture downgrade (mechanical soft, blenderized, etc.) prior to admission the Registered Dietician will resume with that recommendation and communicate with food service. Resident #1 was admitted on [DATE] at 4:39 PM to the facility with diagnoses that included sepsis (a serious condition in which the body responds improperly to an infection), Parkinson Disease (movement disorder of the nervous system), and asthma. The Minimum Data Set Assessment Brief Interview of Mental Status score was not completed as Resident #1 was at the facility for less than 24 hours. Resident #1 did not have a baseline comprehensive care plan completed. Review of Hospital Discharge paperwork dated 09/09/2024 at 3:48 PM documented Resident #1 was ordered a diet consistency of minced moist with thick liquids. Review of facility orders for Resident #1 dated 09/09/2024 at 5:04 PM documented Resident #1 was to have a chopped consistency with thin liquids. Nursing Progress Note dated 09/10/2024 at 10:52 AM documented Resident #1 became unresponsive in the dining room on 09/10/2024 at 09:35 AM. Hospital medical records received and reviewed on 05/05/2025 documented Resident #1 had a change in mental status due to respiratory arrest from upper airway obstruction. Resident #1 was admitted to the hospital on [DATE] at 10:20 AM. Resident #1 was unresponsive with food suctioned out of the patient's airway during intubation by Emergency Medical Services and afterward from their mouth in the Emergency Department. The medical records also documented Resident #1 had a change in mental status due to upper airway obstruction from food. Resident #1 was placed on a ventilator due to anoxic (lack of oxygen) brain injury. Resident #1 subsequently expired. During an interview on 05/01/2025 at 2:57 PM, Registered Nurse #1 (Admissions Nurse) stated they transcribed the diet incorrectly and Resident #1 should have been placed on a ground diet consistency with thick liquids based on hospital discharge records. Registered Nurse #1 stated that new admissions are initially placed on chopped consistency unless they have a downgraded consistency from the hospital. During an interview on 05/01/2025 at 4:06 PM, Certified Nursing Assistant #1 stated Resident #1 was a total assist with meals and activities of daily living. This instruction was given during morning report by the unit nurse. Certified Nursing Assistant #1 stated they did not assist Resident #1 with their breakfast meal on 09/10/2024. During an interview on 05/01/2025 at 4:48 PM, Licensed Practical Nurse #1 stated that Resident #1 had been provided with their food tray prior to becoming unresponsive. The tray was opened. Licensed Practical Nurse #1 stated their back was turned when Resident #1 became unresponsive and did not see them consume food. The resident was not provided assistance with the breakfast. When Resident #1 became unresponsive, a code was called, cardiopulmonary resuscitation was initiated, and 911 was called. During an interview on 05/01/2025 at 5:21 PM, the Director of Nursing stated Registered Nurse #1 (Admissions Nurse) transcribed the diet incorrectly and Resident #1 should have been placed on a ground diet consistency with thick liquids based on hospital discharge records. During a breakfast meal observation on 05/06/2025 at 9:08 AM, two (2) sample breakfast trays were presented by the dietary supervisor, one (1) tray was labeled chopped and the other was labeled ground. Both trays contained scrambled eggs and bread. One (1) tray had wheat bread the other white bread, both pieces of bread were served whole. The consistency of the eggs was the same. There was no noted difference in texture between a chopped consistency and a ground consistency diet. During an interview on 05/06/2025 at 2:44 PM, Medical Doctor #2 stated they were aware cardiopulmonary resuscitation was done on Resident #1 the morning of 09/10/2024. They stated it was very unlikely the food suctioned out of Resident #1's mouth was from the night before. They further explained, the timespan between dinner and breakfast was 12 hours, which is too long of a timeframe for the regurgitation of food to be contents from dinnertime. 10 NYCRR 415.14(d)(3)

Based on observations, record review, and interviews during the Recertification Survey initiated on 4/21/2025 and completed on 4/28/2025, the facility did not ensure that each resident was treated with respect and dignity and cared for in a manner that promoted maintenance or enhancement of their quality of life. This was identified for two (Resident #78 and Resident #155) of the two residents reviewed for Dignity. Specifically, during a lunch meal observation on 4/21/2025, Occupational Therapist Assistant #1 was observed standing over Resident #78 while they assisted the resident with the lunch meal. During the same lunch meal observation, Transporter #1 was also observed standing over Resident #155 while they assisted the resident with their lunch meal. The findings are: The undated facility's policy titled Assistance with Meals, documented that residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example, not standing over residents while assisting them with meals and keeping interactions with other staff to a minimum while assisting residents with meals. 1) Resident # 78 was admitted with diagnoses including Cerebral Vascular Disease, Malnutrition, and Type 2 Diabetes Mellitus. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 3, indicating the resident had severely impaired cognitive function. The resident required Partial to moderate assistance with eating. The Comprehensive Care Plan reviewed on 3/20/2025 documented that Resident #78 ate with supervision or touch assistance. During the dining task observation in the Unit 5 North dining room on 4/21/2025 at 12:55 PM, Occupational Therapist Assistant #1 was observed assisting Resident #78 with their lunch meal while standing over them. The resident was observed grabbing food off their tray, and Occupational Therapist Assistant #1 held the resident's hand with one hand and fed the resident with the other hand, offering bites of food and sips of liquids. During an interview on 4/21/2025 at 12:59 PM, Occupational Therapist Assistant #1 stated they had to stand to keep the resident from grabbing their food. Occupational Therapist Assistant #1 stated the resident usually feeds themselves, but today, the resident was not eating, which is why Occupational Therapist Assistant #1 came over to assist the resident. Occupational Therapist Assistant #1 stated that they should have been seated by the resident while they assisted the resident with their meal. 2) Resident # 155 was admitted with diagnoses including Parkinson's Disease, Dementia, and Malnutrition. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 99, indicating the resident was unable to complete the interview. The Minimum Data Set documented that the resident required substantial/maximal assistance with eating. The helper does more than half the effort and assists by lifting or holding the trunk or limbs. The Comprehensive Care Plan reviewed on 3/25/2025 documented that Resident #155 ate their meals with substantial/maximal assistance of one person. During the dining task observation in the Unit 5 North dining room on 4/21/2025 at 12:55 PM, Transporter #1 was observed assisting Resident #155 with their lunch while standing over them. During an interview on 4/21/2025 at 1:04 PM, Transporter #1 stated they did not know they should be sitting down while assisting the resident with a meal. Transporter #1 stated they normally do not assist with meals, but today they were asked by their supervisors to assist with the lunch meal. During an interview on 4/22/2025 at 2:23 PM, Licensed Practical Nurse #5 stated that staff should not stand over the resident when assisting with meals. During an interview on 4/22/2025 at 3:00 PM, the Infection Preventionist/Registered Nurse Educator stated that staff assisting a resident during meals should be sitting and not standing over the resident. During an interview on 4/25/2025 at 1:29 PM, the Director of Nursing Services stated that staff should not stand while assisting residents with meals. 10 NYCRR 415.3(d)(1)(i)

Based on observations, record review, and interviews during the Recertification Survey initiated on 4/21/2025 and completed on 4/28/2025, the facility did not ensure that each resident who is unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. This was identified for one (Resident #232) of one resident reviewed for Bowel and Bladder Incontinence. Specifically, Resident #232's room was observed with a strong urine smell. Staff Interviews and record review revealed the resident did not receive staff assistance with incontinence care and assistance with personal hygiene as per the resident's plan of care. The finding is: The facility's policy titled Activities of Daily Living, dated 10/1/2024, documented to provide Activities of Daily Living care to all residents based on assessment of needs. Activities of Daily Living care consists of but is not limited to bathing, dressing, eating, transfers, toileting, bed mobility, and ambulation. The purpose is to ensure all residents' needs are met in a timely manner. In accordance with the plan of care, the Certified Nursing Assistant provides the necessary assistance the resident requires with each activity of daily living. If a resident refuses care, the Certified Nursing Assistant notifies the charge nurse and social services for intervention. Resident #232 was admitted with diagnoses including Obstructive Uropathy (a condition where urine flow is blocked or obstructed within the urinary tract), Hypertension, and Anxiety Disorder. The 2/13/2025 Annual Minimum Data Set assessment documented a Brief Interview for Mental Status score of 8, indicating the resident had moderate cognitive impairment. The Minimum Data Set assessment documented that the resident had an indwelling urinary catheter (which was discontinued on 2/27/2025) and needed partial/moderate assistance for toileting hygiene and supervision for personal hygiene. A Comprehensive Care Plan titled Activities of Daily Living effective 3/5/2025 documented the resident was incontinent of bladder (having no or insufficient voluntary control over urination) and needed supervision for toilet use and cleanup assistance for personal hygiene. A Comprehensive Care Plan titled Behavior, effective 3/6/2025, documented the resident was combative, resisted all care and changing clothes, wore an incontinence brief over clothes, exhibited agitation and wandering, and had removed the Foley and Nephrostomy tubes. The interventions included ambulating if the resident needed to walk or felt restless, providing the resident with reality orientation, redirecting from dangerous situations, and separating from [negative] situations. A care plan note added on 3/28/2025 documented that the resident continued to refuse laboratory services. The care plan did not include interventions related to refusal of incontinence care. During an observation and interview on 4/22/2025 at 8:24 AM, Resident #232 was in bed in their private room. There was a strong urine odor in the room. The resident was not dressed and was wearing an incontinence brief. The resident stated they had no complaints. During an observation and interview on 4/23/2025 at 8:15 AM, Resident #232 was in bed in their private room. There was a strong urine odor in the room. The resident was covered with a sheet. The resident stated they go to the bathroom by themselves and do not need any assistance with toileting. During an observation on 4/23/2025 at 10:28 AM, Resident #232 was not in their room. The resident's bed was made, and there was no urine odor. During an interview on 4/23/2025 at 10:35 AM, Certified Nursing Assistant #2 (7:00 AM-3:00 PM staff assigned to Resident #232) stated that Resident #232 takes a lot of time for Activities of Daily Living care, and that is why they provide morning care to the resident after they rendered care to all other residents on their assignment. Resident #232 is confused; however, they did not exhibit negative behaviors when Certified Nursing Assistant #2 was assigned to care for them. Certified Nursing Assistant #2 stated the resident had a strong urine odor in their room because of the lack of care during the overnight shift. Certified Nursing Assistant #2 stated that when they cleaned the resident this morning, the resident's incontinence brief was saturated with urine, and the bed sheets were also wet with urine. During an interview on 4/23/2025 at 1:00 PM, Certified Nursing Assistant #3 (assigned to Resident #232 during the 11:00 PM-7:00 AM shift on 4/21/25 to 4/22/25) stated the resident was continent (can control urination) of urine and used the bathroom by themselves, and performed their own personal hygiene care. Certified Nursing Assistant #3 stated they conduct 30-minute rounds to check on the resident to ask if the resident needs anything, and if the resident says no, they leave the resident alone. A review of the Certified Nursing Assistant Accountability Record for April 2025 revealed that Certified Nursing Assistant #3 documented that the resident was continent of urine and no personal hygiene care, including toileting, was provided on 4/21/2025 and 4/22/2025 during the 11:00 PM-7:00 AM shift. During an interview on 4/23/2025 at 1:50 PM, Certified Nursing Assistant #4 (assigned to Resident #232 during the 11:00 PM-7:00 AM shift on 4/22/2025 to 4/23/2025) stated the resident's room usually smells bad with a urine smell. Certified Nursing Assistant #4 stated that when they try to provide care for Resident #232, the resident becomes angry, and they just leave the resident alone. Certified Nursing Assistant #4 stated that on the night of 4/22/2025, when they went to the resident's room, the resident was in a deep sleep, so they did not bother to touch the resident and did not provide any care. Certified Nursing Assistant #4 stated they did not want to upset the resident. During an observation on 4/25/2025 at 8:15 AM, Resident #232 was dressed in the hallway, sitting in their wheelchair by the nurse station. In the resident's room, the sheets were removed from the bed, and there was a slight urine odor in the room. During an interview on 4/25/2025 at 8:37 AM, Certified Nursing Assistant #5 (assigned to Resident #232 during the 7:00 AM-3:00 PM shift on 4/25/2025) stated they washed and dressed the resident. Certified Nursing Assistant #5 stated they had to encourage the resident a lot to get washed and dressed, the resident was not combative. Certified Nursing Assistant #5 stated there was a strong urine odor when they entered the room this morning. The resident was wearing an incontinence brief, which was dry. Certified Nursing Assistant #5 stated that the housekeeper cleaned the mattress after they provided morning care. The Resident Nursing Instructions (care instructions that certified nursing assistants follow) generated on 4/25/2025 at 11:49 AM documented that the resident had bladder incontinence, needed supervision for toilet use, and needed clean-up assistance for personal hygiene. There were no behaviors documented in the Resident Nursing Instructions. During an interview on 4/25/2025 at 12:16 PM, Licensed Practical Nurse #3 (assigned to the resident during the 11:00 PM-7:00 AM shift on 4/22/2025 to 4/23/2025) stated they did not know that care was not provided to the resident for the entire shift because the Certified Nursing Assistant did not want to upset the resident. Licensed Practical Nurse #3 stated that Certified Nursing Assistant #4 should have reported their concerns, and Licensed Practical Nurse #3 would have assisted Certified Nursing Assistant #4 or changed the assignment. Licensed Practical Nurse #3 stated that Resident #232 should have been provided incontinence care. Licensed Practical Nurse #3 stated they did not smell any urine odor when they went into the resident's room in the morning because they (Licensed Practical Nurse #3) were wearing a mask. The Resident Nursing Instructions generated by the facility on 4/25/2025 at 1:54 PM had added behaviors, including wandering, combativeness, agitation, resisting care such as showers, and changing clothes. The instructions also included approaching the resident calmly, to explain the process before assisting, and to return at a later time if needed. The Comprehensive Care Plan titled Activities of Daily Living effective 3/5/2025 was revised on 4/25/2025 to include that the resident refused care, showers, and changing clothes. The resident had combative behavior and agitation. Interventions were updated to include approaching the resident calmly, explaining the process before assisting, and returning at a later time. During an interview on 4/28/2025 at 8:00 AM, Registered Nurse #3 (unit supervisor) stated Resident #232 was incontinent of urine and the Certified Nursing Assistants must report refusal of incontinence care to the nurse on the unit. The resident's refusal of care should have been documented. During an interview on 4/28/2025 at 8:39 AM, the Director of Nursing Services stated Resident #232 had a lot of noncompliant behaviors and required a lot of attention. The Director of Nursing Services stated if Certified Nursing Assistants are concerned about the resident's behavior, they should go into the resident's room with another staff member to provide care. The Certified Nursing Assistants should document and report refusals of care to the nurse. 10 NYC RR 415.12(a)(3)

Based on observation, record review, and interviews during the Recertification Survey initiated on 4/21/2025 and completed on 4/28/2025, the facility did not ensure that residents received care consistent with professional standards of practice to promote healing, prevent infections, and prevent new ulcers from developing. This was identified for two (Resident #176 and Resident#196) of four residents reviewed for Skin Conditions. Specifically, 1) Resident #176 had a history of a pressure ulcer to the mid-back and utilized an air mattress for pressure relief. During multiple observations, Resident #176 was observed in bed with their air mattress weight setting at 450 pounds. Resident #176 weighed 114.4 pounds on 4/02/2025. 2) Resident #196 required the use of an air mattress to decrease the risk of skin breakdown. The resident was provided a bariatric air mattress, as that was the only air mattress available at the time the need for the air mattress was determined for Reisdnet #196. During multiple observations, the air mattress weight setting was set at 850 pounds; however, Resident #196 weighed 150 pounds. The findings are: The facility's policy titled Skin Prevention: Air Mattress, last revised on 3/14/2025, documented that all staff involved in using air mattresses for skin prevention are knowledgeable about the care and maintenance of air mattresses and the proper positioning of residents on an air mattress. The Wound Care Nurse will evaluate the resident to determine the need for an air mattress. The Director of Maintenance/designee will collaborate with unit staff to set up an air mattress while the resident is out of bed and will set it in accordance with the resident's current weight range. Once the Director of Maintenance is ready to place a mattress, the Nurse will place the (Physician's) order for an air mattress in the Electronic Medical Record. The Maintenance Director or designee will place an air mattress on the bed, ensure that it is plugged in and calibrated according to the resident's current weight. Alternatively, based on the manufacturer's recommendation, air mattress firmness can be calibrated based on residents' comfort and during Activities of Daily Living care. Nursing will be responsible for checking the inflation of the air mattress on each shift and checking that settings are appropriate in accordance with the resident's weight. 1) Resident #176 was admitted with diagnoses including Cerebral infarction (when blood flow to the brain is blocked, causing brain tissue to die), Hemiplegia affecting the left side (paralysis or weakness on one side of the body), and Alzheimer's Disease. The Quarterly Minimum Data Set, dated dated dated [DATE] documented a Brief Interview for Mental Status score of 99, which indicated the resident was unable to complete the interview. The resident had severely impaired skills for daily decision making; the ability to make self understood: rarely/never understood, and the ability to understand others: rarely/never understands. The Minimum Data Set documented that the resident was at risk for Pressure Ulcers and documented the use of a pressure-reducing device for the bed. The operation manual for the Air Mattress included instructions for weight settings to increase or decrease airflow for a softer or firmer setting. The numbers on the main control panel denote suggested settings based on the resident's weight. A Comprehensive Care Plan titled Skin Prevention, dated 1/28/2025, documented immobility and fragile skin. The interventions included utilizing pressure pressure-reducing device for the bed and chair. Wound Care Note dated 4/05/2024 documented Resident #176 had a blanchable redness (a reddened area on the skin that turns white when pressed upon, but then returns to its original red color quickly when the pressure is released) to midback over a raised area. The resident was given an air mattress. A Physician's order dated 12/202/2024 and renewed 4/08/2025 documented an order to place a Protective Silicone foam dressing on the mid-back every two days, prophylactically. A review of the electronic medical record indicated that Resident #176's most recent weight was 114.4 pounds on 04/02/2025. During an observation on 04/21/2025 at 10:06 AM, Resident #176 was in bed sleeping on an air mattress. The weight setting for the air mattress was set to 450 pounds. During an observation on 4/22/2025 at 10:50 AM, Resident #176 was seen in their bed sleeping on an air mattress. The weight setting for the air mattress was set to 450 pounds. During an interview on 04/22/25 at 02:00 PM, the Director of Maintenance stated the Director of Maintenance stated they were responsible for installing the air mattress but were not responsible for adjusting the weight setting on the air mattress. The Director of Maintenance stated they were not trained to adjust the weight setting because the Nurses should input the appropriate weight setting. During an interview on 04/22/25 at 02:34 PM, the Wound Care Registered Nurse stated Resident #176 had a history of pressure ulcers to the mid back and was provided the air mattress a year ago to promote wound healing and from new pressure ulcers from developing. The Wound Care Registered Nurse stated that after the resident's wounds are healed, they do not monitor or follow the resident or monitor the air mattress settings. During an interview on 04/22/25 at 02:46 PM, Registered Nurse Infection Preventionist/Educator stated that an air mattress is used for comfort and to prevent pressure sores. The Certified Nursing Assistant checks the level of firmness of the mattress, and the nurse will set the mattress setting to a comfort level for the resident. Staff are not expected to document the monitoring of the air mattress weight setting. During an observation on 4/23/2025 at 8:54 AM, Resident #176 was observed in bed receiving morning care from the Certified Nursing Assistant, and the air mattress was set to 280 pounds. During a re-interview on 04/25/25 at 10:50 AM, the Wound Care Registered Nurse stated that the air mattress weight setting should be set according to the resident's weight and comfort level as per the manufacturer's recommendations. The nurses must ensure that the air mattress weight setting is set according to the resident's weight and comfort level. The staff should be educated regarding the air mattress settings and functionality. During an interview on 4/25/2025 at 1:11 PM, the Director of Nursing Services stated that all Nursing staff should be aware of the air mattress function, and all staff should be monitoring the air mattress. The Director of Nursing Services stated that staff will be educated on how to adjust the air mattress settings. 49245 2) Resident # 196 was admitted with diagnoses including Polyneuropathy (a disorder that impacts nerve function in multiple areas of the body), Pneumonia, and Pulmonary Fibrosis (chronic lung disease that occurs when lung tissue around the air sacs becomes damaged and scarred, making it harder to breathe). The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 3, which indicated Resident #196 had severely impaired cognition. The resident required staff assistance with bed mobility and transfer from one surface to another. The Quarterly Minimum Data Set (MDS) assessment documented that Resident #196 was at risk for developing pressure ulcers and used pressure-reducing devices for the chair and bed. The operation manual for the Bariatric Air Mattress documented instructions for adjusting the weight setting to increase or decrease airflow for a softer or firmer setting. The numbers on the main control panel denote suggested settings based on the resident's weight. A review of the Comprehensive Care Plan (CCP) titled, Skin: Prevention: Pressure Ulcers, dated 10/28/2022, last revised on 3/22/2025, documented an air mattress provided to decrease the risk of skin breakdown. The interventions included a pressure-reducing device for the bed and chairs, and skin checks by Nurses during shower days. A review of Resident #196's electronic health record revealed that Resident #196 did not have a Physician's Order for an air mattress. A review of Resident #196's electronic health record dated 4/1/2025 documented that Resident #196 weighed 150 pounds. During an observation on 4/21/2025 at 10:00 AM, Resident #196 was in bed. The air mattress weight setting was set at 850 pounds. During an observation on 4/21/2025 at 12:44 PM, Resident #196 was in bed. The air mattress weight setting was set at 850 pounds. During an observation with Licensed Practical Nurse #2 on 4/22/2025 at 7:54 AM, Resident #196's air mattress weight setting was set at 850 pounds. Resident #196 was in bed during the observation. During an interview on 4/22/2025 at 7:54 AM, Licensed Practical Nurse #2, Medication and Treatment Nurse, stated that they do not adjust the weight setting on the control panel because they did not know how to. Licensed Practical Nurse #2 stated that the Director of Maintenance will set up the air mattress. During an interview on 4/22/2025 at 2:05 PM, Certified Nursing Assistant #1 stated that they usually checked the air mattress to make sure the air mattress was inflated and was not responsible for monitoring the weight setting of the air mattress. During an interview on 4/22/2025 at 2:15 PM, the Director of Maintenance stated they were responsible for installing the air mattress but were not responsible for adjusting the weight setting on the air mattress. The Director of Maintenance stated they were not trained to adjust the weight setting because the Nurses should input the appropriate weight setting. During an interview on 4/22/2025 at 2:21 PM, Registered Nurse #2, Unit Manager, stated the air mattress weight setting should be set according to the resident's comfort level. Resident #196's air mattress weight setting was set at 850 pounds, which was too high in comparison to the resident's actual weight. Registered Nurse #2 stated that there is no documentation of the staff checking the mattress. During an interview on 4/25/2025 at 9:42 AM, the Staff Educator stated that they do not provide in-service regarding the air mattress because air mattress care and function were the responsibility of the Director of Maintenance and the Wound Care Nurse. The Staff Educator stated that the air mattress was not set up according to the resident's weight, but according to the resident's comfort level. During an interview on 4/25/2025 at 10:50 AM, the Wound Care Nurse stated Resident #196 needed the air mattress because they were not able to turn and position on their own and were very prone to skin breakdown and developing pressure ulcers. The Wound Care Nurse stated that Resident #196 was given a bariatric air bed mattress, because that was the only bed available at the time Resident #196 needed an air mattress. The resident had been using the same air mattress since they were admitted to the facility. The Wound Care Nurse stated they were responsible for entering the resident's weight range on the air mattress control panel. The Wound Care Nurse stated that the Certified Nursing Assistants (CNAs) were not allowed to change the weight setting. The Wound Care Nurse stated that a Physician's Order was not required for the use of an air mattress. The Wound Care Nurse stated they had just reviewed the current facility policy on an air mattress today and had never seen the air mattress policy before. The Wound Care Nurse stated they will make a recommendation to edit their policy. The Wound Care Nurse stated that Resident #196's air mattress weight setting should not be set at 850 pounds. The Wound Care Nurse stated that the 850-pound setup was too excessive for Resident #196's actual weight of 150 pounds. During an interview on 4/25/2025 at 1:11 PM, the Director of Nursing Services stated that all Nursing staff should be aware of the air mattress function, and all staff should be monitoring the air mattress. The Director of Nursing Services stated that staff will be educated on how to adjust the air mattress settings. 10 NYCRR 415.12(c)(1)

Based on observation, record review, and staff interviews during the Recertification Survey initiated on 4/21/2025 and completed on 4/28/2025, the facility did not ensure all drugs and biologicals were stored in a locked compartment. This was identified for one (Resident #28) of five residents reviewed for Accident Hazards. Specifically, Resident #28 was observed with an unlabeled, clear bottle of Safetussin Cough and Chest Congestion (medication for cough and congestion) on their nightstand with no nursing staff within the vicinity of Resident #28's room. Additionally, there was no Physician's Order for the Safetussin Cough and Chest Congestion medication, and Resident #28 was not assessed to self-administer medications. The finding is: The facility's policy titled Storage Medications, last revised on 3/25/2024, documented that Medications are stored in an orderly manner in cabinets, drawers, or carts of sufficient size to prevent crowding. All medications, including treatment items, are stored in a locked cabinet. Medications are accessible only to licensed nursing personnel. Resident medication storage boxes do not contain non-medication items. The medications of each resident are stored in their original form as received from the pharmacy. Resident #28 was admitted with diagnoses including Asthma, Type 2 Diabetes, and Chronic Obstructive Pulmonary Disease (COPD). The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 8, which indicated that Resident #28 had moderately impaired cognition. The Quarterly Minimum Data Set assessment documented that Resident #28 had shortness of breath when lying flat. A review of the Comprehensive Care Plan titled Respiratory Disorder dated 6/25/2024 documented interventions that included administering medication as per the Physician's order, monitoring response to the medication, and assessing vital signs and pulse oximetry (measurement of the oxygen saturation in the blood). During an initial tour observation on 4/21/2025 at 10:59 AM, Resident #28 was sitting in their wheelchair outside their room. An unlabeled, clear bottle of Safetussin Chest and Cough Congestion with an expiration of 9/2025 was observed on top of Resident #28's nightstand next to their bed. Resident #28 was unable to verbalize where the medication came from. A review of Resident #28's electronic medical record revealed that Resident #28 did not have a Physician's order for the Safetussin Cough and Chest Congestion medication. During an interview on 4/21/2025 at 11:15 AM, the Registered Nurse #1, Unit Manager, stated Resident #28 was not assessed for self-medication administration and did not have an order for the cough medication. Registered Nurse #1 stated that Resident #28 had confusion and should not have had a bottle of cough medication unattended. During an interview on 4/22/2025 at 7:54 AM, Licensed Practical Nurse #1, the Medication and Treatment Nurse, stated that they did not see the bottle of cough medicine on Resident #28's nightstand. Licensed Practical Nurse #1 stated that Resident #28 should not have any medications unattended because Resident #28 was confused. During an interview on 4/25/2025 at 10:30 AM, the Licensed Pharmacist stated that Safetussin Cough and Chest Congestion medication could cause side effects, including drowsiness, dizziness, and at times nausea (urge to vomit). During an interview on 4/25/2025 at 1:32 PM, the Director of Nursing Services stated that all medications must be stored in the medication carts or in the medication room. 10NYCRR 415.18(e) (1-4)

Based on record review and interviews during the Recertification Survey initiated on 4/21/2025 and completed on 4/28/2025, the facility did not ensure its Facility Assessment considered specific staffing needs for each resident unit in the facility and for each shift, such as day, evening, and night. This was identified during the Sufficient and Competent Nurse Staffing Review Task. Specifically, the Facility Assessment, last updated on 3/5/2025, did not specify the number of Certified Nursing Assistants and Licensed Practical Nurses required to care for the resident population. Additionally, the facility assessment staffing plan did not specify the nursing staffing needs per unit per shift. The finding is: The facility's undated policy titled Facility Assessment documented that the facility assessment is conducted annually to determine and update the capacity to meet the needs of and competently care for our residents during day-to-day operations. Once a year, and as needed, a designated team conducts a facility-wide assessment to ensure that the resources are available to meet the specific needs of our residents. The facility assessment also includes a detailed review of the resources available to meet the needs of the resident population. This part of the assessment includes all personnel, including the Directors, Managers, Regular employees (full and part-time), Contracted staff (full and part-time), and Volunteers. The Facility assessment dated [DATE] documented the facility was licensed for 280 beds. The facility assessment identified a total of seven units, each with 40 beds, including: 2 South, a Subacute unit; 5 North, a secured Dementia unit; and 2 North, 3 North, 3 South, 4 North, and 4 South, which are Long-Term Care units. The facility assessment documented the nursing staff needed to provide competent support and care for the resident population included: two full-time Administration Registered Nurses; seven Registered Nurse Unit Managers on the 7:00 AM to 3:00 PM shift; two Registered Nurse Supervisors on the 3:00 PM to 11:00 PM shift; one Registered Nurse Supervisor on the 11:00 PM to 7:00 AM shift; one Infection Control nurse; and one Minimum Data Set full-time Registered Nurse. The facility assessment documented the facility employed full-time and part-time Certified Nursing Assistants and Licensed Practical Nurses. The facility assessment documented the total number of weekly nursing staff hours: Registered Nurses: 375 hours, Licensed Practical Nurses: 1,365 hours, and Certified Nursing Assistants: 4,080 hours. The facility assessment did not specify the number of Certified Nursing Assistants and Licensed Practical Nurses required to care for the resident population. The facility assessment staffing plan also did not outline the nursing staffing needs per unit per shift. During an interview on 4/23/2025 at 10:22 AM, Staffing Coordinator #1 stated the Administrator and the Director of Nursing provided them (the Staffing Coordinator) with the required nursing staffing levels for each unit and per shift. Staffing Coordinator #1 stated they had the nursing staffing requirements memorized, and did not have a document outlining the nursing staffing levels. During an interview on 4/23/2025 at 1:36 PM, the Director of Nursing Services stated that on the 7:00 AM to 3:00 PM shift, the long-term care units require four (4) Certified Nursing Assistants, and the 2 South unit and 5 North unit require five (5) Certified Nursing Assistants. The Director of Nursing Services stated that on the 3:00 PM to 11:00 PM shift, there are four (4) Certified Nursing Assistants on the 2 South unit and long-term units, and five (5) Certified Nursing Assistants on the 5 North unit. The Director of Nursing Services stated that on the 11:00 PM to 7:00 AM shift, there are three (3) Certified Nursing Assistants on the 2 South unit and 5 North unit, and two (2) Certified Nursing Assistants on the long-term units. The Director of Nursing Services stated the staffing requirements for Certified Nursing Assistants were not documented on the Facility assessment. The Director of Nursing Services stated they provide input to the Facility Assessment when requested by the Administrator; however, they were not sure how and by whom the number of Certified Nursing Assistants needed for each unit was determined. During an interview on 4/28/2025 at 10:38 AM, the Administrator stated they did not know how the staffing levels were determined. The Administrator stated that the facility's nursing staffing requirements were not documented in the facility assessment. The Administrator stated they did not know the nursing staffing levels per unit per shift should to be documented in the Facility Assessment. 10 NYCRR 415.26

Based on observation, record review, and interviews during the Recertification Survey initiated on 1/16/2024 and completed on 1/23/2024 the facility did not ensure each resident received adequate supervision to prevent accidents. This was identified for one (Resident #26) of three residents reviewed for Accidents. Specifically, Resident #26 was assessed as a high risk for falls, required extensive assistance of one person for transfers and toileting needs, and was to be placed in a high visibility area when awake as per the resident's Comprehensive Care Plan. On multiple occasions, the resident was observed going into the bathroom unassisted in their room to toilet themselves. The finding is: The facility's policy titled, Certified Nursing Assistant Accountability Record dated 11/16/2023, documented the certified nursing assistant reviews nursing instructions for each resident before providing care; in accordance with the plan of care, provides the necessary assistance the resident requires with each activity of daily living; and in the event that there is a change in resident's needs, the certified nursing assistant must report any changes directly to the charge nurse, if necessary and change is consistent, the physician will refer the resident to rehabilitation for changes in activities of daily living. The facility's untitled policy addressing Falls, dated 5/27/2023, documented it is the policy of this facility to ensure every resident is treated in a manner that reduces the risk of falls and falls-related injuries. The charge nurse completes the falls risk assessment--for a score greater than seven - reviews and implements falls-risk interventions, including making sure that the resident's personal belongings or frequently used items are within the resident's reach; Pause as you ask the resident if they need to go to the toilet and/or have brief changed; Keep the call bell within reach and encourage resident to use it when they need assistance; Ensure, where applicable, that all assistive devices are in place and operational such as eyeglasses, hearing aids, side rails (as enablers), chair, bed alarms, floor mats etc.; and Initiate a Falls Care Plan immediately. Resident #26 was admitted with diagnoses including Non-Alzheimer's Dementia, Cerebrovascular Accident, and Seizure Disorder. The 11/2/2023 Quarterly Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 3, indicating the resident had severe cognitive impairment. The Minimum Data Set documented that the resident had impairment to functional range of motion to bilateral lower extremities; used a walker and a wheelchair; and required partial/moderate assistance for toilet transfers, chair to chair transfers, walking, and toileting hygiene. The most recent Fall Risk assessment dated [DATE] documented a score of 13 indicating the resident was at high risk for falls. The Resident Nursing Instructions (care instructions provided to the Certified Nursing Assistants) currently effective from 1/1/2024-1/22/2024 documented the resident required extensive assistance of one person for transfers and toilet use. Under the monitoring section, the resident was to be monitored for safety precautions related to falls. A Comprehensive Care Plan titled, Actual Fall effective 1/24/2023 and last updated 4/15/2023, documented the resident had falls on 1/24/2023, 2/16/2023, 3/19/2023, 3/23/2023, and 4/15/2023. The interventions included but were not limited to place the resident in high visibility areas while the resident is awake; staff will toilet the resident every 2 hours and when needed and offer toileting during hourly rounds; dayroom Certified Nursing Assistant will sit or stand close to the resident while the resident is in dayroom; staff will keep resident out of bed and in eyes view of staff and redirect as needed. A Comprehensive Care Plan titled, Activities of Daily Living Functional/Rehab Potential effective 12/20/2022 and last updated 1/23/2024, documented interventions that included but were not limited to providing extensive assistance of one person for transfers. This intervention was entered on 1/5/2024. The Comprehensive Care Plan was updated on 1/23/2023 to indicate the resident now required one-person limited assistance with transfers. Resident #26 was observed on 1/16/2024 at 10:30 AM. The resident was self-propelling in their wheelchair from the day room to their own room. The resident was unassisted by staff. The resident was observed going into the bathroom alone in their room. The resident was asked by the surveyor if they needed help and the resident replied they did not need help. There were no staff members observed in the vicinity. On 1/18/2024 at 11:22 AM Resident #26 was not in their room. Licensed Practical Nurse #3 was at the nursing station and stated Resident #26 was in the day room. Upon observation, Resident #26 was not located in the day room. Certified Nursing Assistant #7, who was in the day room, was asked by the surveyor where Resident #26 was. Certified Nursing Assistant #7 looked around the day room and stated the resident was not in the day room. The resident was observed by the surveyor in the hallway in their wheelchair looking out the window. Certified Nursing Assistant #8, who was regularly assigned to Resident #26, was interviewed on 1/22/2024 at 9:03 AM. Certified Nursing Assistant #8 stated Resident #26 self-propels in the wheelchair and does not get into dangerous situations. Certified Nursing Assistant #8 stated the resident toilets and transferred themselves without any difficulties. Certified Nursing Assistant #8 stated they only checked on the resident if the resident was taking a long time in the bathroom because the resident wanted their privacy. On 1/22/2024 at 9:07 AM Resident #26 was observed self-propelling into their room from the hallway to use the bathroom. Certified Nursing Assistant #8 observed the resident and stated to the resident, Call me if you need me. The resident went into their bathroom alone and closed the door behind them. Registered Nurse #3 (unit manager) was interviewed on 1/22/2024 at 10:50 AM. Registered Nurse #3 stated Resident #26 self-propels their wheelchair around the unit. Registered Nurse #3 stated that the resident was a high risk for falls and needed assistance with toileting and transfers. The Certified Nursing Assistants should assist the resident in the bathroom, but the resident tries to be independent. Registered Nurse #3 stated they were aware that the resident was toileting themselves independently. A nursing note written by Registered Nurse #3 dated 1/22/2024 at 12:31 PM documented the resident was noted to need less assistance during toileting. A referral was placed for Occupational Therapy to evaluate the resident's toileting needs and for Physical Therapy to evaluate the resident's transfer needs. A Rehabilitation Department note, written by Physical Therapist #3 on 1/22/2024 at 2:29 PM, documented the resident was seen for an assessment following a nursing referral for improved performance during transfers. Upon assessment, the resident was able to perform transfers in and out of bed and from the toilet to a wheelchair with the limited assistance of one person; able to ambulate with a rolling walker with the limited assistance of one person up to 50 feet. The resident showed improvement in strength, balance, and overall function. Previously upon discharge from skilled physical therapy on 8/17/2023, the resident required extensive assistance of one person for transfers and ambulation. The resident would benefit from skilled physical therapy to improve transfers and ambulatory status in order to facilitate functional independence and safety. Physical Therapist #3 was interviewed on 1/22/2024 at 2:37 PM. Physical Therapist #3 stated when the resident was discharged from rehabilitation on 8/17/2023 they required extensive assistance of one person for transfers and walking. Physical Therapist #3 stated they screened the resident today after getting a referral from nursing. The resident was evaluated and was found to have improved functional status. The resident will now get rehabilitation therapy to improve strength and balance for safety. The resident has been attempting to toilet themselves but still needs cues and supervision from staff for safety. Physical Therapist #3 stated, as of now following the screen the resident is limited assist of one person for toileting and transfers. I still want the certified nursing assistant to help the resident because the resident had balance issues and was still a risk for falls. Registered Nurse #4, the Inservice Coordinator, was interviewed on 1/23/2024 at 8:21 AM. Registered Nurse #4 stated the aides are required to follow the instructions on the Resident Nursing Instruction form, and if there are any changes in the resident's abilities, the Certified Nursing Assistant should report the changes to the nurse. The nurse then reports to the Rehabilitation Department so an assessment can be done. Registered Nurse #4 stated, We want to give residents autonomy, but the staff have to be careful not to give too much autonomy if a resident is not independent and needs assistance with care. Registered Nurse #4 stated that Resident #26 should not be left alone because the resident was assessed as a high risk for falls and required extensive assistance of one person for toileting. The Director of Nursing Services was interviewed on 1/23/2024 at 9:06 AM. The Director of Nursing Services stated no one in a nursing home is truly independent, but the staff should be nearby monitoring the resident rather than leaving the resident alone. The Director of Nursing Services stated that Resident #26 should not have been left alone if they were assessed to be at high risk for falls and needed extensive assistance of one person for toileting. 10 NYCRR 415.12(h)(2)

Based on observations, record review, and interviews during the Recertification Survey initiated on 1/16/2024 and completed on 1/23/2024, the facility did not ensure that each resident who is fed by enteral means received treatment and services to prevent complications of enteral (tube) feeding including but not limited to aspiration pneumonia and vomiting. This was identified for one (Resident #184) of one resident reviewed for Tube Feeding. Specifically, Resident (#184), who was fed by enteral means, had a Physician's order to elevate the head of the bed at a 45-degree angle during and one hour after the tube feeding. Resident #184 was observed lying flat on their back 45 minutes after receiving the bolus (administration of a limited volume of enteral formula over a brief period) feeding. In addition, Licensed Practical Nurse #2 did not administer the enteral feeding to Resident #184 at the time prescribed by their physician. The finding is: The facility Policy and Procedure titled, Tube Feeding last revised on 5/10/2023 documented that Tube feeding would be given as per the physician's order. All residents are to remain in the Semi-[NAME] position (supine position in which the head of the bed is elevated between 30-45 degrees) during feeding and for one hour following the feeding to prevent aspiration. Resident #184 was admitted with diagnoses that include Cerebrovascular Disease, Unspecified Paraplegia, and Pelvic and Spine Fracture. The Minimum Data Set (MDS) assessment dated [DATE] documented that the resident's Brief Interview for Mental Status (BIMS) score was 99 which indicated the resident had severely impaired cognition. Resident # 184 required two-person assistance with bed mobility. The Minimum Data set documented the resident required a feeding tube to meet the total calories per day. The Comprehensive Care Plan (CCP) for Tube feeding dated 10/17/2023 and last updated on 11/01/2023 documented interventions, including an assessment for proper placement and patency of the tube, ensuring that the resident is in a comfortable and appropriate position to receive feeding 45-90 degrees angle while feeding and for at least an hour post feeding. Physician's orders dated 1/17/2024 documented to administer 2Cal HN (a nutritionally complete, high-calorie formula designed to meet increased protein and calorie needs) 237 milliliters via bolus feed four times a day at 10:30 AM, 2:00 PM, 7:00 PM, and 10:30 PM; Aspiration Precautions; and to keep the head of the bed elevated at 45 degrees during and one hour after meals. Resident #184 was observed lying flat in the bed in a supine position on 1/16/2024 at 10:44 AM. Resident #184 was observed lying flat in the bed in a supine position on 1/17/2024 at 11:15 AM. Licensed Practical Nurse #2, who administered the bolus tube feeding to Resident #184 on 1/17/2024, was interviewed on 1/17/2024 at 11:30 AM. Licensed Practical Nurse #2 stated that the bolus tube feeding administration for Resident #184 was completed at 10:30 AM. Licensed Practical Nurse #2 stated the head of the bed was elevated during the bolus feeding and they left the resident's room with the head of the bed elevated once they completed the tube feeding administration for Resident #184. Licensed Practical Nurse #2 stated they continued with the medication administration pass to other residents and did not return to Resident #184's room until now, at 11:15 AM. In an attempt to observe the bolus tube feeding administration, the surveyor contacted Licensed Practical Nurse #2 on 1/22/2024 at 9:15 AM. Licensed Practical Nurse #2 notified the surveyor that Resident #184 already received their bolus tube feeding at 9:00 AM. Licensed Practical Nurse #2 stated they decided to start the feeding earlier than the ordered time because they saw the resident in the hallway and they (Licensed Practical Nurse #2) wanted to save time by not going back to the resident's room later when the tube feeding was due to be administered at 10:30 AM. Licensed Practical Nurse #2 stated they should have administered the bolus tube feeding as per the physician's orders. Registered Nurse # 1, the Unit Manager, was interviewed on 1/22/2024 at 11:15 AM and stated they expected Licensed Practical Nurse #2 to follow the Physician's orders for timely administration of medications and tube feeding. Registered Nurse #1 stated they were not aware that Resident #184 received their tube feeding earlier than the prescribed time on 1/22/2024. Registered Nurse #1 further stated that the residents who are fed by tube feeding must not be placed in a flat position during and one hour after the feeding to prevent complications such as aspiration and vomiting. The Director of Nursing Services was interviewed on 1/22/2024 at 2:00 PM and stated that the nurse has a window of one hour before and one hour after the prescribed time to administer the medications ordered by the Physician. The Director of Nursing Services stated that the staff must follow the Physician's orders for medication and tube feeding administration including special instructions and parameters. The Director of Nursing Services stated that the nurses are responsible for making sure that the head of the bed is elevated during feeding and one hour after to prevent complications such as aspiration and vomiting. 10 NYCRR 415.12(g)(2)

Based on record review and staff interviews during the Recertification Survey initiated on 1/16/2024 and completed on 1/23/2024, the facility did not ensure that the medical care of each resident was supervised by the Physician, including monitoring changes in the resident's medical status. This was identified for one (Resident #75) of four residents reviewed for Nutrition. Specifically, Resident #75 had an 8.5% significant weight loss in 30 days identified in November 2023. The significant weight loss was not addressed by the resident's Primary Care Physician or Nurse Practitioner in the resident's Electronic Medical Record. The finding is: The facility's policy titled, Weight Protocol Policy and Procedure last reviewed on 8/23/2023 documented the Registered Nurses/Charge Nurses were responsible for obtaining weights for newly admitted or readmitted residents within 24 hours of their admission and obtaining a Physician's Order for weekly weights for four weeks and then monthly. The weights will be written in the Electronic Medical Record. The Registered Dietician will be responsible for addressing a confirmed weight gain/loss and informing the Medical Doctor of dietary recommendations (supplements, calorie count, weekly weights, etc.). The policy did not document any Primary Care Physician or Nurse Practitioner responsibilities. The facility's undated policy titled, Nutrition At Risk Committee documented that during the significant weight change meeting, the interdisciplinary team will discuss individuals (residents) who are assessed to be at nutritional risk. The meeting may consist of a Registered Dietitian, Director of Nursing Services, Assistant Director of Nursing Services, and unit (Registered Nurse) Nurse Manager. The Medical Director/Nurse Practitioner will attend as available. The committee will meet monthly or as needed to address the needs of high-risk residents. As significant weight changes are identified by the Registered Dietitian, the interdisciplinary team will be made aware of those residents at risk during the morning report (meeting). The Registered Dietitian will provide the list of individuals via email to be discussed at the meeting who present with a significant weight change: 5% in one month and 10% in 6 months. Each committee member will review the resident's medical record and complete a reassessment as appropriate. Clinical documentation of the medical record will be completed according to the results of the interdisciplinary team's decisions. The policy did not address the responsibilities of the Medical Providers related to documentation of the identified significant weight change. Resident #75 has diagnoses which include Type 2 Diabetes Mellitus and Hypertension. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident had intact cognitive skills for daily decision making. The resident required supervision or touching assistance for eating. The resident's height was 64 inches and they weighed 142 pounds. The Minimum Data Set did not document a weight loss of 5% or more in the last month or 10% or more in the last 6 months. The resident's Weight Monitoring Report documented that on 10/2/2023 the resident weighed 142.2 pounds and on 11/7/2023 the resident weighed 130.0 pounds which indicated a 12.2 pound or an 8.5% significant weight loss in 1 month. The Dietary Progress Note dated 11/7/2023, written by Registered Dietitian #1, documented that the resident had a significant weight loss. The resident's November weight of 128.5 pounds was rechecked to be 130 pounds which reflected a 12.2 pound weight loss or a 5% weight loss in one month. The resident was to start a 3-Day Calorie Count tomorrow and was placed on weekly weights for 4 weeks. The Medical Doctor was to be made aware. The Physician's Order dated 11/7/2023 documented a 3 Day Calorie Count to start Wednesday 11/8/2023 through Friday 11/10/2023. The order was signed by the Medical Director on 11/19/2023. The Physician's Order dated 11/7/2023 documented for the resident to have weekly weights times 4 weeks on Mondays. The order was signed by the Medical Director on 11/19/2023. The Dietary Progress Note dated 11/13/2023, written by Registered Dietitian #1, documented that the resident completed a 3-Day Calorie Count which was initiated for a significant weight loss over one month. Based on the results of the 3-Day Calorie Count, the resident's average caloric intake for just meals was 869 kilocalories per day and their average caloric intake for meals, snacks, and supplements was 1149 kilocalories per day which did not meet the resident's estimated caloric needs of 1773 kilocalories per day based on the resident's 11/7/2023 weight of 130 pounds. The weekly weight obtained today (11/13/2023) was noted to be 127.1 pounds which reflected a 2.9 pound weight loss in one week. The email titled, Significant Weight Change dated 11/24/2023 sent from Registered Dietitian #1 to the Corporate Registered Dietitian, the Director of Nursing Services, the Assistant Director of Nursing Services, and the Medical Director documented that there would be a Significant Weight Change Meeting held on 11/27/2023 after the morning report and that Resident #75' weight status would be discussed at that time. The Nursing Significant Weight Change Note dated 11/27/2023 documented that the resident's weight was 127.4 pounds as of 11/27/2023 and that new interventions put in place were weekly weights. The Dietary Progress Note dated 11/28/2023 documented that an interdisciplinary team meeting was held yesterday (11/27/2023) to discuss the resident's weight trend. The resident was recently addressed on 11/7/2023 for a significant weight loss over one month. The resident's weekly weight of 127.4 pounds for this week reflected a 2-pound loss in one week, and an overall weight loss of 2.6 pounds since the beginning of the month. The Monthly Medical Progress Note dated 12/4/2023 written by Nurse Practitioner #1 documented that the resident was seen on 11/30/2023. Appetite was good and a 3-pound weight loss was noted from 130 pounds to 127 pounds over the last four weeks. The Medical Progress Note did not address the resident's significant weight loss of 8.5% from October 2023 to November 2023. Registered Dietitian #1 was interviewed on 1/22/2024 at 9:45 AM and stated that they usually announce any significant weight losses in the morning report meeting. Registered Dietitian #1 stated that at the end of every month, Nursing and themselves (Registered Dietitian #1) hold a Significant Weight Change Meeting. Registered Dietitian #1 stated that they (Registered Dietitian #1), the Director of Nursing Services, all the Registered Nurse Unit Managers, the Wound Care Nurse, and the Medical Doctor, if available, are present at the meeting. Registered Dietitian #1 stated that the interventions put in place to prevent the resident from having further weight loss are discussed. Registered Dietitian #1 stated that the Medical Director was made aware of all significant weight losses in the facility through a Significant Weight Change Meeting monthly email. Registered Dietitian #1 stated that the Medical Director would then inform the resident's Primary Physician or Nurse Practitioner of the significant weight loss. Registered Dietitian #1 was interviewed again on 1/22/2024 at 1:45 PM for clarification of the weight loss percentage in their Dietary Progress Note dated 11/7/2023. Registered Dietician #1 stated that Resident #75 had a significant weight loss of 8.5 % from October 2023 to November 2023; however, in the Dietary Progress Note, they (Registered Dietician #1) documented that the resident only had a 5% weight loss. Registered Dietician #1 explained that if a resident loses at least 5% of their body weight in one month they only document a 5% weight loss even though the weight loss may be more than 5%. Nurse Practitioner #1 was interviewed on 1/22/2024 at 2:45 PM and stated that they were not aware that Resident #75 had a significant weight loss and were never informed about the significant weight loss. Nurse Practitioner #1 stated that the Registered Dietitian sends an email to the Medical Director monthly regarding notification of any significant weight loss. The Medical Director then forwards the information to them (Nurse Practitioner #1). Nurse Practitioner #1 stated that the reporting of a significant weight loss did not have to wait for the monthly Significant Weight Change Meeting email. The Registered Dietitian or Registered Nurse, Nurse Manager could also let them (Nurse Practitioner #1) know directly when they (Nurse Practitioner #1) are on the unit or by telephone call. Nurse Practitioner #1 stated they completed a monthly note for Resident #75; however, did not compare the October to November weights, they only looked at the November 2023 weights when they wrote the note. Nurse Practitioner #1 stated it was an oversight. The Director of Nursing Services was interviewed on 1/23/2024 at 10:10 AM and stated that when a significant weight loss is identified, Registered Dietitian #1 would request a reweigh. The Director of Nursing Services stated that if a significant weight loss was verified, the resident would be put on weekly weights. The Director of Nursing Services stated that the Registered Nurse Nurse Manager, Charge Nurse, or any Nurse should have notified the resident's Primary Care Physician or Nurse Practitioner of the significant weight loss and written a Nursing Progress Note documenting that they made them (Primary Care Physician or Nurse Practitioner) aware. The Director of Nursing Services stated that there was no Nursing Progress Note written indicating that the resident's Primary Care Physician or Nurse Practitioner was notified and there should have been. The resident's Primary Care Physician, who is also the facility's Medical Director, was interviewed on 1/23/2024 at 10:40 AM and stated that after they (Medical Director) get the Significant Weight Change email every month from Registered Dietitian #1, they (Medical Director) distribute it among the medical personnel for them to order blood work, review vital signs, review weight notes, and look for different causes which could have attributed to the resident's significant weight loss. The Medical Director stated that there was no direct documentation in place addressing the resident's significant weight loss by themselves or from the Nurse Practitioner and there should have been. 10 NYCRR 415.15(b)(1)(i)(ii)

Based on observation, record review, and interviews during the Recertification Survey initiated on 1/16/2024 and completed on 1/23/2024, the facility did not ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. This was identified for one (Resident #75) of five residents reviewed for Unnecessary Medications. Specifically, Resident #75 was started on Risperdal (Risperidone-an antipsychotic medication) on 8/21/2023 in an attempt to reduce the resident's non-compliant behavior of refusing to take their medications which is not the appropriate indication for the use of Risperdal. The finding is: The facility's policy titled, Psychoactive Medications last reviewed on 2/2023 documented to use psychoactive medications for residents who require psychoactive medications for various reasons such as Psychosis, Schizophrenia, Bipolar Disorder, Depression, Anxiety, Mood Disorders or Sleep Disorders under the direction of a Psychiatrist and Primary Care Physician. According to the Mayo Clinic Risperidone is used to treat schizophrenia, bipolar disorder, or irritability associated with autistic disorder. This medicine should not be used to treat behavioral problems in older adults who have dementia. According to the Physician Desk Reference (PDR), the boxed warning for Risperidone includes: Antipsychotics are not approved for the treatment of dementia-related psychosis in geriatric adults and the use of Risperidone should be avoided if possible due to an increase in morbidity and mortality in elderly adults with dementia receiving antipsychotics. The Beers Criteria considers antipsychotics to be potentially inappropriate medications (PIMs) in elderly patients except for treating Schizophrenia, Bipolar Disorder, and nausea/vomiting during chemotherapy. The Beers panel recommends avoiding antipsychotics in geriatric patients with Delirium, Dementia, or Parkinson's disease. Non-pharmacological strategies are first-line options for treating delirium- or dementia-related behavioral problems unless they have failed or are not possible and the patient is a substantial threat to self or others. Resident #75 has diagnoses which include Type 2 Diabetes Mellitus, Hypertension, Atrial Fibrillation, and Unspecified Dementia with Agitation. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident had intact cognitive skills for daily decision making. The Minimum Data Set indicated the resident did not exhibit any potential indicators of Psychosis or behavioral symptoms in the Minimum Data Set look-back period. The Nursing Progress Note dated 8/16/2023, written by Registered Nurse #2 who was the Nurse Manager, documented that the resident was noted with noncompliance with their medication regime despite encouragement. Nurse Practitioner #1 was made aware of the resident's noncompliance. Nurse Practitioner #1 ordered blood work and a Psychiatric Consultation. The Physician's Order dated 8/16/2023 documented to obtain Psychiatric Consultation secondary to Noncompliance with medication. The Medical Progress Note dated 8/20/2023, written by the Psychiatric Nurse Practitioner, documented that the resident was seen on 8/17/2023. The reason for the consult was an initial psychiatric appointment and assessment of mood/medication. The resident's psychiatric history was Major Depressive Disorder and Vascular Dementia as per the Electronic Medical Record. The resident has been refusing medication/non-compliance with no episodes of aggression or agitation. The Psychiatry review of symptoms revealed no reported Psychotic/Manic symptoms, Major Depressive symptoms, or Anxiety symptoms. Diagnoses: Major Depressive Disorder, Vascular Dementia per chart, and Unspecified Psychosis. Plan: Start Risperidone 0.5 milligrams daily at hour of sleep for Psychosis. The Physician's Order dated 8/21/2023 documented for the resident to receive Risperidone 1 milligram per milliliter oral solution - give 5 milliliters (5 milligrams) by oral route once daily at bedtime for Unspecified Dementia, Unspecified Severity, with Agitation. The Psychiatric Nurse Practitioner had recommended to start 0.5 milligrams daily at hour of sleep for Psychosis as per the above Medical Progress note dated 8/20/2023. The Nursing Progress Note dated 8/22/2023 written by Registered Nurse #2 who was Nurse Manager, documented that the resident was seen by the Psychiatric Nurse Practitioner on 8/17/2023 for noted behavior of refusing medications and aggressive behavior. Received recommendation to start Risperidone 0.5 milligrams daily at hour of sleep for Psychosis. Nurse Practitioner #1 was made aware of and agreed with the plan of care. The Nursing Progress Note dated 8/23/2023 written by Registered Nurse #2 documented that the resident was noted to continue to refuse medications as ordered despite encouragement. Nurse Practitioner #1 was made aware and ordered a Psychiatric Evaluation regarding the resident's medication refusal. The Physician's Order dated 8/23/2023 documented for the resident to have a Psychiatric Consultation; Reason: Medication Refusal. The Medical Progress Note dated 9/3/2023, written by the Psychiatric Nurse Practitioner, documented that the resident was seen on 8/31/2023. The reason for the consult was: Follow-up appointment and assessment of mood/medication. The resident was referred for continued non-compliance and continuing to refuse medication as per staff. As per staff, there have been no episodes of aggression or agitation. The Psychiatry review of symptoms revealed no reported Psychotic/Manic symptoms, Major Depressive symptoms, and Anxiety symptoms. No Delusions or Paranoia. Diagnosis: Major Depressive Disorder, Vascular Dementia per chart, and Unspecified Psychosis. Plan: Increase Risperidone to 0.5 milligrams 2 times per day for Psychosis. The Physician's Order dated 9/5/2023 documented for the resident to receive Risperidone 1 milligram per milliliter oral solution - give 0.5 milliliters (0.5 milligrams) by oral route 2 times per day for Unspecified Dementia, Unspecified Severity, with Agitation. Despite the Psychiatric Nurse Practitioner recommending an increase in the resident's Risperidone, this Physician's Order was actually a decrease in the medication dosage because when the Risperidone was first ordered on 8/21/2023, the order was transcribed incorrectly as 5 milliliters (5 milligrams) by oral route once daily. The Physician's Order dated 9/27/2023 documented for the resident to have a Psychiatric Consultation. The Medical Progress Note dated 10/1/2023, written by the Psychiatric Nurse Practitioner, documented that the resident was seen on 9/28/2023. The reason for the consult was: Follow-up appointment and assessment of mood/medication. The resident was referred for continued non-compliance, continuing to refuse medication as per staff, and for being agitated and aggressive towards staff. The Psychiatry review of symptoms revealed no reported Psychotic/Manic symptoms, Major Depressive symptoms, and Anxiety symptoms. No Delusions or Paranoia. Diagnosis: Mood Disorder, Major Depressive Disorder, Vascular Dementia per chart, and Unspecified Psychosis. Assessment: Will switch psychotropics to liquid form to promote compliance. Plan: Switch to liquid Risperidone to 0.5 milligrams 2 times per day for Psychosis. A review of the resident's Physician Orders revealed no change of the resident's Risperidone medication to liquid form as the resident was already receiving the Risperidone medication as a liquid. The Nursing Progress Note dated 10/4/2023 documented that Registered Nurse #2 had a meeting with the resident and the resident's Social Worker (Social Worker #1) regarding their medications and refusal of blood work. The resident stated there were some medications they would not take because the medications hurt their stomach and the resident believes they did not need these medications. The resident had been refusing several medications for months. The resident's overall mood had been stable and no agitation was noted at that time and in the past few weeks. The resident agreed to be compliant with some medications and with blood work. The medication regime was reviewed with Nurse Practitioner #1. Nurse Practitioner #1 ordered to change the resident's blood sugar monitoring with insulin coverage to twice a day, discontinue Vitamin C, discontinue Senna (laxative medication), discontinue ferrous sulfate (Iron supplement), discontinue Gabapentin (anticonvulsant medication), discontinue Mirtazapine (antidepressant medication), and discontinue Sertraline (antidepressant medication). The Medical Progress Note dated 10/22/2023, written by the Psychiatric Nurse Practitioner, documented that the resident was seen on 10/19/2023. The reason for the consult was: Follow-up appointment and assessment of mood/medication. As per staff, the resident's mood was stable and at baseline with no reported psychiatric distress. The Psychiatry review of symptoms revealed no reported Psychotic/Manic symptoms, Major Depressive symptoms, and Anxiety symptoms. No delusions or paranoia. Diagnosis: Mood Disorder, Major Depressive Disorder, Vascular Dementia per chart, and Unspecified Psychosis. Assessment: No increase in anxiety or mood dysregulation. Plan: Continue current regime - mood stable. The Nursing Progress Note dated 10/27/2023, written by Registered Nurse #2, documented that the resident refused their medications despite encouragement. The resident was educated on the importance of taking their medications. The resident stated that they did not want to continue to take certain medications, including: Janumet (a Type 2 diabetes medication) 50 milligram-1,000 milligram tablet. Nurse Practitioner #1 was made aware of the resident's concerns and ordered as per the resident's request to discontinue Janumet 50 milligram-1,000-milligram tablet; Risperidone was changed to 0.5 milligrams once in the evening, and Magnesium 1 tablet was changed to daily. The resident agreed to be compliant with their medication regime. The Physician's Order dated 10/27/2023 documented to administer Risperidone 1 milligram/milliliter oral solution - give 0.5 milliliters (0.5 milligrams) by oral route once daily in the evening for Dementia, unspecified severity, with agitation. The Nursing Progress Note dated 11/16/2023, written by Registered Nurse #2, documented that at times the resident refuses their medication and fingersticks. The resident's primary language was Spanish and an interpreter was provided by Social Worker #1. The Interpreter stated that the resident stated that they did not want to take any pills, but would check their blood sugar and take their insulin. The resident was educated on the importance of taking their medications. Nurse Practitioner #1 was made aware and ordered to continue to encourage the resident to take their medications as ordered. The Physician's Order dated 11/29/2023 documented to obtain a Psychiatric Consultation. The Medical Progress Note dated 12/3/2023, written by the Psychiatric Nurse Practitioner, documented that the resident was seen on 11/30/2023. The reason for the consult was: Follow-up appointment and assessment of mood/medication. The resident had no episodes of aggression or agitation. The Psychiatry review of symptoms revealed no reported Psychotic/Manic symptoms, Major Depressive symptoms, and Anxiety symptoms. No delusions or paranoia. Diagnosis: Mood Disorder, Major Depressive Disorder, Vascular Dementia per chart, and Unspecified Psychosis. Assessment: No increase in depression, anxiety, or Mood dysregulation. Plan: Continue current regime - mood stable. The Nursing Progress Note dated 12/8/2023, written by Registered Nurse #2, documented that the resident refused medications at times despite education on refusal of medications. Nurse Practitioner #1 and Social Worker was made aware. The resident agreed to try to be compliant with taking their medications. Registered Nurse #3, the Nurse Manager, was interviewed on 1/19/2024 at 1:55 PM and stated that Resident #75 is legally blind and sometimes hits staff because of trouble seeing. Registered Nurse #3 stated that the resident would get agitated sometimes. Registered Nurse #3 stated that the resident was started on Risperidone to see if there was anything psychologically going on that was causing the resident to refuse their medications. Certified Nursing Assistant #11 was interviewed on 1/19/2024 at 2:30 PM and stated that they were the resident's regular 7 AM-3 PM Certified Nursing Assistant and had cared for the resident for months. Certified Nursing Assistant #11 stated that the resident had never been aggressive with them, but that the resident prefers to do things the way they (Resident #75) want to do. Licensed Practical Nurse #2 was interviewed on 1/22/2024 at 11:00 AM and stated that they were the regular 7 AM-3 PM Nurses who gave Resident #75 their medication. Licensed Practical Nurse #2 stated that they had never seen the resident agitated or aggressive. Licensed Practical Nurse #2 stated that the resident understood the importance of taking their medicine; however, would just choose not to take their medications sometimes. The Psychiatric Nurse Practitioner was interviewed on 1/22/2024 at 12:30 PM and stated that based on collateral reports, staff told them (Psychiatric Nurse Practitioner) that the resident was not taking any of their medications. The Psychiatric Nurse Practitioner stated that the symptoms of psychosis the resident was exhibiting was that they (Resident #75) told staff that they were poisoning the resident. The Psychiatric Nurse Practitioner stated that they recommended the resident be given Risperidone to treat their refusal of medication and to stabilize them, so the resident would take their medication and not end up in the hospital due to medical complications. The Psychiatric Nurse Practitioner stated that they do not prescribe medication, but assess and give their opinion what medication would be appropriate and if the Physician is in agreement, they (Physician) order the medication. The Psychiatric Nurse Practitioner stated that it was a resident's right to refuse their medication; if the resident could make that decision and understand the harm. The Psychiatric Nurse Practitioner stated that they had never assessed the resident to determine their capacity to make medical decisions. Nurse Practitioner #1 was interviewed on 1/22/2024 at 2:15 PM and stated that the resident was refusing a lot of their medications, so to help with their (Resident #75) compliance, they were started on Risperidone. Nurse Practitioner #1 stated that they used the resident's Spanish-speaking Social Worker (Social Worker #1) as an interpreter because although the resident understood English, they (Nurse Practitioner #1) wanted to make sure that the resident understood everything as their primary language was Spanish. Nurse Practitioner #1 stated that the resident felt that some of the medications were not good for their body, and by giving them all these medications, we were trying to kill them (Resident #75). Nurse Practitioner #1 stated that residents have a right to refuse their medication, but prior to August 2023, the resident was refusing all of their medications and that was why they (Nurse Practitioner #1) ordered a Psychiatric Consultation for the resident to try and help with their care. Nurse Practitioner #1 stated that they were hoping that when a certain level of Risperidone was reached in the resident's system, it would calm the resident down and encourage compliance with taking their medication. The facility's Medical Director who is also the resident's Primary Care Physician was interviewed on 1/23/2024 at 9:30 AM and stated that they (Medical Director) would defer to the Psychiatric Nurse Practitioner's recommendation to see if a trial of Risperidone would settle the resident down to help them take their medications. The Medical Director stated that if the Psychiatric Nurse Practitioner recommended the Risperidone, they (Medical Director) would order the medication because it is their (Psychiatric Nurse Practitioner) expertise. Social Worker #1 was interviewed on 1/23/2024 at 12:55 PM and stated the resident had told them (Social Worker #1) that they (Resident #75) did not like the aftertaste of medications and found them bitter tasting and that was why they (Resident #75) often refused to take their medication. Social Worker #1 stated that even though Nurse Practitioner #1 spoke Spanish, they (Social Worker #1) had also met with the resident to make sure they understood the importance of taking their medication. Social Worker #1 stated that the resident understood everything that was said to them (Resident #75) at these meetings and that the resident was alert and oriented times three (person, place, and time). Social Worker #1 stated that they speak to the resident on a daily basis and they have never found the resident to be paranoid or hallucinatory. 10 NYCRR 415.12(l)(2)(i)

Based on the observation, record review, and interviews during the Recertification survey completed on 12/21/2021, the facility did not ensure that each resident environment remained free from accident hazards. This was identified for one (Resident #124) of seven residents reviewed for Accidents. Specifically, Resident #124's room was observed with sharp metal that was protruding out of the heating/ventilation unit. The finding is: The Facility Environmental Maintenance Policy reviewed on 11/28/2021 documented that all staff should report any issues regarding equipment that may need repair to the Maintenance Director, so the problem can be addressed in a timely manner. Resident #124 was admitted with diagnoses including Depression and Hypertension. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #124 had intact cognition. The MDS documented Resident #124 required extensive assistance of two staff members for walking in the room. The MDS also documented Resident #124 required limited assistance of one person for locomotion on the unit. The resident utilized a wheelchair and a walker. During an observation on 12/20/2021 at 11:53 AM, Resident #124 was observed self-propelling their wheelchair in their (Resident #124) room and a sharp metal part was observed protruding from the heating/ventilation unit in Resident #124's room. During a subsequent observation on 12/20/2021 at 11:59 AM, with Maintenance Worker #8, the sharp metal part protruding from the heating/ventilation unit in Resident #124's room was observed. Maintenance Worker #8 measured the protruding part and determined the protruding part was 2 feet long. Maintenance Worker #8 was interviewed immediately after the observation on 12/20/2021 at 11:59 AM and stated that the heating/ventilation unit was broken, and the protruding metal was part of the heating and ventilation unit. Maintenance Worker #8 stated that they (Maintenance Worker #8) were unaware that the heating unit was broken until now. Maintenance Worker #8 stated that they (Maintenance Worker #8) were not informed of any issue related to Resident #124's heating and ventilation unit until today. Maintenance Worker #8 stated weekly rounds were conducted to ensure all equipment was in proper working condition however, the facility did not keep a log or documentation of the weekly rounds. The Director of Environmental Services was interviewed on 12/21/2021 at 3:40 PM and stated that the protruding metal part from the heating unit is not normal and was not safe for Resident #124. The Director of Environmental Services stated that they (Director of Environmental Services) were not informed of any issues related to the heating and ventilation unit in Resident #124's room and expected staff to report safety concerns to the maintenance department immediately to prevent accidents. The Director of Environmental Services further stated that the heating and ventilation unit in Resident #124's room will be replaced immediately. 415.12(h)(2)

Based on observation, record review, and interviews during the Recertification Survey completed on 12/21/2021, the facility did not ensure that each resident who needs respiratory care is provided such care consistent with professional standards of practice and their comprehensive person-centered care plan. This was identified for one (Resident # 494) of one resident reviewed for Respiratory care. Specifically, Resident #494 was observed receiving oxygen at a flow rate of 4 liters per minute (L/min) via a nasal cannula (tubing used to deliver supplemental oxygen) without a Physician's order. The finding is: The facility policy and procedure for oxygen, revised in October 2020 documented to ensure there is a Physician's order for oxygen use. Resident #494 was admitted with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of one which indicated the resident had severely impaired cognition. The MDS did not indicate Resident #494 utilized oxygen therapy. The Comprehensive Care Plan (CCP) for Cardiac Disease dated 12/9/2021 documented the resident may use supplemental rescue oxygen as needed (PRN) at 2 L/min via nasal cannula as per the Physician's order and or if the oxygen saturation rate falls below 93%. The CCP for Respiratory care dated 2/9/2021 documented interventions including but not limited to administering respiratory medications as ordered. The CCP did not include the use of oxygen as an intervention. Resident #494 was observed in their room in bed on 12/14/2021 at 10 AM receiving oxygen via a nasal cannula at a flow rate of 4 liters per minute. Resident #494 was again observed on 12/14/2021 at 3 PM receiving oxygen via a nasal cannula at a flow rate of 4 liters per minute. In a subsequent observation on 12/15/2021 at 10:45 AM Resident #494 was observed in their room in bed receiving oxygen via a nasal cannula at a flow rate of 4 liters per minute. A review of the Physician's orders from 12/7/2021 to 12/15/2021 was conducted. The Physician's orders did not include an order to administer oxygen therapy to Resident #494. A review of the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) from 12/7/2021 through 12/15/2021 was conducted. Both the MAR and the TAR did not indicate evidence of oxygen administration for Resident #494. The Licensed Practical Nurse (LPN) #5, Medication Nurse, was interviewed on 12/20/2021 at 3:40 PM and stated that they (LPN #5) were the assigned nurse for Resident #494. LPN #5 stated that the resident was receiving supplemental oxygen continuously and LPN #5 made sure that the oxygen concentrator was functioning properly. LPN #5 stated that they (LPN #5) were not aware that Resident #494 did not have a Physician's order to administer oxygen therapy. LPN #5 stated that they did not check Resident #494's physician's order for oxygen administration. LPN #5 further stated that they (LPN #5) did not sign the MAR or the TAR for Resident #494 to indicate the resident was administered oxygen therapy. LPN #5 stated that there should have been a Physician's order to administer oxygen therapy. Registered Nurse (RN) #4 was interviewed on 12/20/2021 at 3:46 PM and stated Resident #494 was receiving oxygen therapy, however, they (RN #4) were not aware that the resident did not have a Physician's order for oxygen administration. RN # 4 stated that there should have been a Physician order to administer oxygen to a resident and they (RN #4) did not know the reason why Resident #494 did not have a Physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Director of Nursing Services (DNS) was interviewed on 12/21/2021 at 11:15 AM and stated they (DNS) were unaware Resident #494 was receiving oxygen without a Physician's order. The DNS further stated that a Physician's order should have been obtained for oxygen use for Resident #494 as per the facility's policy. The Primary Care Physician (PCP) was interviewed on 12/21/2021 at 11:56 AM and stated that they (PCP) did not know Resident #494 needed oxygen. The PCP stated that they (PCP) were not contacted by facility staff to obtain orders for Resident #494 regarding oxygen administration. The PCP stated that Resident #494 should have had a Physician's order for oxygen administration. 415.12(k)(6)

Based on observation, interviews, and record review during the Recertification Survey and the Abbreviated Survey (Complaint #NY 905) completed on 12/21/2021, the facility did not ensure there was no more than 14 hours between a substantial evening meal and breakfast the following day for one (Resident #88) of 5 residents reviewed for Food and Nutrition. Specifically, Resident #88 verbalized that the time between dinner and breakfast next morning was too long and they (Resident #88) did not consistently get a midnight snack and felt hungry at night. The finding is: An undated document titled Meal Delivery documented the mealtimes were approximate to when the trays/meals would arrive on the 3rd floor: Supper: Unit 3 North: 5:00 PM Unit 3 South: 5:30 PM Breakfast: Unit 3 North: 8:00 AM Unit 3 South: 8:30 AM The mealtimes for the units on the third floor included a lapse of 15-hours between the evening and breakfast meals the following day. Resident #88 was admitted with diagnoses including Low Back Pain, Hypertension and Hyperglyceridemia. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident had intact cognition. Resident #88 had no chewing and swallowing problems and received a therapeutic diet (Low salt, Diabetic, Low cholesterol). The Comprehensive Care Plan (CCP) for Nutrition dated 10/21/2019 documented Resident #88 has potential for nutrition alteration secondary to therapeutic diet for Hypertension and [CONDITION(S)] and the resident was not compliant with their diet. The interventions included to provide a Regular, no added salt (NAS), low fat diet and to provide nourishment: juice with breakfast/lunch/supper; yogurt and 2 servings of cottage cheese with breakfast. The Physician's order dated 1/8/2021 documented to provide a diet with no added salt (Low sodium). The resident may have bacon and sausage when on the menu. The Nutrition assessment dated [DATE] documented that Resident #88 was on NAS Regular diet with no supplements or nourishments. Resident #88 was non-compliant with diet related to requesting extra sandwiches with meals. The resident council minutes for October, November and December 2021 were reviewed and there were no documented discussions related to the time lapse between evening meal and breakfast the following day. Resident #88 was interviewed on 12/14/2021 at 12:23 PM and stated they (Resident #88) had requested extra sandwiches on their meal tray to eat at a later time at night because Resident #88 is not offered a snack after supper and gets hungry at night. Resident #88 further stated that often they do not receive the sandwich on their meal tray to eat at a later time. Resident #88 stated they (Resident #88) would often go down to the food service supervisor's office to request a sandwich. The Dietitian was interviewed on 12/17/2021 at 9:42 AM and stated that a high-protein substantial snack was not offered to all residents in the facility every night. The Dietitian stated that evening snacks were entered into the food service management system (Meal Track) for specific residents if found to be clinically necessary or as per resident's request. The Dietitian stated that Resident #88 did not receive bedtime (HS) snack at this time. The Dietitian stated that Resident #88 was not compliant with their diet and often requested extra food. The Dietitian stated that they (Dietitian) gave extra sandwiches to Resident #88 with the meals, however, the resident does not receive a sandwich or snacks at night. The Food Service Director (FSD) was interviewed on 12/20/2021 at 9:32 AM and stated that the meal delivery time for the breakfast and dinner meals had remained unchanged for at least 3 years. The FSD was aware that the hour lapse between the dinner and breakfast meals the following day was 15 hours but was not aware that there must be no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack is served at bedtime. The FSD stated that the facility did not provide a substantial nourishing snack to all residents at bedtime. The Director of Recreation was interviewed on 12/21/2021 at 4:10 PM and stated that they (Director of Recreation) reviewed monthly resident council meeting minutes. The Director stated that they did not recall any minutes that documented a discussion of the time lapse between meals with the resident council members. The Director of Recreation further stated that if the time lapse between meals was discussed, the discussion would have been recorded into the minutes during the resident council meeting. The Director of Nursing Service (DNS) was interviewed on 12/17/2021 at 1:52 PM and stated the facility did not provide a substantial snack to all the residents after dinner. The DNS stated that only residents who were identified by the Dietitian to have needs and residents who requested extra bedtime snacks would be provided snacks at bedtime. All other residents usually were provided with juice and cookies every night. The DNS was not aware that the hour lapse between the dinner and breakfast meals the following day was 15 hours. The DNS stated that the facility did not have a policy on bedtime snack distribution. 415.14(h)

Based on observation and interviews during the Recertification Survey completed on 12/21/2021, the facility did not make staffing information readily available to residents and visitors. Specifically, daily staffing was not observed posted in a prominent area in the facility on 12/16/2021. The finding is: During a tour of the facility on 12/16/2021 from 10:35 AM to 10:45 AM the Nursing Staffing information was not observed posted at a prominent area in the facility including the entrance lobby, receptionist desk, and the elevators. The Staffing Coordinator was interviewed on 12/16/2021 at 11:50 AM and stated they (staffing coordinator) were not aware of the requirement to post the daily nursing staffing in a prominent area that was accessible to residents and visitors at all times. The Director of Nursing Services (DNS) was interviewed on 12/16/2021 at 1:07 PM and stated that the daily nursing staffing should be posted in an area that was accessible to everyone. The DNS expected that the staffing coordinator would post the daily nursing staffing during the day shift. During the evening and night shifts the nursing supervisors are responsible to post the daily nursing staffing on their respective shifts. The DNS stated that the daily nursing staffing was usually posted on the bulletin board by the elevators. The DNS stated they (DNS) were not aware that the daily nursing staffing was not posted. 415.13

Based on observation, record review, and interviews during the recertification survey, the facility did not ensure the Comprehensive Care Plans (CCPs) were developed and implemented for each resident with person-centered measurable objectives and timeframes to meet the residents' specific medical and nursing needs as identified in the comprehensive assessments. This was evident for 1 (Resident #249) of 2 residents reviewed for catheter, and for 1 (Residents #92) of 3 residents reviewed for positioning. Specifically, 1) Resident #249's CCP developed for Foley Catheter (F/C) use had inaccurate and inappropriate interventions which are not related to the use of a Supra Pubic Tube (SPT)/FC tube. The interventions addressed a resident who is toileted for urination; 2) Resident #92 had orders for a left (L) wrist brace. The resident was observed on two occasions without the (L) wrist brace applied. The findings are: 1) The facility policy titled Catheter Care, effective date (MONTH) 1995, Page 2, Section 1 j. Check the position of the catheter and drainage bag to assure a non-obstructed downhill flow of urine. The drainage bag must always remain below the level of the bladder, the tubing should be placed over the leg and a privacy bag will be provided. Resident #249 has [DIAGNOSES REDACTED]. The resident was readmitted to the facility from the hospital on [DATE]. The 5-day Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. The MDS documented the resident's Urinary Continence was not rated due to the resident having a catheter. The Physician's admission orders [REDACTED]. The CCP titled [MEDICAL CONDITION], initiated 5/3/19, documented the resident should verbalize discomfort when voiding and to monitor for urinary urgency, frequency, hesitancy and dribbling. The CCP titled Foley Catheter dated 5/3/19 and revised 6/17/19, documented that the resident was at risk for Urinary Tract Infection [MEDICAL CONDITION]. The interventions included to monitor for signs and symptoms of discomfort with urination and the frequency of urination. The CCP documented that the resident has a FC. There were no interventions addressing FC care that included the use and care of the drainage bag and the collection and monitoring of the urine. The CCP for toilet use, initiated 5/3/19 and revised 6/17/19, documented interventions which included to educate the resident/family on proper drainage of catheter bags. The resident had a physician's orders [REDACTED]. This information was not updated as part of the plan of care. The resident was observed on 6/18/19 at 10:44 AM. The resident had a FC tube in place with a bedside drainage bag holding a moderate amount of clear, amber colored urine. The resident stated that he has been utilizing a FC since his admission in (MONTH) 2019. The Registered Nurse (RN)/MDS Coordinator was interviewed on 6/24/19 at 12:30 PM. The RN stated that it was the responsibility of the MDS department to complete the resident's CCPs for FC, Toilet Use and [MEDICAL CONDITION]. The RN stated that the CCPs for Resident #249 should have been more specific. The Director of Nursing Services (DNS) was interviewed on 6/24/19 at 1:00 PM and stated that the CCP was not specific for the resident's FC and Toilet Use. 2) The facility's policy and procedure titled Provision of Splint, Supportive, and Self-Help Devices dated 11/2018 documented 1) All splints and supportive devices will be prescribed by the Physician . 3) Once the device is received, the resident and nursing staff will be given directions in the proper use of the device and its care. Instructions will include when and how long the resident is to wear the device . Resident #92 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Quarterly MDS assessment dated [DATE] documented the resident had short and long term memory problems and the resident was severely impaired in cognition. The resident required extensive assistance of one person for eating. The MDS documented the resident had impairment of functional limitation in range of motion of one upper extremity. The CCP developed for at risk for potential for decline in musculoskeletal status demonstrating weakness on bilateral lower extremities (BLE) and upper extremities (UEs) affecting functional Activities of Daily Living (ADLs) and mobility related to Dementia, dated 5/2/18 and currently revised on 4/15/19, documented a goal for the resident to be able to maintain a functional resting position of the left wrist with use of an adaptive device and will not develop contractures through the next review. Interventions included to provide a Left wrist brace to be worn all the times except during ADL care, bed time, and PRN. The physician's orders [REDACTED]. The resident was observed in the dining room on 6/18/19 at 10:00 AM and on 6/19/19 at 12:20 PM not wearing the left wrist brace. The Licensed Practical Nurse (LPN) Unit Charge was interviewed on 6/19/19 at 12:20 PM. The LPN stated that the resident was not wearing the left wrist brace and the wrist brace should be applied. The resident's room was inspected with LPN Unit Charge Nurse. The wrist brace found inside the night stand table drawer. CNA #1 was interviewed on 6/20/19 at 8:38 AM. CNA #1 stated that the left wrist brace was not applied and the brace should be applied. CNA #1 stated that she might have forgotten to apply the brace. 415.11(c)(1)

Based on record review and staff interviews during the Recertification Survey the facility did not ensure that each resident was given the appropriate treatment and services to maintain or improve his or her ability to carry out activities of daily living, including ambulation. This was identified for one (Resident #138) of one resident reviewed for Activities of Daily Living (ADLs). Specifically, Resident #138 had a physician's orders [REDACTED]. The resident frequently refused the FAP, and there was no documented evidence that nursing supervision or the Rehabilitation (Rehab) Department was notified. The finding is: The facility's policy titled Nursing Rehabilitation Policy dated (MONTH) (YEAR) documented that multiple refusals of the FAP greater than ten days should be brought to the attention of the supervisor. Resident #138 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 5/5/19 Quarterly Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 10, indicating the resident had moderate cognitive impairment. The resident required extensive assistance of one person for transfers out of bed and chair and that walking in the room and corridor did not occur. The resident had no functional limitation in range of motion and utilized a wheelchair for mobility. A Physical Therapy (PT) discharge recommendation dated 5/6/19 recommended a FAP with the nursing unit Certified Nursing Assistant (CNA), 50 feet with a rolling walker and limited assist of one person during nursing care for 15 minutes per day. A physician's orders [REDACTED]. A Comprehensive Care Plan (CCP) initiated 1/26/19 documented that the resident had alteration in Musculoskeletal status demonstrating weakness of bilateral upper and lower extremities affecting functional mobility and ADL skill performance related to [DIAGNOSES REDACTED]. An intervention in the care plan included to follow the Physician orders [REDACTED]. A CCP effective 2/6/19 documented that the resident is non-compliant with daily care needs. An update on 6/19/19 documented that the resident refused the FAP by CNA. Review of the (MONTH) 2019 CNA Accountability Record (CNAAR) revealed that for the day shift, starting 5/6/19-5/31/19, there were 21 refusals or not applicable codings for the FAP with 5/25/19 left blank. For the evening shift, starting 5/6/19-5/31/19, there were 9 refusals for the FAP with 5/16/19 left blank. Review of the (MONTH) 2019 CNAAR revealed for the day shift, starting 6/1/19-6/19/19, there were 18 refusals or not applicable codings for the FAP with 6/12/19 left blank. For the evening shift, starting 6/1/19-6/19/19, there were 13 refusals or not applicable codings for the FAP with 6/1/19, 6/2/19, 6/15/19, and 6/16/19 left blank. The resident's day shift CNA was interviewed on 6/19/19 at 1:45 PM. She stated the resident does not want to walk with her and she always refuses. She stated that sometimes she helps the resident walk to the bathroom in her room, but not every day. She stated she did not remember how many times the resident walked in her room and that she let the nurse know about the refusals. The Director of the Rehabilitation (Rehab) Department was interviewed on 6/19/19 at 2:18 PM. She stated Resident #138 was discharged from skilled Rehab on 5/4/19 with a recommendation of 50 feet on the FAP with the unit CNA. She stated if the nursing staff was having a problem walking the resident on the FAP, then the resident's refusals should have been reported to the Rehab Department. She stated she has not heard of any problems related to Resident #138's FAP. She stated that when the resident was discharged from PT in (MONTH) 2019 the resident was able to walk about 50-75 feet. Resident #138's Licensed Practical Nurse (LPN) medication nurse was interviewed on 6/20/19 at 8:03 AM. She stated that no one reported to her that the resident was refusing to ambulate on the FAP. The Registered Nurse (RN) Unit Supervisor was interviewed on 6/20/19 at 8:06 AM. She stated that just yesterday (6/19/19) the CNA reported to her that the resident has been refusing to ambulate on the FAP. She stated she was unaware that the resident was refusing until 6/19/19. The Rehab Director was re-interviewed on 6/20/19 at 9:42 AM. She stated that the resident already walked this morning with a Rehab Therapist. She stated that the resident walked about 20 feet, and the resident will be placed back on Skilled Rehab to get her back to 50 feet. A Rehab note written on 6/20/19 at 9:45 AM documented that the resident was referred to Skilled PT services due to documented recent refusals to perform the FAP with staff. The note documented that the resident ambulated with a rolling walker and extensive assist of one person for 20 feet in the room only and presents with decreased functional activity tolerance, decreased lower extremity strength, and impaired standing balance. The current FAP was discontinued secondary to inability to perform and necessity for Skilled PT services to restore function. The resident's evening CNA was interviewed on 6/20/19 at 11:09 AM. She stated she is assigned to the resident 5 days per week and the resident always refuses to do the FAP in the hallway. She stated in the past month she walked with the resident a little in her room, from the bathroom to the bed, whatever she could manage. She stated she was not measuring how many feet the resident walked and that sometimes she refuses to walk in the room. She stated that the nurses were aware that the resident likes to stay in her room, so she assumed the nurses knew that the resident was not doing the ambulation program. The resident's Attending Physician was interviewed on 6/20/19 at 2:22 PM. He stated he would expect staff to let him know if the resident was refusing to ambulate on the FAP. He stated if the resident was refusing we would just encourage the resident to continue with the FAP, and if the resident did not do the FAP, it would not cause the resident to decline. The Director of Nursing Services (DNS) was interviewed on 6/24/19 at 12:42 PM. She stated we will have to update the policy so that nursing supervision is alerted sooner if the resident is refusing to ambulate on the FAP. She further stated that the resident has the right to refuse, but the CNAs should report it. 415.12(a)(2)

Based on record review and interviews during the Recertification Survey the facility did not ensure that a resident identified with a hearing loss had interventions to address the hearing loss. This was evident for one (Resident #128) of one resident reviewed for Hearing. Specifically, Resident # 128 was observed being hard of hearing (HOH). An Audiologist consultation dated 1/12/16 identified that the resident was a candidate for a hearing aide and recommended an Ear, Nose and Throat (ENT) follow up and hearing aid fitting. The follow up ENT consultation for a hearing aid fitting was not done. The finding is: The facility's Hearing Aid policy and procedure dated (MONTH) 1998 documented under Assessment and Care Planning for Residents with Hearing Difficulties: As indicated, the unit nurse notifies the MD (Medical Doctor) and a referral is made to the Ear, Nose, and Throat specialist and/or Audiologist. Resident #128 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident was usually understood and could usually understand. The resident's Brief Interview for Mental Status (BIMS) score was 3, which indicated that the resident had severely impaired cognitive skills for daily decision making. The MDS also documented that the resident had minimal hearing difficulty in some environments (e.g when person speaks softly or setting is noisy) and no hearing aid or other hearing appliance was used. The 7:00 AM-3:00 PM Certified Nursing Assistant (CNA) assigned to the resident on 6/18/19 was interviewed at 10:35 AM and stated that she has floated to the 3 South unit in the past and whenever she is assigned to the 3 South unit she cares for the resident, as the resident speaks primarily Creole and she is fluent in Creole as well. The CNA stated that the resident is able to make her needs known, but you have to speak in a loud tone of voice to the resident because she is hard of hearing. The resident was interviewed on 6/18/19 at 10:40 AM with their assigned 7:00 AM-3:00 PM CNA acting as a Creole speaking interpreter. The CNA would often have to lean over and speak directly in the resident's left ear. The resident stated that she has never had a hearing aid, but would like one. The Physician order [REDACTED]. The Physician order [REDACTED]. The Director of Social Services, who had completed the resident's BIMS assessment for the quarterly MDS assessment dated [DATE] was interviewed on 6/21/19 at 1:05 PM. The Director of Social Services stated that she uses a Creole speaking facility employee when conducting the interview to complete the BIMS assessment in the MDS. The Director of Social Services stated that staff have to get close to the resident when speaking to her because she is hard of hearing. The 3 South Registered Nurse (RN) was interviewed on 6/24/19 at 12:30 PM and stated that she obtained the Physician order [REDACTED]. The Audiology consult dated 1/12/16 revealed that a severe to profound hearing loss could not be ruled out in the better ear at that time and that the resident was a candidate for a hearing aid. The recommendation was for the resident to be referred for an ENT follow-up and hearing aide fitting. The Director of Nursing Services (DNS) was interviewed on 6/24/19 at 2:20 PM and stated that she did not find any documentation that the resident was ever evaluated for hearing aides. The DNS stated that if a resident is observed to have difficulty hearing they should be seen by an ENT and/or an audiologist. 415.12(3)(b)

Based on observation and staff interviews during the Recertification Survey the facility did not ensure that the resident environment remained as free of accident hazards as is possible for two (Resident #126 and #87) of six residents reviewed for Accidents. Specifically, in Resident #126 and #87's rooms clothing was observed hanging from the wall extension arm lamps, including hanging from the lamp light switches. The findings are: 1) Resident #126 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 5/3/19 Quarterly Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. The MDS documented that the resident required supervision for set-up help only for bed transfers, dressing, and walking in room and corridor. A Comprehensive Care Plan (CCP) effective 5/7/19 documented that the resident demonstrates positive psychosocial strengths as evidenced by no behavioral symptoms. On 6/17/19 at 11:19 AM there were eight pieces of clothing observed hanging from hangers on the resident's wall extension arm lamp. One of the hangers was hanging from the lamp light switch. Resident #126's Certified Nursing Assistant (CNA) was interviewed on 6/17/19 at 11:28 AM. She observed the clothing hanging from the lamp and stated it was related to the resident's behavior. She said she will put the clothes in the closet and the resident will take them out and hang them on the lamp. The CNA stated that the last time she had put the clothes in the closet was several days ago. The CNA left the room and did not remove the clothing from the lamp. The Registered Nurse (RN) unit supervisor was interviewed on 6/19/19 at 11:38 AM. She stated that the resident has room for her clothes in the closet, and that placing the clothing on the lamp was behavioral. The Director of Nursing Services (DNS) was interviewed on 6/24/19 at 12:43 PM. She stated the resident should not be hanging clothes on the lamp and we should ensure clothing is not hung from the lamp. 2) Resident #87 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 4/21/19 Quarterly MDS documented a BIMS score of 15, indicating the resident was cognitively intact. The MDS documented that the resident did not walk, needed extensive assist of one staff member for dressing, and that the resident required supervision with set up help only for locomotion on the unit with his wheelchair. On 6/17/19 at 1:15 PM there were several pieces of clothing hanging from the wall extension arm lamp with hangers, and there was a plastic bag with clothing hanging from the lamp switch. A CCP effective 5/17/16 and last updated 6/17/19 documented that the resident had a behavior of hanging his clothes on the night light in his room. A goal added on 6/17/19 was for the resident to verbalize understanding of risk/consequences of non-compliance. There were no new interventions. The resident's CNA was interviewed on 6/17/19 at 1:41 PM. She observed the clothing and plastic bag hanging from the lamp. She stated the resident hangs the clothing on the lamp and that he would probably scream if the clothing was moved to the closet, and the clothing would have to be moved back to the lamp. The CNA did not remove the clothing from the lamp. The resident was interviewed on 6/18/19 at 8:49 AM. The clothing was observed removed from the lamp. He stated that he was storing clothes on the lamp and he knew they should not be there. He stated the closet was hard for him to get to due to the wheelchair and that no one ever offered to put an additional clothing rack that was more accessible in his room. The RN Unit Supervisor was interviewed on 6/19/19 at 11:37 AM. She stated she could talk to maintenance about putting up an additional rack for the resident's clothes in his room. The DNS was interviewed on 6/24/19 at 12:43 PM. She stated the resident should not be hanging clothes on the lamp. She stated that we have approached this resident to see if he needs everything or if we can put things in storage and that he tells us not to touch any of his stuff. She further stated she was not sure if an additional clothing rack can be added, but the staff should be ensuring that the clothes are not hanging on the lamp. 415.12(h)(1)

Based on observation, record review, and staff interviews during the recertification survey, the facility did not ensure that equipment on the nursing units was maintained in operational condition. Specifically, the drinking fountains located on 5 North, 4 North, 4 South, 3 North, 3 South, and 2 North Units were non-operational. The finding is: During an observational tour of the 5 North Unit on 6/17/19 at 10:00AM, it was observed that the resident's two water drinking fountains were rusting and non-operational. One fountain spout was missing. The unit had no drinking water station in place. There was no ice/water machine available on the unit. There were no hydration carts present on the unit. Observations of the resident's drinking fountains located on the 4 North, 4 South, 3 North, 3 South, and 2 North Units were made on 6/24/19 between 9:00 AM and 10:00 AM. The drinking fountains were also non-operational. An interview with the Lead Maintenance Staff was conducted on 6/24/19 at 10:10 AM. The Maintenance Staff member stated that the problem with the drinking fountains was the compressor. He stated that the water fountain problem had been noted for awhile but he could not show documentation or provide the timeframe for when the fountains became out of order. An interview with the Director of Environmental Services was conducted on 6/24/19 at 10:35 AM. The Director stated that the water fountains are non- functional. He also stated that he will have the drinking fountains removed since they were not in use and should be removed. The Director did not say when the fountains were non-operational. An interview with the Registered Nurse (RN) 5 North Unit Supervisor was conducted on 6/24/19 at 10:45 AM. The RN stated that the Unit does not have a drinking station. The RN stated that the residents have to ask the Certified Nursing Assistants (CNAs) for water. 415.29

Based on record reviews and staff interviews during the recertification survey the facility did not ensure that each resident's medical record was complete and accurately documented in accordance with accepted professional standards and practices. This was identified for 1 (Resident #15) of 2 residents reviewed for hydration; for 1 (Resident #132) of 2 residents reviewed for range of motion; and for 1 (Resident #253) of two residents reviewed for rehabilitation. Specifically, 1) Resident #15's Input and Output (I & O) Worksheet documentation did not specify the total amount of fluid that the resident consumed in a day. The I & O Worksheet also did not consistently document the resident's daily output. 2) Resident #132 had an order for [REDACTED].# 253 had an order for [REDACTED]. The findings are: 1) The facility's policy and procedure titled Intake and Output dated 4/2019 documented It is the policy of the facility that a resident will be placed on intake and/or output (I and O) monitoring, based on a physician's orders [REDACTED]. 3. The CNA will report to charge nurse the resident's total amount of fluid intake per meals and nourishments. 4. The Nurse will document the fluid intake for the shift to include meals and nourishments . Resident #15 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The physician's orders [REDACTED]. The physician's orders [REDACTED]. The Treatment Administration Record (TAR) for (MONTH) 2019 was reviewed and documented free water flush 60 milliliter (ml) via percutaneous endoscopic gastrostomy (PEG) tube every shift. The Comprehensive Care Plan (CCP) developed for potential fluid deficit related to medication side effects dated 3/28/19 documented goals including that the resident will be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgor through the review period. Interventions included to monitor and to document intake and output as per facility policy; to provide extra liquids, encourage PO fluids 240 cc every shift, and to provide extra juice with meals. The Input and Output Worksheet for (MONTH) 2019 was reviewed. The I and O's were inconsistently documented. The daily totals for input and output did not add up to the daily ordered fluids. Additionally, on some days there were no output documented. An interview with the Licensed Practical Nurse (LPN) Unit Charge Nurse was conducted on 6/21/19 at 8:38 AM. The LPN stated that she records whatever the CNAs are documenting. She stated that they only document the 240 cc order and not the total resident intake for the shift. An interview with the Certified Nursing Assistant (CNA) was conducted on 6/21/19 at 8:45 AM. The CNA stated that he only documents the 240 cc and not the total resident's fluid intake for the shift. An interview with the Assistant Director of Nursing Services (ADNS) was conducted on 6/24/19 at 11:00 AM. The ADNS stated that the I and Os should be properly documented as per the CCP. 2) Resident #132 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had short and long term memory problems and the resident was severely impaired in cognition. The physician's orders [REDACTED]. The Certified Nursing Assistant Accountability Record (CNAAR) for (MONTH) 2019 documented Rehabilitation Nursing CNA to perform PROM exercises to Bilateral LEs daily for 15 minutes to maintain range and to prevent further contractures. The CNAAR did not document Bilateral UE ROM. The CNA was interviewed on 6/21/19 at 8:34 AM and stated that she would cleanse the resident and while doing so she does the exercises to both upper and lower extremities. An interview with the LPN Unit Charge Nurse was conducted on 6/21/19 at 10:00 AM. The LPN stated that the CNAAR documentation should include bilateral UE PROM also. 3) Resident #253 has [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented severely impaired cognitive skills for daily decision making with short and long term memory problems. The resident had no functional limitation in Range of Motion (ROM) of the upper or lower extremities, and was receiving Restorative Nursing Program PROM 7 days for least 15 minutes per day in the last 7 calendar days. The physician's orders [REDACTED]. The order did not specify the duration of time or the repetitions (reps) required for the Certified Nursing Assistant (CNA) to follow while providing care. An interview with Physical Therapist (PT) was conducted on 6/21/19 at 9:00 AM. The PT stated that the CNAs were in-serviced on how to do PROM neck extension and (R) and (L) rotation. An interview with the Director of Rehabilitation was conducted on 6/21/19 at 9:29 AM. The Director stated that CNAs were in-serviced and the inservices were documented on an attendance sheet. The Director did not know why the order for the PROM neck extension did not have the frequency of repetition and times to be done daily. An interview with the resident's CNA was conducted on 6/21/19 at 9:54 AM. The CNA stated that she does PROM 4 times for about 15 minutes. An interview with Licensed Practical Nurse (LPN) Unit Charge Nurse was conducted on 6/21/19 at 10:15 AM. The LPN stated the PROM order should have specified the frequency and times per day for the CNA to be guided on what to do for the resident. An interview with the the Attending Physician was conducted on 6/24/19 at 10:00 AM. The Physician stated that the PROM order should have been more specific. 415.22(a)(1-4)

Based on observation, interview and record review during an abbreviated survey (complaint ID # NY 521), the facility did not ensure that adequate supervision was provided to each resident to minimize risk of accidents. Specifically, 1(Resident #1) of 6 residents reviewed for unsafe wandering and elopement had [DIAGNOSES REDACTED]. An exit door alarm was activated. The security guard (SG #1) did not follow facility procedures and take immediate and thorough action to investigate the source of the alarm and promptly notify appropriate staff. Resident #1 was missing for over 2 ½ hours; was hit by a car on a highway and was sent to the hospital due to multiple trauma. The findings are: The Policy and Procedure for Exit Door - Code E (Exit) dated 03/2017 documented that the facility will institute measures for timely response to door alarms triggered by any person that exits the building from an unauthorized/secured door. All staff and new hires will be in-serviced on the Code E policy annually. If any secured exit door alarm is triggered, the receptionist/security guard will check the panel that identifies the location of the door that was alarmed. The Receptionist/Security Guard will alert all staff via paging overheard calling Code E with the location of the door breached. Any staff in immediate area is responsible for checking the door that was alarmed, along with exiting the same door and checking the outside perimeter. From the hours of 4PM-8AM Security must immediately respond to triggered door alarm, exit the building and complete a search around the entire building. Once the entire area has been checked and all residents are accounted for, the security guard will reset the door alarm. Once a Code E is called the supervisor must immediately report to the front desk to relieve the security guard so that he/she can conduct a search. Nursing is responsible to initiate immediate head count of all residents. If a resident is deemed missing a Code Yellow for the missing resident will be called. Once every resident is accounted for a Code E All Clear can be called. The Policy and Procedure for Missing Residents dated 12/2001 documented it is the policy of the facility that the missing residents (Code Yellow) will be immediately implemented upon discovery of a missing resident. Each staff member is responsible for immediately reporting to the supervisor any resident who cannot be accounted for. The Code Yellow will be announced by the Receptionist and the unit. All units will initiate a head count and report to the nursing supervisor. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS-an assessment tool) dated 06/26/2017 documented that the resident had severely impaired cognitive status, walked without a mobility device, required supervision of one person with walking and locomotion and demonstrated wandering behavior daily. A hospital record dated 04/05/2016 (prior to Resident #1's admission to the facility) documented that resident had a prior history of emergency room visit in 08/2015 when he was found wandering around the street 2 blocks from his residence and he attempted to enter a wrong house and he was unable to remember where he lived. Elopement/Wandering Risk Assessments dated 04/13/2016 and 06/29/2017 documented the resident was cognitively impaired, ambulatory, had a history of [REDACTED]. The Comprehensive Care Plan (CCP) for elopement risk/wanderer dated 04/13/2016 and 04/26/2016 documented that the resident was an elopement risk, wandered aimlessly, and had impaired safety awareness. Interventions included to keep resident's picture at the front desk, make sure all staff were aware of elopement risk and provide resident with a wander guard (electronic alarmed elopement prevention bracelet) and provide close supervision. The CCP was reviewed on 7/20/2016, 10/3/2016, 4/5/2017 and 07/08/2017. No history of actual or attempted elopement was noted. The Nurse's Progress Note dated 09/18/2017 at 08:37 PM by the Registered Nurse Supervisor (RNS) #2 documented at around 9:45 PM (on 9/17/17), she was leaving the 2 South unit and she saw a Certified Nursing Assistant (CNA) #5 who stated that she could not locate the resident. RNS #2 instructed CNA #5 to continue with her search and to keep her informed. RNS #2 saw Licensed Practical Nurse (LPN) #2 upon entering the elevator who was also searching for resident. RNS #2 initiated the facility elopement code and had the staff members do a head count and perimeter check throughout the building. 911 was activated. The RNS instructed the nurse (LPN #5) to drive to the main roads to continue searching while other staff searched within close proximities. At around 10:20 PM a nurse (LPN #5) called and stated they found resident and he was hurt. The hospital patient care report dated 09/17/2017 at 10:16 PM documented the resident was found lying prone on the side of the roadway, bystanders at scene stated that the patient was hit by a vehicle, thrown into the air and onto the ground. Patient was unresponsive upon arrival, bleeding from the mouth, some swelling to the forehead above right eye. Right leg had a visible compound fracture. 9/18/17 diagnosed with [REDACTED]. The hospital emergency room Discharge note dated 09/25/2017 at 6:05 PM documented the resident had blossoming head bleeds, multiple pelvic fractures, open tibia fibula fracture that was reduced and splinted. On 09/18/2017 patient underwent decompressive laparotomy (abdominal surgery), on 09/21/2017 patient went for ileostomy creation (opening created to connect part of the small intestine to the surface of the abdomen) and right lower extremity external fixation (surgery to place pins or screws to immobilize the bone for healing). On 09/24/2017 patient had revision of end ileostomy with small bowel resection and creation of new ileostomy secondary to ischemia (insufficient blood supply to the area). Resident remains at the hospital in surgical intensive care unit. The facility investigation dated 09/18/2017 documented that on 09/17/2017 Resident #1 was in the 3rd floor unit dining room until 6:28 PM. At 8:20 PM RNS #2 was on the main floor and heard an alarm sounding at stairwell G (main floor) and went to investigate. She opened the door and checked the perimeter and did not see anyone. She went to Security Guard (SG) #1 and asked about the alarm and SG #1 told her that she checked it and it was ok. At 9:00 PM CNA #5 went to look for the resident to get him ready for bed. She looked on 3 North because that was his usual routine, to walk between the 3 South and 3 North units. CNA #5 could not find the resident and LPN #2 told her to check other units and proceeded to check the building but they could not find the resident. RNS #2 met CNA #5 at 9:45 PM on the second floor and was informed that Resident #1 was missing. RNS #2 called the code when LPN #2 expressed her concern for the missing resident. At 10:30 PM staff reported that they found the resident at the highway and he was injured and was being evaluated by the EMS. Resident was sent to the hospital. The facility investigation summary dated 09/18/2017 documented that the resident had a history of [REDACTED]. The facility investigation findings included that SG #1 appeared confused and could not explain what happened. SG #1stated that the she was aware that an alarm went off and she did not notify any one. The video surveillance indicated that the alarm went off at 6:45 PM, SG #1 looked at the panel and silenced the alarm. The alarm rings at the reception desk and local location of stairwell. The staff on the units were not on the main floor to hear the alarm that indicated door breached at the stairwell. As per policy the SG must announce a Code E and name of the stairwell that was breached. SG #1 failed to follow the facility policy, she did not alert the staff of the breach, as a result resident was able to exit the building. At 8:20 PM RNS #2 responded to the alarm, checked the immediate area and outside perimeter. RNS #2 was assured by SG #1 that everything was checked when she asked SG #1 about the alarm that was sounding. RNS #2 did not call for a head count and as a result there was a delay in identifying that there was a missing resident. The security logbook revealed an undated entry by SG #1. SG #1 documented that she was on duty and that that a resident went down the wrong hallway by the receiving area and it set the alarm off towards the stairways Exit 8 (No time was specified in the entry). The nurse supervisor came to tell her it was still going off so she paged Housekeeping, he came and relieved her, so she disarmed the alarm. Video surveillance dated 09/17/2017 was reviewed for various available camera views and revealed: 6:26 PM Resident #1, as identified by the Administrator, exiting the 3 South dining room. 6:27 PM Resident #1 boarded the 3rd floor elevator with another resident and a family member. 6:28 PM Resident #1 exited the 1st floor elevator. 6:37 PM Resident #1 opened the first door to the landing space and touching the exit door (to the outside) Egress bar, looking out from the small glass window on the same exit door. 6:54 PM Resident #1 exited the facility via the Stairwell G exit door. 6:54 PM The SG #1 looked at and reached for the alarm panel that displays the exit door alarms. 6:55 PM The SG #1 reached toward the panel. 8:20 PM RNS #2 was observed by the Stairwell G exit door. She looked outside through the door and went out the exit door. 8:21 PM RNS #2 came back into the building. 8:23 PM RNS #2 was observed conversing with SG #1. 8:25 PM RNS #2 left the front desk. 8:28 PM SG #1 was observed keying the alarm in Stairwell G, pressing on the button, checking the door and trying to key in the alarm. 8:29 PM The Housekeeper was seen at the front desk and SG #1 exited the camera view. 8:31 PM SG #1 left the Stairwell G exit door. Multiple unsuccessful attempts were made to contact SG #1 without success via phone, voicemail message and written correspondence. LPN #2 who worked 3:00 PM-11:00 PM was interviewed by phone on 09/21/2017 at 11:19 AM and stated she worked on 09/17/2017. The last time she saw Resident #1 was in the dining room at 6:00 PM eating his dinner. She stated that, usually after eating, Resident #1 walked around from 3 North to 3 South. At about 9:50 PM, CNA #5 reported to her that she could not find Resident #1. She told CNA #5 to check 3 North and 3 South. She called the front desk but nobody picked up the phone. She called every unit to make sure Resident #1 was not on another unit. She called the front desk again but nobody picked up. When she got on the elevator she saw RNS #2 on the 1st floor at about 10:00PM and told her Resident #1 was missing. Less than a minute later RNS #2 told SG #1 to page Code E. LPN #2 stated she would do headcount if there was a Code E. LPN #2 described regular behavior for Resident #1. He was always calm and quiet and had no behavior of going to the exit doors or elevator. He usually sat near the nursing station or walked up and down the hallway but did not exhibit exit seeking behaviors. He looked out the window. He had a wander guard because he ambulated but he never attempted elopement. LPN #2 stated that the staff had to check on him, keep an eye on him and look for him. LPN #2 stated that the CNAs account for residents throughout their shift and check and provide incontinence care every 2-3 hours. LPN #2 stated it was not required to document the whereabouts of the resident at a certain time in a care plan and there was no order on specific time to monitor him. LPN #2 was further interviewed on 10/2/2017 at 10:57AM and stated that she was supposed to report to the RNS as soon as possible after staff reported to her that the resident was missing. When she learned that Resident #1 could not be located, she tried to call the front desk and nobody answered the phone so she came down to the lobby to look for RNS #2 and found the RNS #2 and reported Resident #1 was missing. CNA #5, who worked 3:00 PM-11:00 PM and was assigned to the resident on 09/17/2017, was interviewed on 09/21/2017 at 12:45 PM. CNA #5 stated that the resident was not on a specific monitoring schedule. CNA #5 stated that she never saw the resident go to elevators or exit doors. CNA #5 stated that she saw Resident #1 at 6:00 PM on 09/17/2017 walking in the 3 South hallway and assisted him to the dining room. She set up his dinner and left him in the dining room. At 9:00 PM she was looking for Resident #1 because she wanted to try to put him to bed, as that time was his normal routine. She stated that, usually, Resident #1 walks back and forth from 3 South to 3 North and sometimes looks out the window. She looked for him on 3 North where he usually stayed but she did not find him. CNA #5 went back to 3 South and reported to LPN #2 that she did not find Resident #1. LPN #2 told her to check each room which she did however, she could not find Resident #1. She went back to LPN #2 at about 9:35 PM and LPN #2 told her to go to other units. CNA#5 went to other units and she saw RNS #2 on 2 South and told her that she was looking for Resident #1. She went to the lobby and asked SG #1 who stated nobody passed through the door. When she was on 3 South, somebody called and stated they found Resident #1 and he was hit by the car. The Security Guard #2 (SG #2) was interviewed 09/21/2017 at 3:30PM and stated that he worked 10am -6pm as Receptionist on 09/17/2017. He knew Resident #1 walked from 3 South to 3 North. On 09/17/2017, there was nothing unusual, the resident walked back and forth and to the window near the door but he did not observe him opening the door and he did not go to elevator. The Administrator called him after 10 PM and told him somebody eloped and he came in at 10:15 PM. The SG #2 stated SG #1 went and silenced the alarm with a key. SG #2 reported that he spoke with SG #1 and SG #1 did not tell him that she silenced the alarm. She told him stairway 8 which is actually stairwell G- zone 8, and appears on a panel at the security desk with that indication. SG #2 saw on the video that the SG #1 silenced the alarm at the front desk. SG #2 stated that, based on video review, it was 6:48 PM when the door was breached, no one responded to that door until 8:20PM, and that was RNS #2. SG #2 was further interviewed on 09/25/2017 at 11:33AM and stated that he was familiar with SG #1 and that she was working at the facility for 3 months. He stated that the new hire SGs were in-serviced by the Security agency and that he did walk throughs with the SGs and told them the procedures to follow for Code E and how to use the key to activate the alarms. SG #2 stated that he taught SG #1 the procedures and she indicated to him that she understood it clearly. He stated that he went over the procedures for Code E and the alarms with SG #1 more than once. Housekeeper #3 was interviewed by phone on 09/22/2017 at 2:36 PM and stated that he worked from 7AM-11PM on 09/17/2017. He stated that he never covered the front desk. That day, the SG #1 paged him overhead between 8PM-8:30PM to come to front desk and SG #1 asked him if he could assist her for a second. He told SG #1 that he did not know what to do. SG #1 told him to push the button to let the visitors out because she would not be long. He stayed at the front desk for 5-15 minutes. The Director of Nursing Services (DNS) was interviewed by phone on 09/25/2017 at 9:35 AM. The DNS stated that she viewed the surveillance camera the following day after the elopement with the Administrator. They saw that, when Resident #1 left the building, it appeared that SG #1 was silencing the alarm and did not notify anybody. No one knew that the alarm went off. The DNS stated that when an exit door alarm was activated at the front desk the SG at the front desk was expected to inform the staff and call Code E. The staff knew what to do during Code E, however, nobody knew that Resident #1 was out of the building. The DNS stated that the facility investigation revealed that all alarms worked, the system was working; it was the human error of SG #1 that caused the issue. The Administrator was interviewed by phone on 09/25/2017 at 10:38 AM and stated that, on 09/17/2017, he got a call at 10:15 PM from the DNS that Resident #1 could not be found. Within 10-15 minutes the DNS called him back and notified him that Resident #1 was found and was hit by a car. The Administrator and SG #2 spoke to SG #1 who stated that she heard an alarm and she was not sure if it was a wander guard alarm or an exit door alarm. The Administrator asked SG #1 if she notified anybody and she stated no. SG #1 did not provide a statement. The following day, they reviewed the surveillance video and determined that SG #1 did not follow the policy and procedure of the facility. SG #1 did not follow the facility procedures of calling code E when any exit door is breached and search the perimeter of the building that would have triggered a head count and continued search until the resident was found. Registered Nurse Supervisor (RNS) #2 was interviewed by phone on 09/25/2017 at 2:59 PM and stated that, between 8:00 PM-8:15PM after doing her rounds, she went to the nursing office and she heard an alarm coming from G stairwell. She went towards the alarm, opened the door and checked the perimeter where the alarm was sounding. There was no person outside. She went to SG #1 and told her that there was an alarm sounding and as per protocol they had to call a code. SG #1 reassured her that she already checked the area and it was cleared. SG #1 told her she was waiting for the Housekeeper to assist her in resetting the alarm. RNS #2 stated she did not call the code E when she heard the alarm because SG #1 reassured her twice that it was all cleared. RNS #2 went on doing her routine rounds. Between 9:45 PM-10 PM, she saw CNA #5 on 2 South unit who told her that she was looking for Resident #1. RNS #2 told her to continue with search and keep her informed. RNS #2 saw LPN #2 in the elevator on 2 South less than 5 minutes when she saw CNA#5. LPN #2 stated that she was looking for Resident #1. RNS #2 immediately went to front lobby and told SG #1 to call Code E but SG #1 refused to call the Code so RNS #2 immediately called Code E. The staff responded quickly and RNS #2 gave directives. LPN #5 called the facility and stated that they found Resident #1 and he was hurt. RNS #2 spoke to one of the EMS personnel and stated that they would take Resident #1 to hospital as they have trauma unit and he was hit by a car. RNS #2 stated that about 3-4 weeks ago they had a Code E drill. When staff heard the alarm, staff were supposed to go where alarm sounded and call a head count on the unit. The SG would announce Code E and, as RNS, she would give instruction to do head count and check the perimeter. 415.12 (h)(1)(2)

Based on observation, staff interviews and record review during a recertification survey the facility did not ensure that a resident having pressure sores received necessary treatment and services to promote healing and prevent infection. This was noted for 1 (Resident #54) out of 3 reviewed for pressure ulcers, in a total sample of 40 residents. Specifically, the facility did not complete Resident #54's admission (admitted [DATE]) assessment accurately and timely regarding the resident's right heel pressure ulcer. The facility's admission assessment dated [DATE] identified the resident with a pressure ulcer on the right and left buttocks. No heel pressure ulcer was identified or treatment rendered. Subsequently, the pressure ulcer of the resident's right heel deteriorated to a stage 3 due to the resident not reciecing treatment to the area until it was identified on 8/15/12. This resulted in actual harm which is not immediate jeopardy. The finding is: Resident #54 was admitted to the facility on [DATE] at 6:30 PM with [DIAGNOSES REDACTED]. A skin impairment assessment flow-sheet from the hospital dated 8/2/12 documented three stage II pressure ulcers (right buttock, left buttock and right heel). The right heel was documented to be 1 x 0.5 x 0 centimeters (cm) with red wound bed and dry scaled peri wound. A Physician's initial assessment dated [DATE] documented that the resident had pressure ulcers and "for details see the wound care sheet." A Physician/Registered Nurse Wound Assessment -Treatment Form dated 8/8/12 documented a stage III wound to the right buttock and a stage II to the left buttock. A weekly audit of decubitus ulcers dated August 8, 2012 documented that the resident was newly admitted on [DATE] with two hospital acquired pressure ulcers, a stage III on right buttock and a stage II on left buttock. The weekly audit of decubitus ulcers dated 8/15/12 documented the left and right buttock decubitus ulcers and a right heel stage III pressure ulcer developed in house on 8/15/12 measuring 3 x 2 x 0.3 cm, 90% slough and 10% granulation, with a treatment of [REDACTED]. A Physician/Registered Nurse Wound Assessment -Treatment Form dated 8/15/12 documented a stage III pressure ulcer to the right buttock and a stage II to the left buttock. It also documented a stage III pressure ulcer to the right heel measuring 3 x 2 x 0.3 cm with 90% slough and 10% granulation tissue. A two page Pressure Ulcer Investigation dated 8/15/12 documented, " R heel-DTI (Deep Tissue injury) (Blister) " . The investigation also documented that the pressure ulcer was unavoidable due to "[MEDICAL CONDITION] Lt side hemi, immobility and acute [MEDICAL CONDITION]." The investigation did not include staff interviews to determine whether any observations of the right heel were made prior to 8/15/12. The investigation was signed by the Director of Nursing (DON) on 8/16/12 and by the unit Charge Registered Nurse (RN) on 9/12/12. Review of the Treatment Administration Record dated August 2012, documented an order on 8/16/12 to "cleanse right heel wound with n.s. (normal saline), pat dry and apply [MEDICATION NAME] ointment with hydrogel daily and PRN (as needed) then cover with a dry dressing". In an interview with the unit Charge RN on 10/15/12 at 8:38 AM he stated that he was on vacation in August and that upon his return to work on 9/16/12, he saw the Pressure Ulcer Investigation in his mail box and signed it. Wound care observation took place on 10/15/12 at 9:50 AM . A stage 4 pressure ulcer with serosanguinous drainage was observed on the right heel. The wound RN was interviewed on 10/15/12 at 1:00 PM. The RN stated that she has been the Wound RN since June 2011. She stated that she had been on two week vacation and initiated the Pressure Ulcer investigation for the DTI/ Blister after she came back. The RN was unable to specify the source of her information documented in the investigation regarding the right heel having a DTI/Blister. The RN stated that she was not here when it happened and that upon return she saw a wound consult request from the RN unit Manager to the wound Physician. She stated that the right heel pressure ulcer was first seen by the wound team during wound rounds on 8/15/12. The RN stated further that she was only given the two investigation forms to fill in, and never told to do staff interviews with a three days look back. She stated that she did not know if the unit RN manager completed any staff interviews regarding the newly developed pressure ulcers. The RN who had completed the resident's admission assessment was interviewed on 10/12/12 at 2:00 PM. The RN stated that the supervisor told her to complete the admission assessment during her shift. The RN stated that the previous shift supervisor had already completed part of the assessment and gave the information about the pressure ulcers on the buttocks. The RN stated that she was unable to complete the skin assessment as the resident was sleeping and communicated the same to the next shift in writing via the communication book and verbally to the incoming AM supervisor The DON was interviewed on 10/15/12 at 9:23 AM and stated that the Pressure Ulcer Investigation was completed by the Wound RN, who should have gone back three days and spoken with the staff on all three 3 shifts to get the details. The DON stated that the Wound RN only brings these two pages of investigation to her and that she was assuming that the Wound RN obtains staff interviews for a three day look back period. The DON stated that this investigation was not complete. The following documentation was noted in the communication book dated 8/6/12, "(Resident #54's name): please follow up with assessments, information was endorsed to me by 3:00 PM-11:00 PM supervisor. Patient was sleeping unable to assess." The 8/7/12 7:00 AM -3:00 PM RN supervisor was interviewed on 10/15/12 at 10:00 AM and stated that she read the written communication, but had received no verbal communication from the night RN. The RN supervisor stated, when she went into the Admission Assessment in the computer, it had been signed and she assumed it had been completed by the RN after her notation in the communication book. The unit Charge RN was interviewed on 10/15/12 at 8:38 AM. The RN stated that when he came back from his 4 week vacation on 9/13/12, he ran his computer census and noticed that the resident's admission assessment was completed but not closed out, so he clicked on the close tab and closed it. The hospital records documenting the resident having a stage II pressure ulcer on right heel were reviewed with the unit charge RN. The RN stated that based on Hospital admission record, we have to assume that the admitting nurse missed the right heel pressure ulcer. The DON was interviewed and stated on 10/15/12 at 9:23 AM the following; the Nurses Admission assessment should be completed within first 8 hrs of admission or much sooner, the resident should receive a shower and a body survey before she was put to bed. If the resident was admitted at 6:30 PM she should have had a skin check before resident being put to bed and before the nurses called the Physician for treatment and the medications orders. In order to ensure that the assessments are completed timely, the unit RN Manager and Head Nurse should check the unit census the next day when they come in to see if everything was completed. The Braden scale dated 8/7/12 documented a score of 15 with mild pressure ulcer risk category. Very limited mobility, chairfast, friction and shear were listed under the factors for pressure ulcers risk. The Comprehensive Care plan and the Certified Nurses Aide (CNA) Accountability records dated 8/6/12 through 9/25/12 did not include pressure relieving devices for the heels. The Comprehensive Care Plan (CCP) initiated Goals on 8/15/12 documenting that the resident's right heel Pressure Ulcer will show signs of healing and remain free from infection within the next 90 days. The CCP was updated (initiated) on 9/29/12 to include: "the resident has R (right) Heel- now stage IV Pressure Ulcer. Interventions were updated on 9/29/2012 to include heel booties to both feet while in bed. The Certified Nurses Aide (CNA) Accountability records dated 8/6/2012 through 9/30/2012 documented under intervention/task: Heel booties apply to: (no instruction was documented). The CNA Accountability record was signed for booties 9/7/2012 through 9/24/2012 on all three shifts. A second Intervention/Task documented to: Apply heel booties to both feet when in bed. The CNA Accountability record was signed for booties 9/7/2012 through 9/30/2012 on all three shifts. The CNA Accountability record dated August did not include Intervention/Tasks to Turn and Position the resident. The CNA Accountability record dated September 2012 included Intervention/Tasks to Turn and Position q 2 hrs q shift (every two hours every shift). The Intervention was first signed on 9/29/2012. One Certified Nurses Aide (CNA) who was assigned to the resident's care for 11:00 PM-7:00 AM shifts on 8/7, 8/8, 8/9, and 8/13/12 was interviewed on 10/15/12 at 12:00 noon. The CNA stated that she checked skin of the residents assigned to her and if she had seen any changes she would have informed the nurses. Two other CNAs assigned to the resident's care during the week of 8/6-8/15/12 were not available for interview. The Physical Therapist (PT) and the Occupational Therapist (OT) were interviewed on 10/12/12 at 11:00 AM. The PT and OT stated that the resident received rehabilitation from 8/7/12. The PT stated that the resident was non ambulatory and did not have her own shoes. The resident was provided with Darco shoes to enable her to stand up for transfer purposes. The PT stated that skin checks are completed on visible parts and that the resident's skin was intact. The PT stated that if there was an issue with the heels, a heel/pressure relief shoe would be provided in place of Darco shoes. 415.12(c)(1)(2)

Based on interviews of facilty staff, funeral parlor staff and the family, in addition to record reviews during an abbreviated survey, facility staff neglected to properly address the handing of the remains of one (Resident #1) of three residents who expired in the facility. Specifically, Resident #1 expired in the facility on [DATE] at 7:05 PM and her body was placed in the facility's holding room on the evening of that date. The body remained in that holding room until picked up by the funeral parlor on [DATE] at 12:05 PM, a total of four days. Facility staff were no longer aware of the presence of Resident #1's body in the holding room between the end of the night shift on the morning of [DATE] and the morning of [DATE]. The facility neglected to have policies or procedures in place at the time to ensure that the body in the holding area was monitored/checked on a periodic basis, the air-conditioning unit in the room was functioning, and that timely contact (directly or indirectly via the family) with the funeral home to coordinate the removal of the body from the facility was maintained. Subsequently, the resident's body decomposed to the extent that an open casket viewing, as per the family's wishes, was not possible, resulting in mental anguish to the family. This resulted in actual harm that was not immediate jeopardy. (Complaint #NY 1) The finding is: Resident #1's Death Certificate dated [DATE] documented that she expired in the facility on [DATE] at 7:05 PM, with a final primary [DIAGNOSES REDACTED]. The evening shift Registered Nurse Supervisor (RNS #1) was interviewed by telephone on [DATE] at 5:20 PM. RNS #1 stated that as per facility policy she contacted the resident's Physician regarding the expiration, the Physician contacted the resident's family, and the family then arrived on the unit to view the body. The body was then transferred to the facility's holding room in the basement, a room for deceased residents until the body was picked up by a family selected funeral parlor. The family informed RNS #1 that the funeral arrangements will be made on the morning of [DATE]. RNS #1 stated that she documented on both the 3 South unit's 24 Hour Report and the Supervisor's Communication Book that the resident's body was in the facility's holding area so that the following nursing shifts would be aware of the body residing in the holding area awaiting pick-up by the funeral parlor. She stated that she made both entries as it was her responsibility as a nursing supervisor so that the following nursing shifts would be aware of the body located in the holding area awaiting pick-up by the funeral parlor. Security Guard #1 (SG #1) who transported Resident #1's body to the holding room at approximately 10:45 PM to 11:00 PM on [DATE] was interviewed on [DATE] at 4:28 PM. SG #1 stated that he informed his replacement Security Guard #2 (SG #2) who came on duty at the end of his shift at midnight that there was a body in the holding room. Review of SG #1's written statement to the facility dated [DATE] documented that he transported the body to the holding room with a Certified Nursing Assistant (CNA) and an individual from the Housekeeping Department late in the evening on [DATE]. Review of the 3 South 24 Hour Report dated [DATE] (evening shift) documented that the resident's body was in the facility's holding area and this was also noted by the [DATE] to [DATE] night shift. The next documentation in reference to Resident #1's body being in the holding area was on [DATE] in the Supervisor's Communication Book indicating that the body was picked up at 12:05 PM on that date. A document regarding Resident #1 dated [DATE] provided by the facility revealed that Resident #1's Death Certificate was completed on [DATE] at approximately 6:00 PM. It also revealed that the deceased resident's family had visited the facility on [DATE] at about 1:00 PM to obtain some information, but staff failed to notify them that the resident's body was still in the facility at that time. The document also revealed that the facility was not aware that Resident #1's body had not been picked up by a funeral parlor until an employee on the morning of [DATE] entered the Maintenance Shop near the holding room and observed fluid on the floor. Notifying his supervisor, it was then discovered/observed that Resident #1's body was still in the holding room and was the origin of the fluid on the floor. The Maintenance Supervisor notified nursing staff. The two RN staff members (one of them identified as RNS #2) who were notified of the fluid on the floor by the Maintenance Supervisor were interviewed by telephone on [DATE] between 2:45 PM and 3:00 PM. The RNs stated that they entered the holding room on the morning of [DATE], at that time the holding room was warm with no running air-conditioner, there were bodily fluids on the floor and there was a foul odor from the body. One of the RNs (not RNS #2) stated that even though Resident #1's face and a hand were partially visible, she could not bring herself to view the face. RNS #2 was interviewed in the facility on [DATE] at 2:26 PM and by telephone on [DATE] at 2:52 PM. RNS #2 stated that funeral parlors usually pick up the remains of deceased residents within a few hours after death and no later than 24 hours after that time. It was her expectation that when she left the faciity on [DATE] at approximately 5:15 PM and next returned to the facility on the morning of [DATE] for her day shift, that Resident #1's body was no longer in the facility. RNS #2 further stated that if someone had notified her during her day shift on [DATE] that Resident #1's body was still in the holding room, she would have addressed it. Once she learned that Resident #1's body was still in the facility on the morning of [DATE], she telephoned the family to make them aware of such. The Medical Director (MD) was interviewed by telephone on [DATE] at 12:15 PM. The MD stated that he was in the facility late on the afternoon of [DATE] to sign Resident #1's Death Certificate and he was next in the facility early in the morning on [DATE]. He was not aware that Resident #1's body was still in the facility at those times until he received a phone call from the Administrator on [DATE] at about 3:00 PM. The Manager of the funeral parlor Resident #1's family selected was interviewed by phone on [DATE] at 8:45 AM. The Manager stated that he phoned the Nursing Home (NH) on [DATE] at around 10:30 AM and again at 4:00 PM. During both calls he stated that he gave the NH's staff the name and phone number of the funeral parlor. He stated he was told by NH staff that the body was being kept refrigerated and he would be notified as soon as the Death Certificate was completed. The Manager further stated that he learned from his staff and his computerized telephone answering system that no one from the NH had telephoned the funeral parlor at any time from [DATE] until after the body was picked up on [DATE]. He was not aware that the resident's body was still at the facility until [DATE] at approximately 9:15 AM, when he received a telephone call from Resident #1's family stating that the body was still in the NH's holding room. The Manager stated that by the time he was able to reach RNS #2 by phone and have the body picked up from the holding room at the facility on [DATE] at approximately 12:05 PM, the body was badly decomposed to the point that an open casket viewing by the family, as was their wish, was not possible. He stated that the individual who picked up the body from the facility stated that the holding room was warm, there was no operating air-conditioning, there were bodily fluids all over the floor and the foul odor from the body was horrific. The Manager stated that he shared that information with the family and they were very upset. He could not understand, even if by some chance the facility could not contact the funeral parlor in a timely manner, why they did not seek out some other source of adequate refrigeration for the body such as contacting the Nassau County Medical Examiner or a proper Morgue. Resident #1's family was interviewed by telephone on [DATE] at 11:40 AM and on [DATE] at 3:10 PM. The family member stated she and her entire family were very upset that Resident #1's body was so decomposed that there could not be an open casket viewing. She further stated that the body was so decomposed that the funeral home Manager, to spare her from the shock, would not even let her view the body on [DATE]. She could not understand how the facility could so neglect the resident's remains, and not even inform her on [DATE] when she personally visited the facility, that the body was still there. The facility Administrator was interviewed on [DATE] at 6:36 PM. The Administrator stated that she first learned of the incident the morning of [DATE]. Sometime between the night of [DATE] and the morning of [DATE], the air-conditioner unit in the facility's holding room failed. Prior to the incident the facility had no policies or procedures in place that could be implemented to ensure that facility staff would continually monitor the presence of the body in the facility until it was removed. The Administrator further stated that there should have been a more consistent follow through by her Nursing Department. 415.4(b)

Based on observations, record review, and interviews of facility staff, family members and funeral parlor staff during an abbreviated survey, the facility did not ensure that each expired resident's body was maintained in a dignified manner. Specifically, for one (Resident #1) of three residents reviewed who expired in the facility, staff interviews and record reviews revealed that the facility did not coordinate the removal of the resident's remains with the resident's family and the funeral parlor in order to ensure that the resident's remains were maintained and removed from the facility in a dignified manner. Resident #1 expired on [DATE] at 7:05 PM and her remains were not transferred to the funeral parlor until [DATE] at 12:05 PM. Facility staff were unaware that the resident's remains had not been transferred to the funeral parlor and the resident's body was kept in an inappropriate environment in the facility for four days, causing the remains to become badly decomposed. The resident's body became significantly decomposed to the extent that an open casket viewing, as per the family's wishes, was not possible. The family complained of deeply suffering from the emotional distress caused by the facility's handling of the loss of their family member. This resulted in actual harm that was not immediate jeopardy. (Resident #1) (Complaint #NY 1) The finding is: Resident #1's Death Certificate dated [DATE] documented that she expired in the facility on [DATE] at 7:05 PM, with a final primary [DIAGNOSES REDACTED]. The evening shift Registered Nurse Supervisor (RNS #1) was interviewed by telephone on [DATE] at 5:20 PM. She stated that just after Resident #1 was pronounced on [DATE], she telephoned the resident's physician, who then telephoned the resident's family, who arrived to view the body on [DATE] at approximately 8:00 PM. The family told RNS #1 that they would make funeral arrangements with a funeral parlor the morning of [DATE]. RNS #1 further stated that as per facility policy the body was transferred to the facility's Holding Room for deceased residents and documented that the resident's remains were in the facility's holding area on both the 3 South unit's 24 Hour Report and in the Supervisor's Communication Book, citing both entries as being her responsibility as a nursing supervisor so that the following nursing shifts would be aware of the body located in the holding area awaiting pick-up by the funeral parlor. Review of the 3 South 24 Hour Report (evening shift) documented that the resident's body was in the facility's holding area and that was also noted by the [DATE] to [DATE] night shift. Following those [DATE] shifts, the next documentation of Resident #1's body still being in the facility was on [DATE] in the Supervisor's Communication Book indicating that her body was picked up at 12:05 PM on that date. Security Guard #1 (SG #1) working in the facility the evening of [DATE] was interviewed on [DATE] at 4:28 PM, as he accompanied the investigator to the facility's holding area. The area was observed to be a small room located in the basement; there were no bodies present in the area at the time. SG #1 stated that he transported Resident #1's body to the holding room at approximately 10:45 PM to 11:00 PM on [DATE], with the assistance of a unit Certified Nursing Assistant (CNA #1). He stated that the holding room air-conditioner was working properly at the time and when he passed on the keys to the holding room to his replacement SG #2 at midnight, he informed him that there was a body in the holding room. SG #1 provided a written statement to the facility dated [DATE]. He documented that he transported the body to the holding room on [DATE] at 10:30 PM, accompanied by CNA #1 and an individual from the Housekeeping Department. Review of a facility document dated [DATE] regarding Resident #1 and provided to the investigator, documented that a Death Certificate was completed by Resident #1's Physician on [DATE] at approximately 6:00 PM. The family of deceased Resident #1 was in the facility on [DATE] at approximately 1:00 PM to obtain information both regarding the resident's personal account and residency for the cemetery. At no time during that visit was the family informed that Resident #1's body was still in the facility. The facility had not been contacted by the funeral parlor on [DATE], [DATE], [DATE], or on [DATE] until approximately 11:37 AM. The facility was not aware that Resident #1's body had not been picked up by the funeral parlor until an employee on the morning of [DATE] entered the Maintenance Shop near the holding area and observed fluid on the floor. He notified his supervisor who observed a body in the holding room and that the holding room was the origin of the fluids. The supervisor contacted the RN Unit Manager. The RN Unit Manager was interviewed by telephone on [DATE] at 2:45 PM. She stated that she was contacted on the morning of [DATE] and with RNS #2 they went to the holding room. She stated that the room was warm and either the air-conditioning unit was not on or had malfunctioned. She further stated that there was a very foul odor from the body, there were bodily fluids on the floor and though the face and a hand were partially visible, she could not bring herself to view the face. RNS #2 was interviewed in the facility on [DATE] at 2:26 PM, and by telephone on [DATE] at 2:52 PM. She stated that as funeral parlors usually pick up the remains of deceased residents within a few hours after death and no later than 24 hours after that time, it was her expectation that when she left the faciity on [DATE] at approximately 5:15 PM and next returned to the facility on the morning of [DATE] for her day shift, that Resident #1's remains were no longer in the facility. She further stated that if someone had notified her during her day shift on [DATE] that Resident #1's remains were still in the holding room she would have addressed it. She stated that when she first saw the body in the holding room on the morning of [DATE], there was a foul body odor and the room was warm. The air-conditioner was either off or not working properly. She then contacted the family and told them that the body was still in the facility's holding room. Shortly thereafter, the family informed her that the funeral parlor would be there shortly to pick up the body. She stated that until the funeral parlor had left a message for her on the morning of [DATE], to the best of her knowledge, no one in the facility had the name or the phone number of the funeral parlor. She stated that she received a telephone call from the funeral parlor at approximately 11:37 AM on [DATE] who asked if the Death Certificate was ready and she informed them that the Death Certificate had been ready since [DATE]. The Medical Director (MD)was interviewed by telephone on [DATE] at 12:15 PM. The MD stated that he was in the facility late on the afternoon of [DATE] to sign Resident #1's Death Certificate and he was next in the facility on [DATE] at approximately 6:45 AM to 7:00 AM. Aware of the usual practice of funeral parlors picking up the bodies of deceased residents generally within a few hours, upon neither visit was he aware that Resident #1's body was still in the facility. He further stated that it was usual procedure that the funeral parlor would pick up a body within just a few hours of death and send someone back to the facility afterwards to pick up the Death Certificate once it was completed. He was not aware that Resident #1's body had not been picked up from the facility until around 3:00 PM on [DATE]. The Funeral Parlor's Manager was interviewed by telephone on [DATE] at 8:45 AM. He stated that he was first notified of the resident's death by the family on [DATE] at about 10:00 AM. He was aware that the family wanted the body embalmed for an open casket viewing. The funeral parlor telephoned the Nursing Home (NH) on [DATE] at around 10:30 AM and was told that the Death Certificate had not yet been completed. He stated that as the NH was located in Nassau County and the funeral parlor was located in Queens, a New York City borough, it was illegal to transport a body across county lines without a Death Certificate and such was shared with the individual spoken with at the NH. The Manager asked if the body would be refrigerated and was told yes. He also stated that they again telephoned the NH on [DATE] at about 4:00 PM and again were told that the Death Certificate had not yet been completed and that the body was being refrigerated. The funeral parlor's computerized telephone answering system records were reviewed and no calls were made from the NH to the funeral parlor from [DATE] through [DATE]. The Manager stated that he received a telephone call from Resident #1's family on [DATE] at about 9:15 AM. After speaking with the family he immediately telephoned the NH and left a message asking to be called back. Another funeral parlor staff person again called the NH on [DATE] at around 11:15 AM and was able to speak with RNS #2 who told her that the Death Certificate had been completed since late [DATE]. Once learning on the morning of [DATE] that the Death Certificate had been completed, he arranged to have the body picked up from the facility's holding room. The individual who picked up the body stated to him that the NH's holding room had not been refrigerated, it had only an air-conditioner that was not working, it smelled horrific and there were bodily fluids all over the floor. Once the body was placed in the van, he received a call from the driver that the body was badly decomposed. The Manager further stated that when he saw the body on [DATE] it was badly decomposed and very much beyond being embalmed or having an open casket viewing. One family member viewed the body with him on [DATE] at about 3:20 PM. He could not understand even if by some chance the facility could not contact the funeral parlor in a timely manner, why they did not seek out some other source of adequate refrigeration such as contacting the Nassau County Medical Examiner or a proper Morgue. Resident #1's family was interviewed by telephone on [DATE] at 11:40 AM and on [DATE] at 3:10 PM. She was informed by the funeral parlor that they could not pick up the body from the facility and transport it to the funeral parlor without a Death Certificate. Not hearing about any problem from the facility about the body being picked up, she was not aware of any problem. She knew that the facility had her phone number and she was informed by the funeral parlor that they had left instructions with the facility to contact them as soon as the Death Certificate was ready so that the body could be transported. She stated that she required some information from the facility for the cemetery. Unable to obtain the information she needed by telephoning the facility on [DATE], she went to the facility on that date. She met with someone from Admissions and a social worker. She stated that no one had shared with her that there was any problem or that Resident #1's body was still in the facility at the time. She stated it was not until about 9:15 AM on [DATE] that she received a call from someone at the facility that the resident's body was still there. She received a call later in the day on [DATE] that the body was in the funeral parlor, it was badly decomposed and that there could be no open casket viewing of the body. She stated that the family was very upset that there could be no open casket viewing of the body. The facility Administrator was interviewed on [DATE] at 6:36 PM. She stated that she first learned of the incident the morning of [DATE] and began an investigation shortly thereafter. She stated that sometime between the night of [DATE] and the morning of [DATE], the air-conditioner unit in the facility's holding room had failed. She did not feel that it was an incident that needed to be reported to the New York State Department of Health as it involved a deceased resident. Regarding the incident and her staff, she stated that there should have been a more consistent follow through by her Nursing Department. The facility's nursing staff did not maintain reasonable and expected communication between their shifts and Resident #1's family between the day shift on [DATE] until the body was found in the holding room on the morning of [DATE], to ensure that the dignity of the resident's remains was met. 415.5(a)

Based on interviews of facility and funeral parlor staff and record reviews during an abbreviated survey, the facility Administration did not ensure that policies and procedures had been developed and that facility resources were effectively and efficiently utilized to maintain the proper sanitary storage and removal of each resident who expired in the facility in a timely manner. Specifically, for one (Resident #1) of three records reviewed for residents who expired in the facilty, the body was placed in a holding area in the basement from [DATE] to [DATE], a total of four days. The resident's body was not checked/monitored by the facility staff during this time. The air-conditioning unit in the holding room was not on or malfunctioned. Subsequently, the resident's body decomposed to the extent that an open casket viewing was not possible. This resulted in actual harm that was not immediate jeopardy. (Complaint #NY 1) The finding is: Resident #1's Death Certificate dated [DATE] documented that she expired in the facility on [DATE] at 7:05 PM, with a final primary [DIAGNOSES REDACTED]. The evening shift Registered Nurse Supervisor (RNS #1) was interviewed by telephone on [DATE] at 5:20 PM. RNS #1 stated that as per facility policy, after she contacted the resident's Physician he contacted the resident's family, the body was viewed by the family, and the body was then transferred to the facility's holding room in the basement, a room for deceased residents, until the body was picked up by a family selected funeral parlor. The family informed RNS #1 that the funeral arrangements will be made on the morning of [DATE]. RNS #1 stated that she documented on both the 3 South unit's 24 Hour Report and the Supervisor's Communication Book that the resident's body was in the facility's holding area so that the following nursing shifts would be aware of the body residing in the holding area awaiting pick-up by the funeral parlor. Security Guard #1 (SG #1) who transported Resident #1's body to the holding room at approximately 10:45 PM to 11:00 PM on [DATE] was interviewed on [DATE] at 4:28 PM. SG #1 stated that he informed his replacement Security Guard #2 (SG #2) who came on duty at the end of his shift at midnight that there was a body in the holding room. Review of SG #1's written statement to the facility dated [DATE] documented that he transported the body to the holding room with a Certified Nursing Assistant (CNA) and an individual from the Housekeeping Department late in the evening on [DATE]. Review of the 3 South 24 Hour Report dated [DATE] (evening shift) documented that the resident's body was in the facility's holding area and this was also noted by the [DATE] to [DATE] night shift. The next documentation in reference to Resident #1's body being in the holding area was on [DATE] in the Supervisor's Communication Book indicating that the body was picked up at 12:05 PM on that date. A document regarding Resident #1 dated [DATE] provided by the facility revealed that the deceased resident's family had visited the facility on [DATE] at about 1:00 PM to obtain some information, but they were not notified that the resident's body was still in the facility. The facility was not aware that Resident #1's body had not been picked up by a funeral parlor until an employee on the morning of [DATE] entered the Maintenance Shop near the holding room and observed fluid on the floor. Notifying his supervisor, it was then discovered/observed that Resident #1's body was still in the holding room and was the origin of the fluid on the floor. The Maintenance Supervisor notified nursing staff. The two RN staff members (one of them identified as RNS #2) who were notified of the fluid on the floor by the Maintenance Supervisor were interviewed by telephone on [DATE] between 2:45 PM and 3:00 PM. The RNs stated that they entered the holding room on the morning of [DATE], at that time the holding room was warm with no running air-conditioner, there were bodily fluids on the floor and there was a foul odor from the body. RNS #2 was interviewed in the facility on [DATE] at 2:26 PM and by telephone on [DATE] at 2:52 PM. RNS #2 stated that funeral parlors usually pick up the remains of deceased residents within a few hours after death and no later than 24 hours after that time. It was her expectation that when she left the faciity on [DATE] at approximately 5:15 PM and next returned to the facility on the morning of [DATE] for her day shift, that Resident #1's body was no longer in the facility. RNS #2 further stated that if someone had notified her during her day shift on [DATE] that Resident #1's body was still in the holding room, she would have addressed it. Once she learned that Resident #1's body was still in the facility on the morning of [DATE], she telephoned the family to make them aware of such. The Medical Director (MD) was interviewed by telephone on [DATE] at 12:15 PM. The MD stated that he was in the facility late on the afternoon of [DATE] to sign Resident #1's Death Certificate and he was next in the facility early in the morning on [DATE]. He was not aware that Resident #1's body was still in the facility at those times until he received a phone call from the Administrator on [DATE] at about 3:00 PM. The Manager of the funeral parlor Resident #1's family selected was interviewed by phone on [DATE] at 8:45 AM. The Manager stated that he phoned the Nursing Home (NH) on [DATE] at around 10:30 AM and again at 4:00 PM on [DATE]. During both calls he inquired if the Death Certificate was completed and he shared with staff that as the NH was in Nassau County and his funeral parlor was in Queens County, he could not legally cross county lines with a body without a Death Certificate. Manager gave the NH's staff the name and phone number of the funeral parlor. He was told by NH staff that the body was being kept refrigerated and he would be notified as soon as the Death Certificate was completed. The Manager further stated that he learned from his staff and his computerized telephone answering system that no one from the NH had telephoned the funeral parlor at any time from [DATE] until after the body was picked up on [DATE]. He was not aware that the resident's body was still at the facility until [DATE] at approximately 9:15 AM, when he received a telephone call from Resident #1's family stating that the body was still in the NH's holding room. The Manager stated that by the time he was able to reach RNS #2 by phone and have the body picked up from the holding room at the facility on [DATE] at approximately 12:05 PM, the body was badly decomposed to the point that an open casket viewing by the family, as was their wish, was not possible. He stated that the individual who picked up the body from the facility stated that the holding room was warm, there was no operating air-conditioning, there were bodily fluids all over the floor and the foul odor from the body was horrific. The Manager stated that he shared that information with the family and they were very upset. He could not understand, even if by some chance the facility could not contact the funeral parlor in a timely manner, why they did not seek out some other source of adequate refrigeration for the body such as contacting the Nassau County Medical Examiner or a proper Morgue. The facility Administrator was interviewed on [DATE] at 6:36 PM. The Administrator stated that she first learned of the incident the morning of [DATE]. Sometime between the night of [DATE] and the morning of [DATE], the air-conditioner unit in the facility's holding room failed. Prior to the incident the facility had no policies and procedures in place that could be implemented to ensure that facility's staff would continually monitor the presence of the body in the facility until it was removed. She stated that the faulty air-conditioner in the holding room was replaced on [DATE], and policies and procedures had now been put into place to check on a daily basis the functioning of the holding room air-conditioner unit. The nursing staff would carry through on a 24 Hour Report the death of a resident and the presence of the body in the holding room until its removal to ensure that such an incident could not reoccur. The Administrator further stated that there should have been a more consistent follow through by her Nursing Department. 415.26