Every finding on record at New Gouverneur Hospital SNF

Based on observation, staff interviews, and record review, the facility failed to initiate Cardiopulmonary Resuscitation (CPR) in a timely manner to an unresponsive resident who had full code status. This was evident in one (Resident #3) of three residents sampled for cardiopulmonary resuscitation. Specifically, on [DATE] at approximately 6:40 PM, staff entered Resident #3's room without emergency medical equipment after being alerted by a family member that the resident was unresponsive. Registered Nurses #11 and #12 failed to initiate any emergency response and action. As a result, approximately 15 minutes had passed before cardiopulmonary resuscitation was initiated, and ultimately, Resident #3 expired at 7:22 PM. This deficient practice resulted in actual harm and had the potential for serious harm to the health and safety of all residents in the facility that was determined to be Immediate Jeopardy Past Non-Compliance. The findings include:The facility's policy and procedure titled, Code Blue and Cardiopulmonary Resuscitation, last reviewed [DATE], documented that a Code Blue can be called for any medical emergency for which help is needed. It is the policy of the nursing facility to initiate a Cardiopulmonary Resuscitation procedure when a resident is unconscious/unresponsive with no sign of breathing in the absence of palpable carotid pulse/any pulse, and without a Do Not Resuscitate order.Resident #3 had diagnoses of atrial fibrillation (irregular heart rhythm), liver cirrhosis (advanced scarring of the liver), and osteomyelitis (bone infection) of right ankle and foot.The Minimum Data Set Assessment (a resident assessment tool) dated [DATE] documented that Resident #3 had moderately impaired cognition. The medical orders dated [DATE] documented Resident #3 as full code/cardiopulmonary resuscitation. The Medical Orders for Life-Sustaining Treatment (a medical form that states a person's wishes about life-saving treatments, so doctors and emergency responders know what care to give or avoid) dated [DATE] documented Resident #3's status as cardiopulmonary resuscitation/attempt cardio-pulmonary resuscitation.The Comprehensive Care Plan dated [DATE] documented Resident #3's advanced directive to include full code/cardiopulmonary resuscitation.On [DATE] at 9:54 AM, the facility's surveillance video was reviewed with the Director of Nursing and the Deputy Director of Nursing. The date and time in the camera's live feed was [DATE] from 6:31 PM to 7:30 PM. The following observations were noted:At 6:33:54 PM, a family member came out of Resident #3's room and walked down the hallway and returned two minutes later.At 6:37:16 PM, the call light outside Resident #3's room had been activated.At 6:37:31 PM, the family member exited the room, spoke out into the hallway and returned to the room; no other individual could be seen in the hallway at that time.At 6:38:16 PM, the family member exited the room and ran down the hallway, then returned one minute later.At 6:40:16 PM, Registered Nurse #11 and Patient Care Technician #5 entered Resident #3's room without medical equipment.At 6:40:39 PM, Patient Care Technician #16 entered Resident #3's room without medical equipment.At 6:40:56 PM, Patient Care Technician #15 entered the room with an automated blood pressure machine.At 6:41:05 PM, the call light outside Resident #3's room was deactivated.From 6:41:00 PM to 7:03:12 PM no medical equipment had been observed to have been brought to Resident #3's room by any staff.From 6:42:54 PM to 6:52:27 PM, Registered Nurse #11 left and re-entered Resident #3's room three times, spending approximately 30 seconds in the resident's room and two to three minutes outside of the resident's room each time.At 6:46:52 PM, Registered Nurse #12, who was the Assistant Director of Nursing, entered Resident #3's room without medical equipment.From 6:53:06 PM to 7:06:18 PM, Registered Nurse #12 left and re-entered Resident #3's room four times.At 6:55:46 PM, Registered Nurse #13 ran into Resident #3's room and exited at 7:20:14 PM.From 7:02:24 PM to 7:08:13 PM, three more nurses, including Registered Nurse #14, were seen entering and exiting the resident's room at varying intervals.At 7:03:23 PM, an automated external defibrillator is brought into Resident #3's room by Registered Nurse #16At 7:05:21 PM Registered Nurse #14 brought an Artificial Manual Breathing Unit (AMBU bag - a handheld medical tool used to push air into the lungs of patients who are not breathing or struggling to breathe) into Resident #3's room.At 7:06:06 PM, the cardiac board (a rigid, flat surface used to stabilize a patient during emergency medical procedures) was brought into Resident #3's room by Registered Nurse #15.At 7:06:13 PM, Registered Nurse #12 pushes the crash cart (a mobile medical station containing medical equipment and supplies intended for medical emergencies) towards Resident #3's room, leaving it outside the room, unopened. Registered Nurse #12 enters Resident #3's room without opening/preparing the crash cart.At 7:08:50 PM, Emergency Medical Services walked up the hallway with equipment on a stretcher and entered Resident #3's room. Emergency Medical Services exited the resident's room at 7:29:00 PM.Review of the Code Blue/CPR/Emergency Response Worksheet dated [DATE] documented that cardiopulmonary resuscitation was initiated for Resident #3 at 7:01 PM. The time Resident #3 was found was left blank. The worksheet documented that at 6:55 PM vital signs were taken, but blood pressure, pulse, respiration, and temperature were all documented N/A. The worksheet also documented that Emergency Medical Services responded at 7:07 PM. The worksheet additionally documented that cardiopulmonary resuscitation was stopped at 7:40 PM. The worksheet was signed by Registered Nurse #12.Review of the 24-Hour Report completed by the Assistant Director of Nursing/Supervisor dated [DATE] documented that Resident #3 was found alert and less responsive to stimuli. At around 7:00 PM, Resident #3's family member called out to say that Resident #3 could not breathe and was unresponsive. Vital signs could not be found. Registered Nurse #12 and the medical staff were notified. Cardiopulmonary resuscitation was started, Code Blue and 911 were called. Emergency Medical Services arrived at 7:15 PM and continued cardiopulmonary resuscitation. Resident #3 expired at 7:22 PMReview of New York City Health and Hospitals Corporation's Hospital Police Crime and Incident Report, dated [DATE], documented that at 7:00 PM Registered Nurse #12 reported a Code Blue incident to New York City Health and Hospitals' Hospital Police, who are stationed as peace officers that provide security to the facility. Emergency medical services (paramedics) arrived at the facility at 7:07 PM. The New York Fire Department arrived at the facility at 7:18 PM. At 7:31 PM both emergency medical services and the New York Fire Department left the facility. The death certificate dated [DATE] documented time of death at 7:22 PM due to myocardial infarction (blockage of blood flow to part of the heart causing damage/death to heart muscle). During an interview on [DATE] at 11:55 AM, Patient Care Technician #5 stated that at around 6:30 PM on [DATE], while monitoring residents in the dining room, Resident #3's family member came over and said that Resident #3 was having trouble breathing. Patient Care Technician #5 stated they immediately notified Registered Nurse #11. They further stated that they saw Registered Nurse #11 get the automated blood pressure machine. Patient Care Technician #5 stated they entered Resident #3's room to see how they were doing, and that Resident #3 was breathing with eyes open. They also stated that because Registered Nurse #11 did not give any instructions, Patient Care Technician #5 left the room to attend to other residents.During an interview on [DATE] at 4:00 PM, Patient Care Technician #15 stated they were trained on how to obtain vital signs, which included, blood pressure, oxygen concentration, pulse, respirations and temperatures. Patient Care Technician #15 stated that while monitoring the residents in the dining room area, they heard Resident #3's daughter yelling that the resident was having trouble breathing. They left the dining room area and grabbed the blood pressure machine. Upon entering the room, Patient Care Technician #15 noticed Registered Nurse #11 and Patient Care Technician #5 were also in the room. Patient Care Technician #15 stated that Resident #3 was breathing slowly, as they observed rise and fall of the chest. They called out the resident's name as the resident's eyes were open. Patient Care Technician #15 further stated they could not obtain a blood pressure reading or a pulse, but oxygen saturation was in the low 90's and dropping. At that point, they noticed that the resident was no longer breathing. Patient Care Technician #15 further stated that they asked Registered Nurse #12 if they were going to begin cardiopulmonary resuscitation, and that Registered Nurse #12 stated the resident had already passed away. Patient Care Technician #15 stated that upon leaving the room, they heard the Code Blue on the overhead speakers.On [DATE] at 4:50 PM, Registered Nurse #14 was interviewed and stated that they responded sometime around 7:00 PM to an overhead Code Blue alert. Registered Nurse #14 further stated that upon entering the resident's room, they observed Registered Nurse #12, standing on the resident's right side, performing cardiopulmonary resuscitation on the resident who was unresponsive. Additionally, they saw Registered Nurse #13 standing on the opposite side of the resident. Registered Nurse #14 stated it was their understanding that Registered Nurse #12 had already called 911. Registered Nurse #14 went to the crash cart, grabbed the Artificial Manual Breathing Unit, and brought it into the room; another nurse grabbed the automated external defibrillator machine.On [DATE] at 8:52 AM, an attempt to interview Registered Nurse #12 was made via telephone but was unsuccessful; a voice message was left asking for a call back. Registered Nurse #12 retired from the facility on [DATE].On [DATE] at 8:59 AM, an attempt was made to interview Registered Nurse #11. Registered Nurse #11 stated that they preferred to return State Agency's call between 9:00 AM - 11:00 AM. The reason for the call was provided. Registered Nurse #11 stated that before being interviewed they wanted to speak with their attorney. Registered Nurse #11 did not make themselves available for interview and did not return the call. Registered Nurse #11 was terminated from the facility on [DATE].On [DATE] at 9:39 AM, an attempt to interview Registered Nurse #13 was made via phone call but was unsuccessful. Registered Nurse #13 resigned from the facility.On [DATE] at 9:42 AM, an attempt to interview Registered Nurse #15 was made via phone call but was unsuccessful.During an interview on [DATE] at 11:35 AM, the Director of Nursing stated that the facility investigated the incident on [DATE]. The Director of Nursing stated that the facility's investigation revealed that cardiopulmonary resuscitation was not initiated until Registered Nurse #13 entered Resident #3's room. Registered Nurse #13 initiated cardiopulmonary resuscitation. The Director of Nursing stated that no one did what they were trained to do in an emergency, which was the worst-case scenario. They stated that licensed staff are expected to know how to identify when someone is experiencing a medical emergency and to react timely, including notifying 911 and the hospital police so that an overhead call for Code Blue is activated. A Code Blue can be called for any medical emergency when help is needed. Initiating Code Blue would alert staff from other units to assist. The Assistant Director of Nursing is responsible for calling 911 immediately after being made aware of an unresponsive resident, to serve as Team Leader during the code, and delegate tasks. They also stated that keeping family members, visitors, and other residents away from what is taking place is crucial to avoid delays and traumatizing others.During an interview on [DATE] at 2:56 PM, the Medical Director stated that if an unlicensed staff finds a resident unresponsive and looking like they are having trouble breathing, they need to call out for help immediately. The licensed staff must immediately assess the resident. Cardiopulmonary resuscitation must begin if there is no pulse, no breaths, the resident is unresponsive and is identified as having full code status. Full code status has no colors on their identification band. Immediate emergency action is necessary to keep the blood circulating, including performing [chest] compressions. Oxygen should be provided through the Artificial Manual Breathing Unit, which forces oxygen into the lungs to oxygenate the blood and organs. The Medical Director stated that there was a clear indication that the resident was in distress and had a change in status. During an interview on [DATE] at 11:50 AM, the Quality and Risk Manager stated that the facility's department heads convened on [DATE] to conduct a root-cause analysis and determined the cause of the deficient practice. They further stated that the facility identified a delay in initiating emergency response protocol and a need for cardiopulmonary resuscitation training post-incident. The root-cause analysis determined failure if multiple system factors including a delay in cardiopulmonary resuscitation due to late recognition of cardiac arrest, and failure to designate cardiopulmonary resuscitation team roles, the absence of a designated team leader, failure to immediately obtain a crash cart, and failure to connect to 911 dispatch. The Quality and Risk Manager stated that the training courses and in-services on this topic continue and are ongoing.During an interview on [DATE] at 2:53 PM, the Administrator stated that outcome measures have been closely monitored post-incident. Since this incident, the facility has experienced three more emergencies requiring cardiopulmonary resuscitation. The Administrator also stated that the facility has conducted meetings and discussions about any potential concerns during codes. The Administrator asserted that upon review of the outcome measures, no other concerns have been identified. Additionally, the Administrator stated that the medical director had called the family and offered condolences, and the family was reassured that this would be investigated. The Attorney General's Office had also requested medical records and requested meetings with the staff involved as well.The Immediate Jeopardy was determined to have begun on [DATE]. The Administrator was informed of the Immediate Jeopardy and provided with the Past Noncompliance Immediate Jeopardy template on [DATE] at 4:35 PM.Based on the following corrective actions taken, there was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance for this specific regulatory requirement prior to the start of this survey. As such, a Plan of Correction is not required for this citation. The facility took immediate corrective action and was found to be in substantial compliance on [DATE], prior to surveyor entrance on [DATE]. The facility's investigation, including staff statements dated [DATE] to [DATE], and summary dated [DATE], revealed that on [DATE] at approximately 6:50 PM, the family member of Resident #3 notified staff that Resident #3 was unresponsive. Registered Nurse #11 went to the room and could not obtain a pulse. Registered Nurse #12, who was the Assistant Director of Nursing, was then notified and went to the room. Registered Nurse #12 found Resident #3 gasping for breath and could not obtain detectable blood pressure. Registered Nurse #12 did not initiate an emergency response action. Cardiopulmonary resuscitation was initiated by Registered Nurse #13. The facility investigation concluded Registered Nurse #11 and Registered Nurse #12 did not follow facility protocol resulting in a delay in providing emergency response and treatment. After calling Code Blue, Registered Nurse #12 failed to bring the crash cart, Artificial Manual Breathing Unit and Automated External Defibrillator.On [DATE], the facility initiated Basic Life Support Certification Audits for all licensed staff to ensure staff maintain valid and current certifications. Audits are conducted monthly by the Human Resources Department.On [DATE], the Director of Nursing conducted an audit of all residents who are full code as potential residents to be affected by the deficient practice.On [DATE] the facility Quality Assurance and Performance Improvement Committee convened to conduct a root-cause analysis of the incident and deficient practice. The policy and procedure for Cardiopulmonary Resuscitation was reviewed and not updated.In-service titled, Code Blue Management, was provided for unlicensed patient care staff and licensed staff on all tours from [DATE] to [DATE] by Registered Nurse #15, the Nursing Educator. In-service topics included team responsibilities, expectations, timing, equipment, and skills. Code Blue Management training session percentage rate of staff compliance:90 of 91 (99%) Registered Nurses completed training19 of 19 (100%) Licensed Practical Nurses completed training149 of 151 (98%) Patient Care Technicians completed training10 of 10 (100%) Medical Providers completed training.The facility implemented the practice of Code Blue Drills to monitor staff response times and staff emergency response skills training. Code Blue Drills conducted included:[DATE] - Tour 1 (night shift)[DATE] - Tour 3 (evening shift)[DATE] - Tour 2 (day shift)The facility implemented a Cardiopulmonary Skills Review Competency and Assessment Checklist on [DATE]. All nursing staff are assessed by the Nursing Educator as part of annual training. Competency Assessment of all licensed staff had been audited quarterly. Staff compliance per quarter:[DATE] to [DATE] - 100%[DATE] to [DATE] - 100%[DATE] to [DATE] - 100%[DATE] to [DATE] - 100%The facility implemented corrective actions and was found to be in substantial compliance on [DATE]. 10 NEW [NAME] CODES, RULES, AND REGULATIONS-415.3(f)(1)(i)

Based on interviews and record review, the facility did not ensure that all allegations of abuse, neglect, exploitation, or mistreatment are reported to the New York State Department of Health (NYSDOH). This was evident in one (Resident #3) out of three residents sampled for Abuse. Specifically, the facility failed to report an incident involving a delay to initiate cardiopulmonary resuscitation for Resident # 3 that resulted in death. The facility investigated the incident but did not report it to the New York State Department of Health. The findings include:The facility's policy and procedure title, Abuse Prohibition Protocol, last revised [DATE], documented, that the facility has developed and implemented written policies and procedures that prevent, screen, investigate, and report all allegations of resident abuse, neglect, exploitation, mistreatment, involuntary seclusion, and misappropriation of resident property and finances. The policy further documents that all employees have an obligation to protect residents from abuse and must immediately report an incident of alleged abuse, neglect, mistreatment, or misappropriation or property. Additionally, it is the responsibility of the Administration, and/or designee, department heads and all staff members to ensure compliance with the policy.Resident #3 had diagnoses of atrial fibrillation (irregular heart rhythm), liver cirrhosis (advanced scarring of the liver), and osteomyelitis (bone infection) of right ankle and foot.The Minimum Data Set Assessment (a resident assessment tool) dated [DATE] documented that Resident #3 had moderately impaired cognition. The medical orders dated [DATE] documented Resident #3 as full code/cardiopulmonary resuscitation. The Medical Orders for Life-Sustaining Treatment (a medical form that states a person's wishes about life-saving treatments, so doctors and emergency responders know what care to give or avoid) dated [DATE] documented Resident #3's status as cardiopulmonary resuscitation/attempt cardio-pulmonary resuscitation.The Comprehensive Care Plan dated [DATE] documented Resident #3's advanced directive to include full code/cardiopulmonary resuscitation.On [DATE] at 9:54 AM, the facility's surveillance video was reviewed with the Director of Nursing and the Deputy Director of Nursing. The date and time in the camera's live feed was [DATE] from 6:31 PM to 7:30 PM. The surveillance video revealed that after Registered Nurse #11 was made aware that Resident #3's status had changed, no emergency treatment or response was performed for at least 10 minutes. Registered Nurse #12 entered Resident #3's room approximately five minutes after Registered Nurse #11's initial encounter with Resident #3 at 6:40 PM. Approximately 10 minutes after Registered Nurse #12 entered Resident #3's room, emergency treatment and/or response were initiated. At 7:08 PM, Emergency Medical Services (paramedics) entered Resident #3's room.Review of the 24-Hour Report completed by the Assistant Director of Nursing/Supervisor dated [DATE] documented that Resident #3 was found alert and less responsive to stimuli. At around 7:00 PM, Resident #3's family member called out to say that Resident #3 could not breathe and was unresponsive. Vital signs could not be found. Registered Nurse #12 and the medical staff were notified. Cardiopulmonary resuscitation was started, Code Blue and 911 were called. Emergency Medical Services arrived at 7:15 PM and continued cardiopulmonary resuscitation. Resident #3 expired at 7:22 PMThe facility's investigation summary, dated [DATE], revealed that on [DATE] at approximately 6:50 PM, the family member of Resident #3 notified staff that Resident #3 was unresponsive. Registered Nurse #11 went to the room and could not obtain a pulse. Registered Nurse #12 was then notified and went to the room. Registered Nurse #12 found Resident #3 gasping for breath and could not obtain detectable blood pressure. Registered Nurse #12 did not initiate an emergency response action. Cardiopulmonary resuscitation was initiated by Registered Nurse #13. The facility investigation concluded Registered Nurse #11 and Registered Nurse #12 did not follow facility protocol resulting in a delay in providing emergency response and treatment. After calling Code Blue, Registered Nurse #12 failed to bring the crash cart, Artificial Manual Breathing Unit and Automated External Defibrillator.During an interview on [DATE] at 2:53 PM, the Administrator stated that they received a letter of complaint from Resident #3's family, which was then forwarded to the Director of Nursing and the Medical Director, prompting an investigation. They also stated that a couple of days after the incident the facility was contacted by the Attorney General's Office. The Administrator stated that they believed that the Attorney General was a higher level agency and so the facility did not report the incident to the Department of Health. The Administrator stated they assumed the Attorney General's Office would communicate with the Department of Health.During an interview on [DATE] at 11:35 AM, the Director of Nursing stated that the facility investigated the incident on [DATE]. The Director of Nursing stated that the facility's investigation revealed that cardiopulmonary resuscitation was not initiated until Registered Nurse #13 entered Resident #3's room. Registered Nurse #13 initiated cardiopulmonary resuscitation. The Director of Nursing stated that no one did what they were trained to do in an emergency, which was the worst-case scenario. They further stated that the incident and investigation were not reported to the New York State Department of Health because the facility was cooperating with the New York State Attorney General's Office immediately after the incident. They assumed that that the Attorney General's Office was in contact with the Department of Health and therefore the incident did not have to be reported.10 NEW [NAME] CODES, RULES, AND REGULATIONS-483.12(c)(i)(4)

Based on record review and interviews conducted during the Recertification Survey from 12/12/2024 to 12/19/2024, the facility did not ensure a comprehensive person-centered care plan was developed for each resident, that includes measurable objectives and timeframes to meet each resident's medical, nursing, and mental and psychosocial needs. This was evident in 1 (Resident #20) of 38 total sampled residents. Specifically, a care plan for a diagnosis of Major Depressive Disorder and the use of antidepressant medication was not developed for Resident #20. The findings are: The facility policy titled Comprehensive Care Planning with a last reviewed date of 10/28/2024 documented that it is the policy of the facility to develop a comprehensive, person-centered plan of care that includes measurable objectives and timetables individualized and appropriate to the resident's needs, strengths, and goals. The comprehensive care plan is developed within seven (7) days of the completion of the required comprehensive Minimum Data Set Assessment. The Interdisciplinary Team must review and update the care plan when the resident has been readmitted to the facility from a hospital stay. Resident # 20 was admitted to the facility with diagnoses that include Dementia and Recurrent Major Depressive Disorder. The Minimum Data Set assessment dated [DATE] documented that Resident #20 had moderately intact cognition and had an active diagnosis of Depression. A Physician's Order dated 10/23/2024 included Sertraline oral tablet 50 milligrams, give 1 tablet by mouth one time a day for Major Depressive Disorder. A Psychiatric Consultant Note dated 11/22/2024 documented psychiatric diagnosis of Major Depressive Disorder with recommendations to continue the current dose of Sertraline 50mg. A Provider Comprehensive assessment dated [DATE] documented Resident #20 was seen for review of chronic medical conditions for provider comprehensive and medication review. Resident had a psychiatric history of Major Depressive Disorder and had orders for Sertraline 50 milligram tablet orally once per day. A Multidisciplinary Care Conference form dated 12/10/2024 documented an interdisciplinary team meeting review for Resident #20's quarterly reassessment identified Major Depressive Disorder as a problem/need for Resident #20. A review of Resident #20's Comprehensive Care Plans from the admitted [DATE] revealed no documented evidence that a care plan for the diagnosis of Major Depressive Disorder or the use/administration of antidepressant medications was developed. On 12/18/2024 at 10:03 AM, Registered Nurse #2 was interviewed and stated it is the admitting nurse's responsibility to create the resident's care plans on admission or readmission. Registered Nurse #2 stated it was both nursing and social services' responsibility to update the resident's admission care plans. They stated that Resident #20's care plan for depression was overlooked. On 12/18/2024 at 9:25 AM, the Director of Social Services was interviewed and stated it is the social workers' responsibility to create the care plan for major mood disorders, but it was all discipline's responsibility to update the care plan during quarterly assessments. The Director of Social Services stated all the disciplines missed entering or updating the care plan for Depression. On 12/18/2024 at 10:36 AM, The Director of Nursing was interviewed and stated that admission care plans are developed based on the resident's needs, diagnoses, and medications. They stated multiple nurses are responsible for completing the care plans. The Minimum Data Set assessment nurse is responsible for developing comprehensive care plans on admission, or it could be the next shift or the Head Nurse. The Director of Nursing stated that on readmission or quarterly assessment, the interdisciplinary team is responsible for reviewing or developing the comprehensive care plans. The Director of Nursing stated that Resident #20's care plan for depression was not re-opened when they were readmitted on ,d+[DATE], and that it should have been added during the quarterly assessment in 11/2024. 10 NYCRR 415.11(c)(1)

Based on record review and interviews conducted during the Recertification and Abbreviated (NY00351380) Survey from 12/12/2024 to 12/19/2024, the facility did not ensure each resident received adequate supervision to prevent accidents. This was evident in 1 (Resident #22) of 3 residents reviewed for Abuse out of 38 total sampled residents. Specifically, Resident #22, who was identified as high risk for falls and had history of numerous falls, was not provided adequate monitoring or supervision. On 08/13/2024 at 3:20 PM, Resident #22 stood up from their wheelchair and fell on to the floor while in the dining room. The findings are: The facility's policy titled Fall Reduction and Injury Prevention Program dated 10/28/2024 documented it is the policy of this facility to take appropriate measures to provide a safe environment and minimize the risk of resident injuries resulting from a fall. The policy documented that after a fall has occurred, the Registered Nurse must perform a complete assessment including neurological status check and assess for injuries before moving the resident. Resident #22 was admitted to the facility with diagnoses of Dementia, Reduced Mobility, and Osteoarthritis of Right Hip and Right Knee. The Minimum Data Set assessment dated [DATE] documented that Resident #22 had severely impaired cognition, non-ambulatory, dependent with transfers, and uses wheelchair for mobility. A care plan for falls was initiated for Resident #22 on 12/19/2020. The care plan documented that Resident #22 sustained actual falls on 12/19/2020, 03/03/2021, 02/20/2022, 02/25/2023, 12/28/2023, and 08/13/2024. The facility interventions include half hourly monitoring, incontinence care every 2 hours when awake, and positioning resident close to staff doing monitoring when in dining/common area. A progress notes by Nurse Practitioner #1 dated 08/13/2024 at 4:32 PM documented that Resident #22 was seen status post witnessed fall episode. The Patient Care Technician saw Resident #22 sliding down their wheelchair but was too late to stop them from falling. Resident #22 had no physical injuries, did not hit their head, and had no change in mental status. A nurse's progress notes by Registered Nurse #8 dated 08/13/2024 at 8:19 PM documented they were informed by the Certified Nursing Assistant that Resident #22 was witnessed sliding out of the wheelchair on to the floor at 3:20 PM in the dining room. Resident #22 had no visible injuries, neurological status within normal limits, and range of motion at baseline. The Nurse Practitioner was notified, x-ray to bilateral hips complete awaiting for results. The Nursing Home Investigative Report completed by the Deputy Director of Nursing documented that on 08/13/2024 at 3:20 PM, Resident #22 stood up from the wheelchair while seated in the dining room and sustained a fall. The report documented there was reasonable cause to believe that abuse, neglect, or mistreatment occurred. Patient Care Technician #10, who was responsible for monitoring the residents in the dining room at the time of the incident, was not being attentive to the residents, nor was observed to be in close proximity to assist residents if needed. Resident #22's x-ray results documented acute right femoral neck fracture. Upon further evaluation at the hospital, computed tomography scan of the right hip revealed no discrete acute fracture, it was an old, healed fracture with superimposed severe right hip osteoarthrosis. A copy of the facility's video surveillance was reviewed by the State Surveyor. The facility's video surveillance showed on 08/13/2024 at 3:16:48 PM, Resident #22 was on a wheelchair in the dining room with 2 other residents. At 3:20 PM, Resident #22 stood up while holding on the arm rest and the footrest of the wheelchair, and then fell backwards onto the floor. It was noted that there was no staff seen in the camera that was in close proximity of the residents during the incident. A review of the Daily Half Hourly Dining Room Monitoring Sheet documented that Patient Care Technician #10 was assigned to monitor the dining room on 08/13/2024 from 3:00 PM - 3:30 PM. The employee written statement completed and signed by Patient Care Technician #10 dated 08/14/2024 documented that on 08/13/2024 at 3:20 PM, they were sitting in the back of the kitchen completing the monitoring sheet when the incident happened. They stated they heard another Patient Care Technician shouting, they rushed but the Resident was already on the floor. On 12/18/2024 at 10:25 AM , Patient Care Technician #10 was interviewed and stated they no longer work at the facility and had no knowledge of the alleged incident. On 12/17/2024 at 11:14 AM, Patient Care Technician #1 was interviewed and stated on the day of the incident, they had Resident #22 on their assignment. They stated they put Resident #22 in the wheelchair and wheeled the Resident in the dining area. Patient Care Technician #1 stated there was a Patient Care Technician who was supposed to be on 30-minute monitoring duty at the dining room to supervise the residents, however, could not recall who it was. Patient Care Technician stated they were standing in the middle of the foyer when they heard someone screaming, and when they turn around, they saw Resident #22 screaming and sliding out of their wheelchair. Patient Care Technician #1 stated they tried to run and catch Resident #22 but was too late. Patient Care Technician #1 stated when they got to Resident #22, the 2 other Patient Care Technicians that were sitting by the window came over to assist. Patient Care Technician #1 stated they were not sure if Resident #22 had history of previous falls or if they have any fall interventions in place. On 12/17/2024 at 10:45 AM, Patient Care Technician #11 was interviewed and stated on the day of the incident, they were doing their charting when they heard Patient Care Technician #1 yelling. They stated Patient Care Technician #1 saw Resident #22 sliding from the wheelchair. Patient Care Technician #11 stated they helped pick up Resident #22 from the floor. On 12/17/2024 at 12:45 PM, Registered Nurse #8 was interviewed and stated they were the nurse in charge on the day of the incident. Registered Nurse #8 stated on the day of the incident they were in the nurse's station when Licensed Practical Nurse #1 came to inform them of Resident #22's fall. Registered Nurse #8 stated that according to Patient Care Technician #1, Resident #22 slid out of their wheelchair and that the Patient Care Technician #1 ran but was too late to catch the Resident. Registered Nurse #8 stated there were 2 other Patient Care Technicians that were supposed to monitor the dining room, but they were not sure where they were at the time of the fall. On 12/17/2024 at 2:39 PM, the Deputy Director of Nursing was interviewed and stated they investigated the incident and upon review of the video surveillance, it was determined that Patient Care Technician #10 who was assigned to monitor the day room, was not in close proximity of the residents prior to the fall. The Deputy Director stated that it is the responsibility of the Patient Care Technicians who are assigned to every 30-minute monitoring duty to not do anything else but monitor the residents in the day room as well as be in close proximity of the residents. They stated the investigation revealed there was no cause to believe neglect occurred to Resident #22. On 12/17/2024 at 2:06 PM, the Director of Nursing was interviewed and stated Resident #22 was identified as high risk for falls. They stated at the time of the incident, Resident #22 was in the dining room but the Patient Care Technician who was assigned to monitor the dining room was not in close proximity of the residents as instructed in the facility policy. 10 NYCRR 415.12(h)(2)

Based on record review and interviews conducted during the Recertification Survey from 12/12/2024 to 12/19/2024, the facility did not ensure that a resident's comprehensive care plan was reviewed and revised to reflect the resident's status. This was evident in 1 (Resident #217) of 8 residents reviewed for Activities of Daily Living out of 38 total sampled residents. Specifically, Resident #217's comprehensive care plan was not revised to accurately reflect the resident's mode of transfer. The findings are: A facility policy titled Comprehensive Care Planning with a reviewed date of 10/28/2024 documented it is the policy of the facility to develop a comprehensive, person-centered plan of care that includes measurable objectives and timetables individualized and appropriate to the resident's needs, strengths, and goals. The interdisciplinary team must review and update the care plan when there has been a significant change in a resident's condition. Resident #217 had diagnoses of Paraplegia, Human Immunodeficiency Virus, and Bipolar Disorder. The Quarterly Minimum Data Set 3.0 assessment dated [DATE] documented Resident #217 had intact cognition and was dependent with chair/bed-to-chair transfers. The Functional Status Endorsement from Rehab to Nursing form dated 11/30/2024 documented that Resident #217's required partial/moderate assistance with 1 person physical assist and a use of a sliding board. Registered Nurse #5 signed the endorsement indicating that they agreed, and the Care Plan and task was updated. A Comprehensive Care Plan for Activities of Daily Living was initiated for Resident #217 on 11/30/2024 and was last revised on 12/18/2024. The care plan documented Resident #217 required a Hoyer lift with two-person physical assist from chair/bed-to-chair transfers. There was no documented evidence that the Comprehensive Care Plan had been revised to reflect that Resident #217 required partial/moderate assistance of one person with a sliding board to transfer to and from a bed to a chair (or wheelchair). On 12/19/2024 at 12:44 PM, the Director of Rehabilitative Therapy was interviewed and stated there was a recent endorsement from the rehabilitative team that Resident #217 required a 1-person physical assist transfer using a sliding board from bed to chair to wheelchair and same way from wheelchair to bed. They stated Registered Nurse #5 reviewed and signed the endorsement but did not update the Certified Nursing Assistant Task instructions or care plan to reflect the endorsement's new instructions. On 12/19/2024 at 1:23 PM, Registered Nurse #5 was interviewed and stated they signed the Physical Therapy Endorsement dated 11/30/2024 acknowledging that they agreed with the recommendation. They stated they were responsible for updating the care plan, however, when Registered Nurse #5 discussed Resident #217's transfer with the assigned aide, the aide stated they used a Hoyer lift to transfer Resident #217 and that was what they documented in the Certified Nursing Assistants Task instructions. On 12/19/2024 at 2:16 PM, The Director of Nursing was interviewed and stated since Registered Nurse #5 picked up the Physical Therapy assessment, they would be responsible for updating the care plan and certified nursing assistant instructions. 10 NYCRR 415.11(c)(2)(i-iii)

Based on observations, record review, and interviews conducted during the Recertification Survey from 12/12/2024 to 12/19/2024, the facility did not ensure the daily nurse staffing information included all the required information. Specifically, the daily posting of nurse staffing information did not include the total number of licensed and unlicensed nursing staff directly responsible for resident care. This was evident during the review of the Staffing task. The findings are: The facility policy and procedure titled Minimum Staffing with a last revision date of 03/06/2024 documented that it is the facility's policy to establish compliance with minimum nursing staffing levels. Posted nurse staffing information shall include the facility name, current date, resident census, the total number of staff and actual hours worked per shift for Registered Nurses, Licensed Nurses, and Certified Nurse Aides. During an observation from 12/12/2024 through 12/19/2024, nurse staffing information was posted next to the elevators, and the nursing units. The information that were documented on the form includes the facility name, current date, actual hours worked, and resident census. There was no documentation of the total number of nursing staff. On 12/19/2024 at 10:38 AM, the Deputy Director of Nursing was interviewed, and stated that the Assistant Director of Nursing from each shift is responsible for posting the nurse staffing information for the following shift. The Deputy Director of Nursing further stated that according to the Director of Nursing, the staff information posting is based on the regulations and done by the hours. They stated they do not document the number of nursing staff. On 12/19/2024 at 11:30 AM, the Director of Nursing was interviewed and stated they do not put the number of staff in the posted daily nurse staffing information and that they had been doing that for a long time. The Director of Nursing stated it was an oversight. On 12/19/2024 at 11:50 AM, the Administrator was interviewed and stated they were unaware that they must post the total number of staff and the hours. 10 NYCRR 415.13

Based on observations, record review and interviews conducted during the Recertification survey from 10/12/22 to 10/18/22, the facility did not ensure person-centered Comprehensive Care Plans (CCP) were developed and implemented for each resident to address the resident's needs. This is evident in 4 (Resident #s 93, 202, 222, and 184) out of 38 sampled residents. Specifically, there was no documented evidence 1) a CCP related to limited range of motion was developed for Resident #93, 2) a CCP related to side rail (SR) use was developed for Resident #202, 3) a CCP related to respiratory care was developed for Resident #222, and 4) a CCP related abuse prevention was developed for Resident #184. The findings are: The facility policy titled Resident Participation-Assessments/ Care Plans dated 03/18/2021 documented the care planning process will include an assessment of the resident's strengths and needs, incorporating the resident's personal and cultural preferences in establishing goals of care. A CCP is developed within seven days of completing the resident assessment, shall be used in developing the resident's daily care routine, and will be available to staff personnel who have responsibility for providing care or services to the resident. 1) Resident #93 had diagnoses of Hemiplegia and hemiparesis. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #93 was severely cognitively impaired and required assistance with Activities of Daily Living. On 10/12/2022 at 9:30 AM, 10/12/2022 at 3:38 PM, and 10/13/2022 at 8:50 AM, Resident # 93 was observed lying in bed with a right-hand contracture without a splinting device or guard in place. A Physician Order dated 05/17/2022 documented to use right-hand palmer guard for Resident #93 always except for AM/PM care. A CCP related to Resident #93's limited physical mobility was initiated on 5/16/2022 and did not document interventions including use a right-hand palmer guard. A Rehabilitation (Rehab) Note dated 07/08/2022 at 9:01 documented Resident # 93 continue to always use the right-hand palmer guard except for hand hygiene. During an interview on 10/14/2022 at 2:52 PM, Registered Nurse (RN) #5 stated that Resident # 93 had a contracture, and a right-hand palmer guard was ordered on 05/17/2022. A CCP for the right-hand palmer guard was not initiated and should have been with initiated with interventions in place. During an interview on 10/18/2022 at 2:38 PM, the Director of Nursing (DON) stated it was the responsibility of the nurse on the unit to develop and implement interventions for the use of the right-hand palmer guard with Resident #93. 2) Resident # 202 had diagnoses of non-Alzheimer's dementia and anxiety. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #202 was severely cognitively impaired, required supervision for bed mobility, was independent with transfers, and did not use SRs. On 10/12/2022 at 9:50 AM, 10/12/2022 at 11:35 AM, 10/12/2022 at 3:17 PM, 10/13/2022 at 8:54 AM, and 10/14/2022 at 10:08 AM, Resident # 202 was observed lying in bed with four 1/2 SRs raised. On 10/14/2022 at 11:48 AM, Resident # 202 was observed out of bed and in the bathroom. Resident #202's bed had 3 1/2 SRs raised and the lower right 1/2 SR was lowered. A Physician Order dated 03/08/2022 documented orders for bilateral SRs for bed mobility. A SR assessment dated [DATE] documented Resident #202 used the 1/2 left and right upper SRs. There was no documented evidence a CCP related to SR use was developed and implemented for Resident #202. During an interview on 10/14/2022 at 2:39 PM, Registered Nurse (RN) #5 denied observing Resident # 202 with four 1/2 SRs raised while in bed. RN #5 stated there is a physician order for Resident #202 to have bilateral SRs, but the order does not specify whether 1/2 or full SRs should be raised. RN #5 further stated no CCP was developed related to Resident #202's SR use prior to today. During an interview on 10/18/2022 at 2:42 PM, the Director of Nursing stated there should have been a CCP developed related to Resident #202's SR use upon admission with updates quarterly. 41709 3) Resident # 222 had diagnoses of respiratory failure and tracheostomy status. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #222 was severely cognitively impaired, received oxygen, required suctioning, and received tracheostomy care. On 10/14/22 at 09:30 AM, Resident #222 was observed lying in bed with a tracheostomy in place. Nursing note dated 10/1/22 documented Resident #222 was provided with tracheostomy care and suctioning. Respiratory Therapy notes dated 10/1/22, 10/3/22, and 10/7/22 documented the Respiratory Therapist (RT) assessed Resident #222 and their tracheostomy care. There was no documented evidence a CCP related to respiratory and tracheostomy care was developed and implemented for Resident #222. On 10/18/22 at 08:29 AM, an interview was conducted with Registered Nurse (RN) #4 who stated Resident #222 returned from the hospital in August 2022 with tracheostomy in place. A CCP related to respiratory and tracheostomy care should have been developed but RN #4 was unable to locate the CCP. RN #4 was unable to provide an explanation a respiratory CCP was not included in Resident #222's medical record. 4) Resident #184 had diagnoses of multiple sclerosis and metabolic Encephalopathy. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #184 was cognitively intact and required extensive assistance of one to two people to perform activities of daily living. The Occurrence Investigation Form dated 10/10/2022 documented Resident #184 reported to the nurse a Rehab staff person grinded their genital area against the resident. Physician note dated 10/10/2022 documented Resident #184 was seen following reports that male therapist would grab the resident around their waist during exercise and would grind against the resident. Physical therapy and Nursing staff aware and further investigation will occur. Nursing notes dated 10/12/2022 documented Resident #184 reported abusive behavior to the head nurse on 10/10/12. There was no documented evidence a CCP related to risk for abuse was developed and implemented for Resident #184. On 10/14/22 at 04:09 PM, an interview was conducted with the Director of Social Services (DSS) who stated the Social Service Department (SSD) is responsible for developing and implementing CCPs related to abuse prevention. The DSS reviewed Resident's #184's medical record and realized a CCP related to abuse had not been developed. Resident #184 is at risk for abuse because of varying cognition, being legally blind and, and requiring assistance with all Activities of Daily Living (ADL). The DSS was unable to provide an explanation Resident #184 did not have a CCP related to abuse and will implement one today. On 10/18/22 at 12:42 PM, the Director of Nursing (DNS) was interviewed and stated the Nursing Department is responsible for developing care plans related to tracheostomy care and they work with the SSD to develop CCPs related to abuse prevention. The charge nurse is responsible for initiation of CCPs upon admission. The residents' CCPs are reviewed during CCP meetings and are updated quarterly, annually, upon significant change and as needed. The DNS monitors the development of CCPs by completing a daily admission checklist. The CCPs related to abuse for Resident #184 and respiratory care for Resident #222 were missed. 415.11(c)(1)

Based on observation, record review, and interviews conducted during the Recertification survey, the facility did not ensure that a resident environment remained free of accident hazards. This was evident in 1 (Resident #202) out of 7 residents reviewed for Accidents/Hazards out of 38 sampled residents. Specifically, there were multiple observations of Resident #202 in bed with four 1/2 side rails (SR) raised. The findings are: The facility policy titled Bed Side Rail Usage dated 03/2021 documented SRs are considered restraints and must be ordered by a physician after assessment or observation to determine its use. Upper SRs, or Enablers, are for bed mobility to promote residents' independence. Resident # 202 had diagnoses of non-Alzheimer's Dementia and anxiety. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #202 was severely cognitively impaired, required supervision for bed mobility, was independent with transfers, and did not use SRs. On 10/12/2022 at 9:50 AM, 10/12/2022 at 11:35 AM, 10/12/2022 at 3:17 PM, 10/13/2022 at 8:54 AM, and 10/14/2022 at 10:08 AM, Resident # 202 was observed lying in bed with four 1/2 SRs raised. On 10/14/2022 at 11:48 AM, Resident # 202 was observed out of bed and in the bathroom. Resident #202's bed had 3 1/2 SRs raised and the lower right 1/2 SR was lowered. A Physician Order dated 03/08/2022 documented Resident #202 was ordered to have bilateral SRs for bed mobility. A SR assessment dated [DATE] documented Resident #202 used the 1/2 left and right upper SRs. The Fall Risk assessment dated [DATE] documented Resident #202 was at risk for falls with a score of 15. There was no documented evidence a comprehensive care plan related to SRs was developed. During an interview on 10/14/2022 at 11:55 AM, Patient Care Technician (PCT) #2 stated that Resident # 202 is independent in transfers and goes to the bathroom on their own. Resident # 202 prefers to have four 1/2 SRs raised and can lower the lower 1/2 SR to come out of bed. Resident #202 always raises the SRs when the staff lowers them. During an interview on 10/14/2022 at 2:39 PM, Registered Nurse (RN) #5 stated they have not observed Resident # 202 with four 1/2 SRs raised while in bed. Resident #202 raises the SRs when the staff lowers them. Resident #202 is ordered to have bilateral SRs and it does not specify whether the SRs should be 1/2 or full SRs. There is no documentation that Resident #202 prefers to and raises 4 1/2 SRs while in bed. During an interview on 10/18/2022 at 2:42 PM, the Director of Nursing (DON) stated that Resident # 202 gets has an order for bilateral SRs and this means the resident is supposed to have bilateral 1/2 SRs, not 4 1/2 SRs, raised while in bed. 415.12(h)(2)

Based on observation, record review, and interview conducted during the Recertification survey from 10/12/22 to 10/18/22, the facility did not ensure that a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion. This was evident for 1 (Resident #93) of 1 resident(s) reviewed for Limited Range of Motion out of 38 sampled residents. Specifically, Resident #93 had a right hand contracture and was observed without a hand splint as per Medical Doctor Order (MDO). The findings are: The facility's policy titled Provision of Care in the Nursing Facility last revised 11/11/2020, states that the Rehabilitation Department (Rehab) implements therapy upon signature of an order/plan of care. Resident # 93 had diagnoses of diabetes mellitus and hemiparesis. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #93 was severely cognitively impaired and required assistance with Activities of Daily Living. On 10/12/2022 at 9:30 AM, 10/12/2022 at 3:38 PM, and 10/13/2022 at 8:50 AM, Resident # 93 was observed lying in bed with a right-hand contracture without a splinting device or guard in place. During an interview on 10/12/2022 at 3:38 PM, Resident # 93's designated representative stated Resident #93 has a right-hand contracture, requires a splint, and staff do not apply the splint to the resident. Staff keep the right-hand splint in the resident's bedside drawer. MDO dated 05/17/2022 documented Resident #93 required total assistance to don/doff a right-hand palmer guard to be worn at al times except during morning and evening care. A Rehab Note dated 07/08/2022 documented Resident # 93 was discharged from Occupational Therapy (OT) with recommendation for right hand palmer guard to be worn except for hand hygiene. There was no documented evidence Resident #93 refused to wear right hand palmer guard. During an interview on 10/14/2022 at 12:02 PM, Patient Care Technician (PCT) #2 stated Resident # 93 has a right-hand contracture, has a splinting device ordered for the right hand, but the resident refuses to wear the splint. Resident #93 went for an appointment this morning and PCT #2 did not apply the splint to the resident's hand. During an interview on 10/14/2022 at 2:52 PM, Registered Nurse (RN) # 5 stated Resident # 93 will not let staff apply the palmer guard to their right hand and refuses to wear the guard. After reviewing Resident #93's medical record, RN #5 stated they could not find documentation of Resident #93's refusal to wear the palmer guard. During an interview on 10/18/2022 at 12:44 PM, the Director of Rehab stated Resident # 93 was provided with a right-hand palmer guard on 5/17/22 and the guard is always to be worn except for hand hygiene. The staff on Resident #93's unit was trained how to apply the palmer guard to the resident's right hand. The Nursing staff did not communicate to Rehab that Resident #93 refused to wear the palmer guard. 415.12(e)(2)

Based on observation, interview, and record review conducted during the Recertification survey from 10/12/22 to 10/18/22, the facility did not ensure a resident's comprehensive care plan (CCP) was reviewed and/or revised after each assessment and as needed for changing needs of the resident. This was evident for 2 (Resident #123 and Resident #230) of 38 sampled residents. Specifically, 1) multiple CCPs for Resident #123 were not reviewed and revised upon comprehensive assessment; and 2) the CCP related to Resident #230's risk for falls was not reviewed and revised after Resident #230 fell . The findings are: The facility policy titled Resident Participation-Assessment/Care Plans dated 3/18/2021 the resident and/or resident's representatives can participate in assessment, development, and implementation of care plans. 1) Resident #123 had diagnoses of dementia and anoxic brain injury. The quarterly Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #123 was moderately cognitively impaired, did not display behaviors, and received antipsychotic and antidepressant medications. The CCP related to impaired cognition initiated 8/16/19 documented the goal was for Resident #123 to communicate basic needs and develop skills to cope with cognitive decline. The CCP was last revised 5/29/22. The CCP related to Resident #123's behavior of trying to enter the elevator, ambulating without asking for assistance, and spitting on the floor documented the CCP was last reviewed and revised 5/29/22. The CCP related to Resident #123's potential to be physically aggressive related to dementia was initiated 10/21/21 and documented the CCP was last reviewed and revised 5/29/22. The CCP related to Resident #123's use of antipsychotic medication related to anxiety disorder was initiated 8/16/19 and documented the CCP was last reviewed and revised 5/29/22. The was no documented evidence the CCPs for Resident #123 were reviewed and revised upon the quarterly comprehensive assessment conducted 8/16/22. 2) Resident #230 had diagnoses of malignant neoplasm of the prostate and difficulty in walking. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #230 was severely cognitively impaired and had no history of falls. The CCP related to Resident #230's risk for falls was initiated 9/8/22 documented a revision date of 9/17/22 when Resident #230 fell . A Nursing Note dated 9/25/22 documented Resident #230 was found on the floor next to the wheelchair. There was no documented evidence Resident #230's CCP related to falls was reviewed and revised after Resident #230's fall on 9/25/22. An interview was conducted on 10/18/22 at 10:25AM with the MDS Assessor who stated the charge nurse is responsible for reviewing and revising the resident's CCPs with the interdisciplinary team at the CCO meeting. The MDS Assessor informs the charge nurse when audits are performed and CCPs are missing or need to be updated. If a resident fall is reported during morning meeting, the charge nurse will be asked the next day if the CCP was updated. An interview was conducted on 10/18/22 at 10:49 AM with Registered Nurse (RN) #1 who stated they are the charge nurse, and the admission nurse initiates CCPs related to falls. If a resident falls, the CCP is updated with when the patient fell , date and time, injury, and new interventions. For each occurrence, the CCP is updated. On 10/18/22 at 12:42 PM, the Director of Nursing Services (DNS) was interviewed and stated the RNs are responsible for initiating and updating all CCPs on admission, updated quarterly, annually, significant change and as needed. The DNS monitors that CCPs are created and/or updated in the morning meeting and the CCP meetings. 415.11(c)(2) (i-iii)

Based on interviews and record review conducted during the recertification and complaint (NY00303700) survey from 10/12/22 to 10/18/22, the facility did not ensure all allegations involving abuse were reported immediately, but not later than 2 hours, to the New York State Department of Health (NYSDOH). This was evident for 1 (Resident #184) of 2 resident(s) reviewed for abuse out of 38 sampled residents. Specifically, an allegation of sexual abuse involving Resident #184 was received by the facility on 10/10/22 and was not reported to the NYSDOH until 10/12/22. The findings include: The facility's policy titled Abuse Prohibition Protocol dated October 2021 documented reports of resident abuse shall be reported immediately and should follow the chain of command. Resident #184 had diagnoses of multiple sclerosis and metabolic Encephalopathy. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #184 was cognitively intact and required extensive assistance of one to two people to perform activities of daily living. The Occurrence Investigation Form dated 10/10/2022 documented Resident #184 reported to the nurse a Rehab staff person grinded their genital area against the resident. Physician note dated 10/10/2022 documented Resident #184 was seen following reports that male therapist would grab the resident around their waist during exercise and would grind against the resident. Physical therapy and Nursing staff aware and further investigation will occur. Nursing notes dated 10/12/2022 documented Resident #184 reported abusive behavior to the head nurse on 10/10/12. The Aspen Complaint Tracking System documented the facility reported the allegation of sexual abuse involving Resident #184 to the NYSDOH on 10/12/2022 at 12:46 PM, two days after report of incident. On 10/18/22 at 11:06 AM, an interview was conducted with the Deputy Director Nursing (DDN) who stated Resident #184 reported an allegation of sexual abuse on 10/10/22 and the DDN initiated an investigation on 10/10/22. The allegation should have been reported to the NYSDOH within 2 hours of being made but was not reported to the NYSDOH until 10/12/22. 415.4(b)(1)(i)

Based on observation, record review, and interviews conducted during the Recertification survey from 10/12/22 to 10/18/22, the facility did not ensure each resident remained free from physical restraints. This was evident for 1 (Resident # 194) of 8 residents reviewed for Activities of Daily Living out of a sample of 38 residents. Specifically, there were multiple observations of Resident #194 with bilateral 1/2 side rails (SR) in use without a Medical Doctor's Order (MDO). The findings are: The facility policy titled Bed Side Rail Usage dated 3/2021 documented SRs are considered restraints and must be ordered by a physician after assessment or observation to determine its use. SRs are ordered based on a particular condition. Resident #194 had diagnoses right femur fracture and dementia. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #194 had severely impaired cognition, required extensive assistance of 1 person for bed mobility, and did not use SRs. On 10/14/22 at 9:41 AM, 10/14/22 at 12:25 PM, and 10/17/22 at 10:15 AM Resident #194 was observed in bed with upper bilateral 1/2 SRs in the raised position. A Comprehensive Care Plan (CCP) related to high risk for falls initiated 2/24/21 and last revised 6/27/22 documented an intervention for Resident #194 to receive SRs as ordered. A Quarterly Side Rail assessment dated [DATE] documented SRs were not considered for Resident #194. The Fall Risk assessment dated [DATE] documented Resident #194 was at risk for falls with a score of 15. There was no documented evidence of MDO for Resident #194 to receive bilateral 1/2 SRs. On 10/18/22 at 11:36 AM, Certified Nursing Assistant (CNA) #1 was interviewed and stated last week the SRs were already in the up position and Resident # 194 used the SRs to turn in bed while receiving care. The electronic medical record (EMR) informs the CNAs whether a resident uses SRs and CNA #1 stated they make sure to check the EMR before using SRs with a resident. On 10/18/22 at 11:32 AM, Registered Nurse (RN) #2 was interviewed and stated Resident #194 controls the SRs by using the remote control on the bed. There should be an MDO for SR use and RN #2 could not explain the reason the SRs were raised for Resident #194 without an MDO. The most recent SR Assessment for Resident #194 documented SRs were not being considered and there were no instructions for the CNA to raise the SRs in the EMR. The Director of Nursing Services (DNS) was interviewed on 10/18/22 at 1:14 PM and stated residents use SRs if they have a medical condition that warrants their use and/or as an enabler for bed mobility. The facility does not use SRs to prevent falls and are considered a restraint if they prevent the resident from getting out of bed. The DNS was not aware SRs were being used for Resident #194 without MDO. 415.4(a)(2-7)

Based on observation, record review, and interviews during the abbreviated survey (NY 00301986), the facility failed to ensure a resident who was at risk for elopement and refused to wear a wander guard was adequately supervised to prevent elopement. This was evident in 1 out of 3 residents sampled (Resident #1). Specifically, on 9/10/2022, Resident # 1 was scheduled for every half hour visual monitoring, the last documented monitoring was done by Certified Nurse Assistant # 1 (CNA # 1) 2:30 PM to 3:00 PM. The Facility's surveillance camera showed that Resident #1 got off the elevator in the lobby at 3:30 PM, walked past Hospital Police # 1 (HP # 1), and left the building at 3:32 PM. At 5:30 PM, CNA #1 informed License Practical Nurse #1 (LPN #1) that Resident #1 was missing from the Unit. The findings are: The Facility's Policy and Procedure entitled Resident Elopement Procedure, (Code Green), revision # 12, dated 9/2022, documented that the Skilled Nursing Facility (SNF) ensures the safety and security of all its residents by identifying those residents who are at risk for wandering and elopement, and will implement a stepwise plan to locate a missing resident from his/her assigned unit. A surveillance camera was reviewed with the Administrator on 9/11/2022 at 5:45 PM and revealed: On 9/10/2022 at 3:27 PM, the video recording from Hallway A 1 camera showed Resident # 1, exit their room, and walked to the elevator. Resident # 1 was dressed in a white t-shirt with a black long-sleeve shirt underneath, dark pants, and a gray cap. Resident # 1 has a book in their hand. On 9/10/2022 from 3:27 PM to 3:30 PM, on Camera Hallway A 2, no staff were seen in the TV room, food serving area, and the elevator area. On 9/10/2022 at 3:28 PM, the elevator camera revealed that Resident # 1 was observed going down elevator # 2. On 9/10/2022 at 3:30 PM, the Camera in the Lobby elevator showed that Resident # 1 got off the elevator, walked past the Hospital Police (security officer) and left the building at 3:32 PM. On 9/12/2022 at 4:30 PM, the camera at the exit door was reviewed with the Administrator and showed that on 9/10/2022, Resident # 1 was standing at the front of the open glass main exit double door. Resident #1 wave to open the door, then touch the frame, and walk toward the second double door. The door automatically opened, and Resident # 1 walked on the sidewalk through the parking lot toward the street, turned left, and disappeared from camera view at 3:32 PM. Resident # 1 with diagnoses including Dementia, Psychosis, and Alcohol Abuse. The Minimum Data Set (MDS, an assessment tool) dated 7/25/2022, documented that Resident # 1 had short-term and long-term memory problems. Resident # 1 requires supervision with walking. An Elopement Evaluation dated 7/23/2022, documented that Resident # 1 scored 0 and is an elopement risk. A Facility's Occurrence Investigative Form dated 9/10/2022, documented that at approximately 5:30 PM, CNA # 1 reported to License Practical Nurse # 1 (LPN #1) that Resident # 1 was missing from the unit. The Assistant Director of Nursing # 1 (ADN # 1) was notified and called the Hospital Police. The family was called but there was no answer. The Deputy Director of Nursing (DDON) was notified at 7:30 PM. A Comprehensive Care Plan: (CCP) Resident at Elopement Risk/Wanderer related to Dementia, Impaired safety awareness initiated on 5/6/2020, with interventions to move Resident # 1 to a room closer to the nursing station, Psychiatric evaluation, identified the pattern of wandering, and to provide 30 minutes monitoring. A CCP documented that on 11/23/2021 at 6:50 AM, Resident #1 went to the lobby by themselves. Interventions included Roam Alert tag 8042401 (wander guard), on the left ankle. On 3/3/2022 at 6:48 AM, Resident # 1 was seen in the lobby by themselves. The CCP was updated with interventions to check the placement of the wander guard, check the room for sharps every shift, and environmental rounds. The CCP was updated on 9/2/2022, with intervention to monitor Resident # 1 every 30 minutes. A non-complaint CCP for Resident # 1 was initiated on 09/21/2020, Resident # 1 was non-complaint and decline to wear a roam alert related to Dementia. The CCP was updated on 9/7/2022, and the documented interventions are to allow Resident # 1 the right to decline the roam alert, educate Resident # 1 of possible outcomes of not complying with roam alert placement, prize the Resident # 1 when behavior was appropriate. A Nursing Note dated 9/2/2022 at 2:27 PM, documented that Resident #1 was alert with periods of confusion and refused to have the roam alert placed. A Physician Order dated 7/24/2022, revised on 9/2/2022, documented that Environmental Check are to be done every 30 minutes. A Purposeful Half Hour Rounds Day Shift Sheet (7:30 AM-4:00 PM) dated 9/10/2022, documented that the CNA last observed Resident # 1 and signed on 2:30 PM-3:00 PM. There were no signatures on 3:30 PM - 4:00 PM. A Nursing Note dated 9/10/22 at 10:28 PM, written by ADN #1 documented that at 5:30 PM, the writer was called by a nurse, LPN # 1, on the 13 th floor and was told that Resident # 1 was not seen. The Staff searched all rooms around the unit and then code Green and the hospital police were called. The hospital police checked the basement, and the clinic rooms. At 7:30 PM, a picture was sent to New York Police Department (NY). A Physician Note dated 9/11/2022 at 5:02 PM, documented that the Family Guarding Service was informed that Resident # 1 left the facility. A CNA Accountability Sheet dated from 9/1/2022 to 9/10/2022, documented that Resident # 1 was monitored for wandering around the unit every shift. During an interview on 9/11/2022 at 3:52 PM, CNA #1 stated that he/she worked on 9/10/22, a double shift he/ she was assigned to Resident # 1 from 7:30 AM to 3:45 PM and stated Resident # 1 had no behaviors. He/she was the Hall monitor after 3:45 PM for the evening shift (worked double). During an interview on 9/11/2022 at 3:55 PM, CNA # 2 stated she was a hall monitor from 3:00 PM to 3:45 PM on 9/10/22, he/she was in the dining room watching the residents. CNA # 2 stated that he/she did not see Resident # 1 leave the unit at 3:30 PM. During an interview on 9/11/2022 at 4:10 PM, LPN # 1 stated that he/she worked on 9/10/2022 and at approximately 3:30 PM was in the activity room. He/she did not see Resident # 1 going on the elevator. During an interview on 9/11/ 2022 at 5:45 PM, Hospital Police #1 (HP #1) stated that he/she was at the command center at the time of the elopement. The command center has three monitors. Monitor one has 36 cameras, monitor two has 30 cameras and monitor three had cameras pointing towards [NAME] Street. It was not possible to recognize the residents who are at risk for an elopement with all the cameras. During an interview on 9/11/2022 at 6:05 PM, HP #2 stated he/she worked at the entrance on that side of the building on 9/10/2022 at 3:30 PM and stated that there was no list of residents on Roam alert on 9/10/2022. He stated that he/she knows Resident # 1 from the past incident when Resident # 1 tried to leave the building and HP # 2 responded. HP #2 stated he/she did not recognize Resident #1 on 9/10/2022 because Resident # 1 wore a baseball cap and normally Resident # 1 wore a red hoodie. During an interview on 9/12/2022 at 10:20 AM, the Administrator stated that currently, Hospital Police (HP) does not require visitors to sign out when leaving the building. The Administrator stated that he/she was notified and went to look for Resident # 1. During an interview on 9/12/22 at 5:09 PM, the Director of Nursing (DNS) stated he/she was notified on 9/10/2022 at 7:30 PM, that Resident #1 was still missing. Resident #1 was identified as a risk for Elopement with 0 score and a wander guard was placed due to a history of attempts to leave the unit unescorted. Resident # 1 had a Dementia diagnosis and wandering behavior and was not permitted to leave the unit without an escort. Resident #1 had no family but had a Guardian. Resident #1 removed the wander guard on 8/31/2022, and refused replacement despite many attempts. A care plan was updated, and Resident # 1 was placed on every 30 minutes monitoring. When residents are identified at risk for elopement, staff initiate a care plan, did a risk assessment, applying wander guard with and did functionality checks every shift, and at least one hourly monitoring. The DNS stated that they do not have a policy on risk for elopement. They have a policy when the residents are missing. The policy did not include what staff should do if the resident refuse to wear a wander guard. The DNS stated that the staff on the unit was supposed to monitor residents and document every 30 minutes. The last signature was between 3:30 to 4:00 PM, but CNA # 2 said that he/she saw Resident # 1 before 3:30 PM. The DNS stated that staff noted Resident # 1 was missing at 5:30 PM. There was no explanation from staff as to why the signatures were missing after 4:00 PM. The DNS stated that in-service on Elopement started an 9/10/2022 and was ongoing. During a follow-up interview on 9/15/2022 at 12:48 PM, CNA #1 stated that he/she was not assigned to Resident #1 on the evening shift. CNA # 1 stated that the CNA who was assigned to Resident # 1 in the evening was supposed to check every 30 minutes and sign the monitoring sheet. He/she was monitoring the hallway from 4:00 PM to 5:00 PM. From 5:00 PM to 6:00 PM CNA # 1 was helping to distribute the trays in the residents' room. CNA # 1 stated that he/she took the tray to Resident # 1's room and Resident # 1 was not there. CNA # 1 stated that he/she looked in the bathroom and TV area where Resident # 1 usually sits. Resident # 1 was not there either. CNA # 1 stated that he/she notified LPN # 1 between 5:00 PM to 5:15 PM that he/she did not see Resident # 1. During an interview on 9/15/22 at 1:10 PM, CNA # 3 stated that he/she was assigned to Resident # 1 on 9/10/2022 3:30 PM -12:00 AM. CNA # 3 stated that he/she last saw Resident # 1 at 3:00 PM watching TV in the dining area and drinking coffee. Resident # 1 had a Bible with them. Resident # 1 walked independently, and was at risk for elopement. The staff was supposed to watch Resident # 1 who refuse to wear a wander guard. CNA # 3 stated that Resident # 1 was on every 30 minutes monitoring and the CNA who was watching the dining area are supposed to check Resident # 1 and sign every 30 minutes monitoring sheet because CNA # 3 was busy with other residents. CNA # 3 stated that CNA # 1 informed them at around 5:00 PM that Resident # 1 was missing, and they immediately started the search for Resident #1. During a follow-up telephone interview on 9/15/2022 at 12:30 PM, the DNS stated that Resident #1 returned to the facility on [DATE], and was currently on one-to-one observation. Resident # 1 agree to wear the wander guard. During a follow-up telephone interview on 9/30/2022 at 1:50 PM, the Deputy Director of Nursing (DDON), stated that the assigned CNA was responsible for monitoring and signing the every 30 minutes monitoring log. If the assigned CNA go on a break or will be busy doing something else, it was the CNA's responsibility to inform the nurse on duty or other CNA on the unit to assist with coverage. 415.12(h)(1)(2)

F 660-D Based on observation, record review and interview conducted during an abbreviated survey ( NY 607), from 05/14/2021 to 06/09/2021, the facility did not develop and implement an effective discharge planning process that focused on the resident's discharge goals, the preparation of the resident to be an active partner and effectively transition the resident to post-discharge care, and the reduction of factors leading to preventable readmission. This was evident in 1 of 3 residents sampled (Resident #1). Specifically, Resident #1 was admitted to the facility on [DATE] and was discharged to the community on 10/17/2019. The Discharge planning process was not developed and implemented for Resident #1. The Finding Include: Review of the facility's Policy and Procedure on Transfer and discharge date d 4/30/2018, documented that it is the policy of the facility to provide for the safe and orderly transfer and discharge of residents from the facility to the community, to other nursing facility or acute care facility. A transfer or discharge is implemented with the recognition of a resident's right to receive considerate and respectful care, participate in his/her discharge plan, and understand right to appeal a transfer or discharge. Purpose of the policy is to establish guidelines for the transfer and discharge of residents to ensure that all necessary and appropriate information is shared among all participants in discharge planning process. Review of facility Policy and Procedure Comprehensive Resident Assessment (MDS 3.0) and Care Planning dated 05/12/2018, documented the intradisciplinary team shall perform an accurate, standardized and comprehensive assessment for each resident in the facility, and shall develop an individualized plan of care in accordance with federal and New York State Department of Health regulations. Review of the facility's Policy and Procedure Patient's and Resident's involvement in care planning dated 05/2/2018, documented that the purpose of the policy is to encourage and support all residents to participate and make their needs known in an individualized care plan meeting. Resident #1 was admitted to facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS, an assessment tool) dated 9/25/2019, documented that Resident #1 had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of 0/15, which indicates severe mental impairment. Resident #1 required extensive assist with bed mobility, transfer, and toilet use. Review of Social Worker (SW) Initial assessment dated [DATE] at 4:52 PM, documented that resident #1 had moderately impaired decision making. Resident #1 had plans to return to the community. Review of the Resident #1's medical record revealed that there were no discharge care plans to address resident #1 needs for safe and orderly discharge from the facility to the community. Review of Medical Doctor Discharge Summary Note dated 10/16/2019, documented that Resident #1's evaluation, medications and follow-up appointments were reviewed with Resident #1 's family member and all questions were answered. Resident #1 was stable to be discharge to the community with appropriate community supports. Review of the Nursing Note dated 10/17/2019 at 5:24 PM, documented that resident #1 was scheduled to be discharged on [DATE]. This document revealed that resident #1 was admitted for restorative nursing services which included Physical Therapy and Occupation Therapy (PT/OT) to attain the highest level of functional status. Resident #1 was noted with significant improvement. Upon admission, resident #1 required total assistance for Activity of Daily Living (ADLs). On discharge, resident #1 required extensive assist and supervision for ADLs. Resident #1 and family member had teaching done, follow up appointment, medications and safety in the home was discussed. Resident #1 left the faciity on [DATE] at 3:00 PM, accompanied by two Senior Care emergency attendants and a family member. Review of Intradisciplinary Discharge Instructions dated 10/15/2019, revealed that Resident #1's family member received teaching about wound care and medications and return demonstration of good understanding. Review of Discharge/Transfer Notice with an appeal information dated 10/17/2019, documented that the reason for discharge was that resident #1 's health improved sufficiently so the resident no longer needs the services of the facility as evidenced by completion of rehabilitation. During an interview on 5/13/2021 at 1:35 PM, Director of Social Service (DSS) stated that Social Service Department was responsible for developing discharge care plans. DSS also stated that Resident #1 had no discharge care plan in place because there was no issue with discharge. The facility develops discharge care plan only if there is a problem with discharge. They stated that discharge prosses for the resident was documented in the progress notes. During the interview on 6/9/2021 at 2:05 PM, Director of Nursing (DNS) stated that the facility had a policy on resident's involvement in care planning and MDS assessment. The Intradisciplinary team discussed the status of care plans during care plan meeting. The staff received education about developing care plan during their orientation. 415.11(d)(3)

F661 Based on interviews and record review conducted during an abbreviated survey (NY 607), the facility did not ensure that resident's Discharge Summary included a post-discharge plan of care that is developed with the participation of the resident and, with the resident's consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. This was evident for 1 out of 3 residents sampled (Resident #1). Specifically, Resident #1 who required personal contact during ambulation, was discharged to the community with no help. The discharge instruction did not specify what assistive equipment Resident #1 required. Resident #1 was severely cognitive impaired and signed the Notice of Medicare Non-Coverage. The Findings are: Review of the facility's Policy and Procedure on Transfer and discharge date d [DATE], documented that it is the policy of the facility to provide for the safe and orderly transfer and discharge of residents from the facility to the community, to other nursing facility or acute care facility. A transfer or discharge is implemented with the recognition of a resident's right to receive considerate and respectful care, participate in his/her discharge plan and understand right to appeal a transfer or discharge. Purpose of the policy is to establish guidelines for the transfer and discharge of residents to ensure that all necessary and appropriate information is shared among all participants in discharge planning process. Resident #1 was admitted to facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS, an assessment tool) dated [DATE] documented that Resident #1 had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation and ability to recall information) and scored ,d+[DATE] (,d+[DATE] severe impairment, ,d+[DATE] moderate impairment and ,d+[DATE] cognitively intact). Resident #1 was discharged to the community on [DATE]. Review of the Occupation Therapy (OT) plan of care note dated [DATE], documented that Resident #1 had the following equipment at home: Rolling Walker, Shower Chair and Grab Bars. The resident lives alone on the first-floor apartment with steps to enter the building. The resident's family live in the same building 2 floors up. This information was not reflected in discharge instructions. Review of the Medical Doctor (MD) Discharge Summary Note dated [DATE], documented that Resident #1's evaluation, medications and follow-up appointments were reviewed with resident #1's family and all questions were answered. Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] #1 to the community. Review of the Nursing Note dated [DATE] at 5:24 PM, documented that resident #1 was scheduled to be discharge home on [DATE]. Resident #1 was admitted for restorative nursing including Physical and Occupational Therapy to attain the highest level of functional status. On admission, resident # 1 required total assistance for ADLs, at discharge Resident #1 required extensive assist and supervision for ADLs. Resident # 1 and the family member had teaching done, follow up appointment, medications and safety in the home was discussed. Resident #1 left facility at 3:00 PM, accompanied by two Senior Care emergency medical attendants and a family member. Review of Intradisciplinary Discharge Instructions dated [DATE], revealed that Resident #1's family member received teaching about wound care and medications with return demonstration. Physician appointment made with Medical Doctor who will make a home visit on [DATE] and Home Care Services referral done. Rehabilitation instructions documented that Resident#1 was ambulating 160 feet and requiring contact guard assistance. Resident #1 occasionally uncooperative but can walk with assistance of one person. There was no documentation about what assistive equipment was recommended for Resident #1. The instructions stated that, family has all assistive devices at home. There was no documentation as to who was going to be providing extensive assistance, supervision and contact guard for Resident #1. There was no backup agreement provided or SW note documenting that the family was going to provide care or that a private aide was going to be hired by the family. Review of the Form Instruction for the Notice of Medicare Non-Covarage (NOMNC) CMS- , documented that the NOMNC must be delivered at least two calendar days before Madicare covered services end or the second to last day of service if care is not being provided daily. The provider must ensure that the beneficiary or representative signs and dates the NOMNC to demonstrate that the beneficiary or representative received the notice and understands that the termination decision can be disputed. Review of the Notice of Medicare Non-Coverage revealed that end of services was [DATE]. Resident #1 signed the Notice on [DATE] (the resident had ,d+[DATE] BIMS score that denote severe impairment in cognitive function). Discharge/Transfer Notice with an appeal information dated [DATE], documented the reason for discharge was that resident's health improved sufficiently so the resident no longer needs the services of the facility as evidenced by completion of rehabitation (completion of rehab is not a regulatory reason for discharge). The notice was signed by complainant on [DATE]. During the interview on [DATE] at 11:00 AM, Resident's family, the Complainant stated that the facility discharged the resident to the apartment with no one to help. Resident #1 fell at home and end up in the hospital. The complainant stated that they were begging the facility not to discharge the resident #1. The complainant cannot take care of the resident #1. There is another sibling who sleep over occasionally. The complainant also stated that they hired a person to stay with the resident #1. During an interview on [DATE] at 12:24 PM, Registered Nurse (RN) stated that resident #1 was confused at times due to Dementia and was monitored for combative behavior during care. Resident #1 required extensive assistance of one person with transfers and bathing. During an interview on [DATE] at 12:40 PM, The Director of Rehab Department (DRD), stated that on discharge, resident #1 required contact guard during walking. They stated that the resident #1 needed someone at home to help with ADL. Resident #1 was unable to ambulate alone. Resident #1 was admitted for short term rehabilitation and completed OT/PT by achieving highest practical level. Resident #1's family received training on how to assist the resident #1 with ADLs including transfer and walking. The OT notes documented that resident #1 had the necessary equipment at home prior to being admitted to the nursing home and it was confirmed by the family member. DRD stated that Resident #1 needed a walker and shower chair at home, but this was not ordered or documented in the discharged summary. During an interview on [DATE] at 12:12PM, Assistant of Director of Nursing /MDS Coordinator stated that at the time of resident #1 discharge, they were responsible to issue Notice of Medicare Non-Coverage Letter. This letter should be given to the resident or family no later than 48 hours after discharge plan was discussed with team. They stated that the letter was given to resident #1 and the family. The family never appealed the discharge and agreed with discharge. The family received all necessary teaching. There were no complaints from the family about discharge process and family did not asked the facility not to discharge the resident home. During an interview on [DATE] at 1:35 PM, Director of Social Service (DSS) stated that resident #1 was discharged home based on insurance cut off letter. The family attended an intradisciplinary meeting and was agreeable with the discharge plan. The Intradisciplinary team completed the discharge summary which included all necessary information for a safe discharge, medication, appointments, assistive equipment, and who will provide the support. The DSS stated that Resident #1 was referred to a Home Care Agency who assess Resident #1 and will provide a feed back to the facility. The Home Care Agency notified the facility that they were not able to complete the evaluation due to resident #1 expired. The DSS stated that Social Service Department are responsible for developing discharge care plan. DSS also stated that the resident had no Discharge Plan in place because there was no issue with the discharge. The facility developing Discharge care plan only if there is a problem with discharging a resident. 415.11(d)(1)(2)

Based on observation, interview and record review conducted during the COVID-19 Focus Infection Control Survey and Complaint Investigation Survey (#NY 899) on 5/14/20 and 5/23/20, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, 1). The facility did not discontinue communal dining on resident units as required in the Health Advisory issued by the New York State Department of Health dated March 13, 2020; and 2). The facility did not follow the cohorting requirements documented in the Dear Administrator Letter (DAL) dated April 29, 2020. This was evident for 7 of 7 resident units observed. The findings are: 1. The Executive Order #202.11 dated March 12, 2020 documented the following: Any guidance issued by the New York State Department of Health related to prevention and infection control of COVID-19 at nursing homes and adult care facilities, including but not limited to guidance on visitation, shall be effective immediately and shall supersede any prior conflicting guidance issued by the New York State Department of Health and any guidance issued by any local board of health, any local department of health, or any other political subdivision of the State related to the same subject. The Health Advisory issued by the New York State Department of Health dated March 13, 2020, documented: At this time NHs (Nursing Homes) are required to take the following actions: If there are confirmed cases of COVID-19 in a NH cancel group activities and communal dining The facility's Policy and Procedure on Management of Coronavirus Disease (COVID-19) dated March 2020, documented that the facility will immediately identify key strategies to prevent the spread of COVID-19. The policy also documented that if guidance changes or is updated after the policy has been approved, the facility shall follow the most current guidelines issued by the governing body. On 5/23/2020, the facility reported 8 COVID-19 positive cases in the facility. On 5/23/2020 between 11:45 AM and 12:00 PM, residents were observed eating together in the dining rooms on units 6,7,8, 9, 10, 11, and 13. On 5/23/20 at 12:03 PM, the Licensed Practical Nurse (LPN) #1 stated most of the alert and oriented residents eat in their rooms with supervision, and the high risk for fall and confused residents eat in the dining room, spaced out for social distancing. During an interview on 5/23/20 at 1:45 PM, the Infection Control Preventionist (ICP) stated that most residents, both unknown and tested negative are eating in their rooms with supervision. Residents at high risk for falls and residents with behavioral concerns eat in the dining room separated at an adequate distance, usually limited to 2 residents per table. 2. The Executive Order 202.11 dated March 27, 2020 documented the following: Any guidance issued by the New York State Department of Health related to prevention and infection control of COVID-19 shall be effective immediately and shall supersede any prior conflicting guidance issued by the New York State Department of Health and any guidance issued by any local board of health, any local department of health, or any other political subdivision of the State related to the same subject. The New York State Department of Health DAL from the Commissioner of Health, dated April 29, 2020, documents the following: As care pertains specifically to COVID-19, state and federal rules and regulations require nursing homes must adhere to appropriate safety measures including, but not limited to: Having protocols to separate residents into cohorts of positive, negative, and unknown as well as separate staffing teams to deal with COVID-19 positive residents and non-positive residents. In order to effectuate this policy, nursing home facilities should transfer residents within a facility, to another long-term care facility, or to another non-certified location if they are unable to successful separate out patients in individual facilities. The facility's Policy and Procedure on Management of Coronavirus Disease (COVID-19) dated March 2020, documented that the facility will immediately identify key strategies to prevent the spread of COVID-19. The policy also documented that if guidance changes or is updated after the policy has been approved, the facility shall follow the most current guidelines issued by the governing body. A tour of the facility on 5/14/20 at 10:30 AM, revealed the presence of 7 resident units, units 6 through11 and unit 13. A Resident Roster sheet was provided which documented: COVID-19 positive residents were isolated to their rooms on units 6,7,8,10 &11. COVID-19 negative residents were placed on all floors of the building including where COVID-19 positive residents were located. Presumed COVID-19 positive residents were placed on floors 9 and 13. Untested and asymptomatic residents were housed throughout the facility, where both positive and negative COVID-19 residents resided On 5/23/2020 at 11:30am, unit rounds were conducted on the 7th Floor with the Licensed Practical Nurse who stated 714A to 720B were for residents who tested positive for COVID-19 rooms. Rooms 701-712 and 721- 730 housed both residents who tested negative for COVID-19, asymptomatic residents who had not been tested and whose status was unknown. COVID-19 residents were not separated from residents whose status was unknown. The remaining units in the facility housed both residents who tested negative for COVID-19 and asymptomatic residents who had not been tested and whose status was unknown. COVID-19 tested residents were not separated from residents whose status was unknown. On 5/23/20 at 11:45 AM, RN # 3 assigned to the 7th floor was interviewed. RN #3 stated that 2 RNs are dedicated to the COVID-19 residents and are separated by the double doors on the floor. RN #3 stated that 1 CNA is dedicated to take care of the COVID-19 residents. RN #3 also stated the rest of the unit is for non-COVID-19 residents with 2 nurses and 3 CNAs. There is no separation between the COVID-19 tested negative and unknown/untested residents on the unit. During an interview conducted on 5/23/20 at 1:50 PM, the ICP stated that residents not yet tested are on the units with the residents who tested negative. These residents are being closely monitored and if any resident shows any sign or symptoms, they are immediately isolated and tested for COVID-19. If the result is positive, the resident is moved to the COVID-19 positive unit. The ICP further stated that testing is expected to be completed next week when all the residents will be appropriately separated based on the outcome of the result. During an interview conducted on 5/23/20 at 2:15 PM, the Director of Nursing (DON) stated the facility has not been separating the residents who tested negative for COVID-19 from the untested residents. The DON further stated that if the state thought it needed to be done, she could ask the staff to identify and separate the unknown/untested residents. The DON further stated that if a resident is noted with symptoms, the resident is immediately swabbed, specimen sent to lab, and the resident will be isolated to their room and monitored pending the result. The Administrator was also interviewed on 5/23/20 at 2:00 PM and stated that the facility was able to separate the COVID-19 confirmed positive to a dedicated unit but has not yet been able to separate the tested from untested residents. The Administrator stated that the facility is working hard. Testing the rest of the residents will start on Tuesday and residents will be separated accordingly when the test result is received. 415.19 (a)(1-3),(b)(1)

Based on record review and interview conducted during the recertification and abbreviated survey(NY 336), the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice, a comprehensive person-centered care plan, and the resident's choices. Specifically, a resident admitted to the facility with a [DIAGNOSES REDACTED]. This was evident for 1 of 1 resident reviewed for Quality of Care- Diabetes Management out of a total investigation sample of 38 residents (NY 336) (Resident #438). The finding is: A facility policy and procedure related to Care of Residents with Diabetes Mellitus was dated 11/20/18 and documented that the licensed nurses are responsible for identifying a diabetic resident upon admission through medication reconciliation, interview with resident and family, and by reviewing medical records. Resident #438 was admitted to the facility with [DIAGNOSES REDACTED]. The Discharge Minimum Data Set (MDS) assessment dated [DATE] documented the resident had moderately impaired cognition. Diabetes Mellitus was not included among the diagnoses. On 12/17/19 at 12:24 PM, an interview was conducted with the complainant, the resident's daughter. The complainant stated that the facility staff told her that they were unaware that the resident had Diabetes and did not administer her regular diabetic medications. Once the family became aware that the resident's blood glucose levels were over 500, they became worried for the resident's well-being and requested that the resident be sent to the hospital. The Patient Review Instrument (PRI) completed on 7/12/19 documented that the resident had a [DIAGNOSES REDACTED]. The Allscripts Online Referral packet sent to the facility on [DATE] documented the resident was diagnosed with [REDACTED]. The PRI Assessment Checklist dated 7/16/19 documented that the resident is Diabetic, had a history of [REDACTED]. The hospital Patient Discharge Instructions dated 7/17/19 documented that the resident received Insulin [MEDICATION NAME] Prandial Scale Pre-Meal unit subcutaneous at 8:19AM and 12:04PM prior to discharge. A list of the resident's medications prior to hospitalization documented that the resident received Basaglar Kwikpen and [MEDICATION NAME] 50-1000mg. An Admit/Readmit Screen completed by the Registered Nurse (RN) dated 7/17/19 did not document any information related to a [DIAGNOSES REDACTED]. The Baseline Care Plan dated 7/17/19 did not include the [DIAGNOSES REDACTED]. Nursing Notes and Medical Doctor (MD) notes from 7/17/19 through 7/23/19 do not document that the resident had a [DIAGNOSES REDACTED]. The Laboratory Report dated 7/24/19 for labs drawn on 7/23/19 documented that the resident's Hemoglobin A1C was flagged as high at 8.0% with a reference range of 4.0%-5.6%. The Glucose was 624 mg/dL with a reference range of 70-99. An MD note dated 7/24/19 documented that the resident had an A1c of 8.0% and that he will start the resident on [MEDICATION NAME] 750mg ER and [MEDICATION NAME] 100mg daily for Type 2 diabetes. A Nursing Note dated 7/24/19 documented the resident was evaluated by the MD at 8:47am for abnormal lab results, and NS IVF at 50 ml/hr for [MEDICAL CONDITION], [MEDICATION NAME] ER 750 mg daily and [MEDICATION NAME] 100 mg daily were ordered. The resident's granddaughter approached the nurse around 9:45am to report that the resident did not look good. The nurse checked vital signs, and the MD spoke to the granddaughter regarding the new plan of care for the resident. The granddaughter called 911 and Emergency Medical Services (EMS) responded. A FS (Finger Stick), taken by EMS, had a result of 500, but EMS refused to let the Registered Nurse administer 10 units of insulin as ordered by the MD. The resident was transferred to the hospital at the granddaughter's request. The physician's orders [REDACTED]. [MEDICATION NAME] 100mg for Diabetes Mellitus II and [MEDICATION NAME] HCI Extended Release 750mg were ordered with a start date of 7/25/19. The (MONTH) 2019 Medication Administration Record [REDACTED]. [MEDICATION NAME] 100mg once daily was ordered for the resident on with a start date of 7/25/19 but was not administered. [MEDICATION NAME] HCI Extended Release 750mg once daily was ordered for the resident with a start date of 7/25/19 but was not administered to the resident. The medical record did not include DM on the resident's [DIAGNOSES REDACTED]. On 12/17/19 at 04:06 PM, an interview was conducted with Registered Nurse (RN) #2, the RN that admitted Resident #438 into the facility. RN #2 stated that she has been working at the facility for 4 years but has only been responsible for admitting residents into the facility since (MONTH) 2019. She did not specifically recall this resident's admission. Prior to a resident being admitted to the unit, the Admissions office provides the RN on the unit with the discharge paperwork available from the hospital so that the RN has an idea of what kind of care the resident will require. The RN reviews the paperwork and prepares any special devices or equipment that may be needed to care for the resident. Once the resident is physically brought into the facility, a new set of discharge paperwork and more detailed information is provided to the RN. The RN reviews this paperwork and completes their own assessment of the resident's condition. The RN is responsible for transcribing the resident's [DIAGNOSES REDACTED]. This review includes looking at whether the resident received FSBS glucose monitoring and insulin administration while in the hospital. After reviewing the hospital discharge records for Resident #438, RN #2 stated that the PRI does list DM as a [DIAGNOSES REDACTED]. There are times that this may be overlooked, and this is what happened in this case. After reviewing the treatment recommendations that include FSBS testing for the resident, the RN agreed that this also should have been transcribed on the resident's orders for the facility MD to review and sign. After RN #2 transcribes the orders onto the resident's medical record, the MD reviews them, makes any changes he deems necessary, and then signs them so that they can be active. Sometimes the MD will not agree with certain orders from the hospital and will delete them from the resident's physician's orders [REDACTED]. When a resident is admitted with a [DIAGNOSES REDACTED]. The RN does not contact the family of the residents to discuss specific [DIAGNOSES REDACTED].#438. An interview was conducted with the MD on 12/19/19 at 10:40 AM. The MD stated that he had reviewed this resident's medical record and does recall that when she was admitted , she looked very sick and toxic. This resident had recently received surgery in the hospital for a perforated [DIAGNOSES REDACTED] ulcer. The MD did review the hospital discharge paperwork upon her admission and did see that there was a [DIAGNOSES REDACTED]. The MD was unable to determine from the record whether any insulin was actually administered to the resident in the hospital. The hospital sends a lot of paperwork with the resident and the MD reviews the information related to the acute issue that caused a resident's hospitalization as well as the recommended medications. He did not review the Allscripts Online Referral packet of information that was included with the hospital discharge paperwork. If any insulin was recorded as being administered to the resident in the hospital, it could have been given acutely pre-operation, not to address a [DIAGNOSES REDACTED]. The MD then performs his own assessment of the resident and reviews the [DIAGNOSES REDACTED]. If the resident is admitted with a [DIAGNOSES REDACTED]. The MD stated that the DM [DIAGNOSES REDACTED]. The A1c value in the labs would give a definitive determination of whether the resident truly had a [DIAGNOSES REDACTED]. The MD stated that although the hospital recommended for the resident to have FSBS monitoring, this is not his treatment approach with residents who have a [DIAGNOSES REDACTED]. The hospital labs did not contain a A1c for Resident #438 and he was unable to determine whether the resident truly had a [DIAGNOSES REDACTED]. He did not do so in this case because he was more concerned with addressing the resident's acute condition. He wanted to take a wait and see approach to watch how the resident responded to being in a post-acute setting for a few days. Once he noticed that she had diabetic breath (an odor specific to patients with a DM diagnosis), he ordered the labs. This is what led to the delay in obtaining the resident's Hemoglobin A1c values. At that point, he ordered the resident to receive diabetic medications and FSBS monitoring; however, the family was worried about the resident's condition and requested that she be sent to the hospital. A follow up interview was conducted with the MD on 12/20/19 at 09:58 AM. The MD stated that he does believe that his approach to treating the resident's diabetic condition was appropriate. In retrospect, he believes that he should have documented his rationale behind not including the DM [DIAGNOSES REDACTED]. An interview was conducted with the Director of Nursing (DNS) on 12/20/19 at 11:36. The DNS stated that the RN responsible for admitting any resident into the facility should be taking the [DIAGNOSES REDACTED]. This is a tedious task that recently became more time consuming for the nurses once the facility launched their Electronic Medical Record (EMR) in (MONTH) 2019. The nurses have expressed that they find it difficult to perform the task of transcribing the resident's [DIAGNOSES REDACTED]. The process was very new at that point and RN #2 was just getting used to it. After reviewing the medical record for Resident #438 and speaking with RN #2, the DNS determined that the [DIAGNOSES REDACTED]. On 12/20/19 at 12:00 PM, an interview was conducted with the Medical Director who has been overseeing the MDs in the facility since 10/2109. The Medical Director stated that he does not disagree with the MD's approach in caring for Resident #438 and addressing her DM diagnosis. He does believe that the MD's treatment approach should have been documented in his progress notes. This would allow the MD to communicate his rationale to other facility staff and medical professionals to see and understand. Without the MD's documentation, it is difficult to understand his line of thinking. The Medical Director stated the he will be speaking with the MDs in the facility to ensure that they understand proper documentation in the resident's medical record. 415.12

Based on interviews and record review conducted during the recertification and abbreviated complaint (NY 336) survey, the facility did not ensure that the physician reviewed and documented a resident's total plan of care upon each visit. Specifically, the physician did not address diabetic managment needs for a resident's Diabetes or document any medical rationale for why Diabetic managment was discontinued. This was evident for 1 of 1 resident reviewed for Quality of Care- Diabetes Management out of a total investigation sample of 38 residents (Resident #438). The finding is: A facility policy and procedure related to Assessment and Reassessment of Residents dated 11/20/19 documented that the Medical Doctor is responsible for conducting an initial assessment inquiring information such as a history and physical examination [REDACTED] Resident #438 was admitted to the facility with [DIAGNOSES REDACTED]. The Discharge Minimum Data Set (MDS) assessment dated [DATE] documented the resident had moderately impaired cognition. Diabetes Mellitus was not included among the diagnoses. On 12/17/19 at 12:24 PM, an interview was conducted with the complainant, the resident's daughter. The complainant stated that the facility staff told her that they were unaware that the resident had Diabetes and did not administer her regular diabetic medications. Once the family became aware that the resident's blood glucose levels were over 500, they became worried for the resident's well-being and requested that the resident be sent to the hospital. The Patient Review Instrument (PRI) completed on 7/12/19 documented that the resident had a [DIAGNOSES REDACTED]. The Allscripts Online Referral packet sent to the facility on [DATE] documented the resident was diagnosed with [REDACTED]. The PRI Assessment Checklist dated 7/16/19 documented that the resident is Diabetic, had a history of [REDACTED]. The hospital Patient Discharge Instructions dated 7/17/19 documented that the resident received Insulin [MEDICATION NAME] Prandial Scale Pre-Meal unit subcutaneous at 8:19AM and 12:04PM prior to discharge. A list of the resident's medications prior to hospitalization documented that the resident received Basaglar Kwikpen and [MEDICATION NAME] 50-1000mg. An Admit/Readmit Screen completed by the Registered Nurse (RN) dated 7/17/19 did not document any information related to a [DIAGNOSES REDACTED]. The Baseline Care Plan dated 7/17/19 did not include the [DIAGNOSES REDACTED]. Nursing Notes and Medical Doctor (MD) notes from 7/17/19 through 7/23/19 do not document that the resident had a [DIAGNOSES REDACTED]. The Laboratory Report dated 7/24/19 for labs drawn on 7/23/19 documented that the resident's Hemoglobin A1C was flagged as high at 8.0% with a reference range of 4.0%-5.6%. The Glucose was 624 mg/dL with a reference range of 70-99. An MD note dated 7/24/19 documented that the resident had an A1c of 8.0% and that he will start the resident on [MEDICATION NAME] 750mg ER and [MEDICATION NAME] 100mg daily for Type 2 diabetes. A Nursing Note dated 7/24/19 documented the resident was evaluated by the MD at 8:47am for abnormal lab results, and NS IVF at 50 ml/hr for [MEDICAL CONDITION], [MEDICATION NAME] ER 750 mg daily and [MEDICATION NAME] 100 mg daily were ordered. The resident's granddaughter approached the nurse around 9:45am to report that the resident did not look good. The nurse checked vital signs, and the MD spoke to the granddaughter regarding the new plan of care for the resident. The granddaughter called 911 and Emergency Medical Services (EMS) responded. A FS (Finger Stick), taken by EMS, had a result of 500, but EMS refused to let the Registered Nurse administer 10 units of insulin as ordered by the MD. The resident was transferred to the hospital at the granddaughter's request. The physician's orders [REDACTED]. [MEDICATION NAME] 100mg for Diabetes Mellitus II and [MEDICATION NAME] HCI Extended Release 750mg were ordered with a start date of 7/25/19. The (MONTH) 2019 Medication Administration Record [REDACTED]. [MEDICATION NAME] 100mg once daily was ordered for the resident on with a start date of 7/25/19 but was not administered. [MEDICATION NAME] HCI Extended Release 750mg once daily was ordered for the resident with a start date of 7/25/19 but was not administered to the resident. The medical record did not include DM on the resident's [DIAGNOSES REDACTED]. On 12/17/19 at 04:06 PM, an interview was conducted with Registered Nurse (RN) #2, the RN that admitted Resident #438 into the facility. RN #2 stated that she has been working at the facility for 4 years but has only been responsible for admitting residents into the facility since (MONTH) 2019. She did not specifically recall this resident's admission. Prior to a resident being admitted to the unit, the Admissions office provides the RN on the unit with the discharge paperwork available from the hospital so that the RN has an idea of what kind of care the resident will require. The RN reviews the paperwork and prepares any special devices or equipment that may be needed to care for the resident. Once the resident is physically brought into the facility, a new set of discharge paperwork and more detailed information is provided to the RN. The RN reviews this paperwork and completes their own assessment of the resident's condition. The RN is responsible for transcribing the resident's [DIAGNOSES REDACTED]. This review includes looking at whether the resident received FSBS glucose monitoring and insulin administration while in the hospital. After reviewing the hospital discharge records for Resident #438, RN #2 stated that the PRI does list DM as a [DIAGNOSES REDACTED]. There are times that this may be overlooked, and this is what happened in this case. After reviewing the treatment recommendations that include FSBS testing for the resident, the RN agreed that this also should have been transcribed on the resident's orders for the facility MD to review and sign. After RN #2 transcribes the orders onto the resident's medical record, the MD reviews them, makes any changes he deems necessary, and then signs them so that they can be active. Sometimes the MD will not agree with certain orders from the hospital and will delete them from the resident's physician's orders [REDACTED]. When a resident is admitted with a [DIAGNOSES REDACTED]. The RN does not contact the family of the residents to discuss specific [DIAGNOSES REDACTED].#438. An interview was conducted with the MD on 12/19/19 at 10:40 AM. The MD stated that he had reviewed this resident's medical record and does recall that when she was admitted , she looked very sick and toxic. This resident had recently received surgery in the hospital for a perforated [DIAGNOSES REDACTED] ulcer. The MD did review the hospital discharge paperwork upon her admission and did see that there was a [DIAGNOSES REDACTED]. The MD was unable to determine from the record whether any insulin was actually administered to the resident in the hospital. The hospital sends a lot of paperwork with the resident and the MD reviews the information related to the acute issue that caused a resident's hospitalization as well as the recommended medications. He did not review the Allscripts Online Referral packet of information that was included with the hospital discharge paperwork. If any insulin was recorded as being administered to the resident in the hospital, it could have been given acutely pre-operation, not to address a [DIAGNOSES REDACTED]. The MD then performs his own assessment of the resident and reviews the [DIAGNOSES REDACTED]. If the resident is admitted with a [DIAGNOSES REDACTED]. The MD stated that the DM [DIAGNOSES REDACTED]. The A1c value in the labs would give a definitive determination of whether the resident truly had a [DIAGNOSES REDACTED]. The MD stated that although the hospital recommended for the resident to have FSBS monitoring, this is not his treatment approach with residents who have a [DIAGNOSES REDACTED]. The hospital labs did not contain a A1c for Resident #438 and he was unable to determine whether the resident truly had a [DIAGNOSES REDACTED]. He did not do so in this case because he was more concerned with addressing the resident's acute condition. He wanted to take a wait and see approach to watch how the resident responded to being in a post-acute setting for a few days. Once he noticed that she had diabetic breath (an odor specific to patients with a DM diagnosis), he ordered the labs. This is what led to the delay in obtaining the resident's Hemoglobin A1c values. At that point, he ordered the resident to receive diabetic medications and FSBS monitoring; however, the family was worried about the resident's condition and requested that she be sent to the hospital. A follow up interview was conducted with the MD on 12/20/19 at 09:58 AM. The MD stated that he does believe that his approach to treating the resident's diabetic condition was appropriate. In retrospect, he believes that he should have documented his rationale behind not including the DM [DIAGNOSES REDACTED]. An interview was conducted with the Director of Nursing (DNS) on 12/20/19 at 11:36. The DNS stated that the RN responsible for admitting any resident into the facility should be taking the [DIAGNOSES REDACTED]. This is a tedious task that recently became more time consuming for the nurses once the facility launched their Electronic Medical Record (EMR) in (MONTH) 2019. The nurses have expressed that they find it difficult to perform the task of transcribing the resident's [DIAGNOSES REDACTED]. The process was very new at that point and RN #2 was just getting used to it. After reviewing the medical record for Resident #438 and speaking with RN #2, the DNS determined that the [DIAGNOSES REDACTED]. On 12/20/19 at 12:00 PM, an interview was conducted with the Medical Director who has been overseeing the MDs in the facility since 10/2109. The Medical Director stated that he does not disagree with the MD's approach in caring for Resident #438 and addressing her DM diagnosis. He does believe that the MD's treatment approach should have been documented in his progress notes. This would allow the MD to communicate his rationale to other facility staff and medical professionals to see and understand. Without the MD's documentation, it is difficult to understand his line of thinking. The Medical Director stated the he will be speaking with the MDs in the facility to ensure that they understand proper documentation in the resident's medical record. 415.15(b)(2)(iii)

Based on observation, and staff interviews during the recertification survey, the facility did not ensure medical supplies containing biologicals were stored with appropriate pharmacy labels, following cautionary and expiration instructions. Specifically, 1 insulin pen was observed in a plastic bag without an open or discard date; and, 1 insulin vial was observed in a plastic bag 16 days after the documented expiration date (9 days after the manufacturer's recommended date). This was evident for 1 of 7 medication carts reviewed during the Medication Storage and Labeling facility task (10th floor). The findings are: A facility policy and procedure related to Storage of Medication was dated 10/28/18 and documented that multiple dose injectable vials once opened, require an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. If a vial or container is found without a date opened, the date opened will automatically default to the date dispensed and expiration date will be calculated accordingly. A facility policy and procedure related to Insulin Storage was dated 10/28/18 and documented that opened and unrefrigerated [MEDICATION NAME] Insulin is to be discarded after 42 days. Opened and unrefrigerated Humalog [MEDICATION NAME] pens are to be discarded after 28 days. On 12/16/19 at 02:28 PM, 1 of 2 medication carts on the 10th floor was reviewed for medication storage. An open [MEDICATION NAME] Insulin vial for Resident #159 had a sticker documenting the open date as 11/2 and expiration date of 1/30. Another plastic bag contained an open Humalog [MEDICATION NAME] Kwikpen with a manufacturer's expiration date of 4/2021 for Resident #133. The Kwikpen was not dated with an open or expiration dated. The [MEDICATION NAME] Insulin Manufacturer Prescribing Information, revised as of 11/2019, documented that the that [MEDICATION NAME] is not to be used past the expiration date printed on the label or 42 days after being opened. The Humalog [MEDICATION NAME] Insulin Manufacturer Prescribing Information, revised as of 3/2013, documented that the insulin vial or pen is to be thrown away after 28 days of being opened. An interview was conducted with Licensed Practical Nurse (LPN) #1, the Medication Nurse for the 10th floor, on 12/16/19 at 02:37 PM. LPN #1 stated that she did not check the medication cart for expired medications that morning when she started her shift because she does not provide insulin to residents on her shift. The insulin medications are supposed to be disposed of once they have been opened and in use for 28 days. She was unable to provide an explanation as to why the expired insulin was not disposed of. LPN #1 then stated that she believes there was a sticker on the Humalog [MEDICATION NAME] Kwikpen documenting when it had been opened but that it must have fallen off. She was unable to locate a sticker on the cart that may have belonged to the pen and was unable to determine a date as to when it had been opened. On 12/20/19 at 10:48 AM, an interview was conducted with Registered Nurse (RN) #1, the Charge Nurse for the 10th Floor. RN #1 stated that every nurse and medication nurse is responsible for ensuring that medications on cart are not expired. There is also a specific task that is given to the Tour 1 shift (12AM to 7:30AM) to review the medications on the cart, make sure there is no refills needed, and to remove expired medications. This includes insulin. RN #1 does spot checks of the medication and treatment carts 1-2 times a week. The facility policy is that every vial or pen of insulin is to have a sticker with the Opened and Expired dated written on it. An interview was conducted with the Director of Nursing (DNS) on 12/20/19 at 11:27 AM. The DNS stated that when insulin vials or pens are opened and in use, they are dated with an Opened date and kept on the medication cart. The facility policy does not require that an Expired date be documented on the sticker. The nurses on the unit have a chart that documents all the different expiration dates for each type of insulin. The night shift is supposed to check the entire cart every evening. The medication nurses should also be checking daily before administering insulin to the resident. The DNS was aware that expired insulin was found on 10th floor medication cart and stated she does not know how it was missed since the nurses checked all the medication carts for expired medications as soon as the recertification survey began. 415.18(e)(1-4)

Based on record review and interview, the facility did not ensure that appropriate Liability and Appeal Notices were provided to residents prior to discharge from Medicare. This was evident for 3 of 3 residents reviewed for Liability Notices and Beneficiary Appeal Rights. (Residents # 135, 71, and 94). The findings are: 1) Resident #135 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission MDS dated [DATE] documented that resident had intact cognition and began receiving Occupational and Physical Therapy on 11/7/15. The Social Work Discharge note dated 11/27/15 documented that resident was discharged back to her assisted living facility on that date. During an interview with the MDS Coordinator on 1/6/16 at 2:20pm she stated that resident was admitted for short-term rehab and used 21 of 100 Medicare days. There was no documented evidence that a liability and appeal notice was provided to the resident prior to discharge from Medicare. 2) Resident #71 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 5-Day PPS Scheduled Assessment for a Medicare Part A Stay dated 11/5/15 documented that resident had severe cognitive impairment and began receiving Occupational and Physical Therapy on 10/30/15. The Social Work Discharge note dated 11/24/15 documented that resident was discharged home on that date. During an interview with the MDS Coordinator on 1/6/16 at 2:20pm she stated that resident was admitted for short-term rehab and used 26 of 100 Medicare days. There was no documented evidence that a liability and appeal notice was provided to the resident prior to discharge from Medicare. 3) Resident # 94 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 30-Day PPS Scheduled Assessment for a Medicare Part A Stay dated 7/22/15 documented that resident had intact cognition and began receiving Occupational and Physical Therapy on 6/26/15. The Social Work Discharge note dated 9/1/15 documented that resident was discharged home on that date. During an interview with the MDS Coordinator on 1/6/16 at 2:20pm she stated that resident was admitted for short-term rehab and used 68 of 100 Medicare days. There was no documented evidence that a liability and appeal notice was provided to the resident prior to discharge from Medicare. On 1/6/16 at 2:20pm, the MDS Coordinator was interviewed and stated that at the daily morning report meetings rounding, all disciplines are in attendance and the resident's status is discussed. She further stated that once the team determines that the resident is ready for discharge, the resident is informed and upon agreement, an appeal notice is given. She also stated that the only time a resident would be given a notice would be if the social worker thinks they are not ready or the resident is not happy with the discharge plan. On 1/7/16 at 9:15am, an interview was conducted with the Director of Nursing who stated that notices are supposed to be given to all residents once it is determined that they are ready for discharge regardless of how many Medicare days they have remaining. She further stated that she was unaware that residents at the facility were not receiving these notices. A review of the facility policy entitled Medicare Coverage and Denial Notification Process (RI 11) dated 2/22/13 documented termination is the discontinuation of certain items or services . An ABN (Advance Beneficiary Notice) would have to be issued prior to the termination of services or therapy. 415.3(g)(2)(i)

Based on observation, interviews and documentation review, the Administrator failed to ensure that systems were in place to provide an environment as free of accident hazards as possible. This was evident for 1 out of 5 sampled residents (Resident #1). Specifically, a cognitively intact resident boarded the unlocked freight elevator and walked through the 1st floor construction area labeled " hard hat-authorized personnel only, " then accessed a patio area with an unsecured lock. The resident straddled a 4 foot brick wall of the patio and fell back approximately 20 feet to the concrete driveway. Subsequently, the resident sustained [REDACTED]. This resulted in actual harm to one resident (Resident #1) and the potential for serious harm to 19 residents who could potentially access the construction site during off hours that is Immediate Jeopardy to resident health and safety and Substandard Quality of Care. Complaint # NY 850 The findings include: On 8/22/13 at 9:30AM an interview was conducted with the Administrator. In regards to residents having access to the freight elevator during off hours, the Administrator stated that the freight elevators have signs that indicate " no passengers " and that the 1st floor has a sign that indicates " authorized access only. " He also stated that the nursing staff provides 30 minute monitoring on the units. He stated that he was not familiar with what in-servicing may have been provided to ancillary staff regarding resident safety during the construction phase. He stated that supervisory staff would have conducted any in-services. He stated that currently the freight elevators are being locked at night and that he is putting together a new in-service for all disciplines. He stated that the facility is also looking into adding keypads on the freight elevator for " an additional layer of protection. " During a subsequent interview on 8/23/13 at 2:30 PM, the Administrator provided a freight elevator policy, stating that there was no freight elevator policy prior to 8/21/13. See F 323 K 415.26

Based on observations, interviews and documentation review during an abbreviated survey, the facility failed to provide an environment as free of accident hazards as possible. This was evident for 1 out of 5 sampled residents (Resident #1). Specifically, a cognitively intact resident boarded the unlocked freight elevator and walked through the 1st floor construction area labeled " hard hat-authorized personnel only, " then accessed a patio area with an unsecured lock overlooking a receiving dock. The resident straddled a 4 foot brick wall of the patio and fell back approximately 20 feet to the concrete driveway. Subsequently, the resident sustained [REDACTED]. This resulted in actual harm to one resident (Resident #1) and the potential for serious harm to 19 residents who could potentially access the construction site during off hours that is Immediate Jeopardy to resident health and safety and Substandard Quality of Care. Complaint #NY 850 The findings include: Resident #1 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 dated 8/23/13 documented that the resident was cognitively intact. The nurse ' s note dated 8/12/13 documented that the resident was ambulatory with a rolling walker. The Psychosocial assessment dated [DATE] documented that the resident had a history of [REDACTED]. The social work note dated 8/14/13 documented that the resident had some feelings of sadness revolving around her recent illness, but that she had no other stressors related to illness, treatment and placement. The Half-hourly Monitoring Rounds Flow sheet dated 8/21/13 documented that Resident #1 was " awake " at 5:00 AM and 5:30 AM and " sleeping " at 6:00 AM and 6:30 AM. The 7:00 AM entry identified that the resident was " out of bed. " The 11:00 PM-7:00 AM Security/Fire Guard Report Log dated 8/21/13 at 7:00 AM documented that the " site " is safe and secured. The report did not specify the location of the "site." The report further documented that the security guard checked the lobby and floors 8, 9, 10, 11 on an hourly basis. The Fire Department of New York (FDNY) Prehospital Care Report dated 8/21/13 at 7:14 AM documented that bystanders requested the Emergency Medical Service (EMS) when the resident was observed " standing on overhang approximately 30 feet up over concrete. " The bystanders witnessed the resident jump. The EMS observed that the resident had obvious fractures to the left hip and right tibia and was bleeding from the mouth and ears. The EMS ventilated and intubated the resident and transported the resident to the hospital. The hospital record dated 8/21/13 documented that the resident landed on her head after falling from the ledge in the facility. The resident sustained [REDACTED]. The neurosurgical evaluation concluded that the resident became permanently paraplegic. The department head ' s Transition Meeting agenda from February 2013 to July 2013 revealed no mention of any items related to security and safety during the 1st floor construction renovation. On 8/22/13 at 2:30 PM the video surveillance was viewed with the Hospital Police Captain and Director of Nursing. The video revealed that on 8/21/13 at 6:39 AM, Resident #1 boarded the freight elevator on the 13th floor. The Plant Maintenance Oiler was inside of the elevator when the resident boarded the elevator. The video revealed that the resident exited the elevator on the 1st floor at approximately 6:40 AM. On 8/22/13 between 7:00 AM and 8:00 AM an observation of the 13th floor (Resident #1 ' s unit) was conducted. The resident ' s room was located approximately 15 to 20 feet from the freight elevators accessed via glass doors in the middle section of 2 hallways of resident rooms. The freight elevator area had its own separate lobby with glass walls and doors on either side. The freight elevator area had a sign stating " Freight Only-No passengers. " On 8/22/13 at around 8:00 AM an observation was conducted of the 1st floor. The 1st floor had signs posted identifying it as a " hard hat authorized personnel only " area. The primary elevator bank that services the upper floors were boarded up and locked on the 1st floor level. The freight elevators were accessible. The 1st floor was an active asbestos removal site, with sheetrock, power tools, engineers and contractors present. There was a patio area enclosed by a glass door. During the surveyor observation, the hasp and padlock to the glass patio door where the resident exited the building was intact. However, the construction staff reported that the screws holding the hasp in place had somehow been removed, enabling the resident to exit onto the patio. It was not determined how the screws were removed from the door or for how long it was in this condition. On 8/22/13 at 7:45 AM an interview was conducted with the Registered Nurse (RN), who worked 11:45 PM to 7:45 AM on 8/21/13. The RN stated that on the morning of 8/21/13 Resident #1 was up early and in good spirits, listening to music, walking and dancing. The RN stated that the resident took her 6:00 AM medications and talked about being discharged to the community. The RN stated that the resident was last seen on the unit between 6:20 AM and 6:30AM. During morning rounds, the staff was not able to locate the resident and initiated Code Green (missing resident search code). On 8/22/13 at 11:32 AM an interview was conducted with the Hospital Police Captain (HPC). The HPC stated that on 8/21/13 a construction staff notified her that there was a female up on the 2nd floor roof. The HPC responded to the patio and observed that the resident was sitting on the wall ledge. The HPC stated that she engaged the resident and walked towards her, but the resident told her " Do not come near me. " The Construction Manager joined the HPC, and they were able talk the resident off the wall ledge. At this time the New York Police Department (NYPD) Emergency Service Unit arrived. The HPC stated that three NYPD police officers came out on the patio and instructed the facility staff to " clear the area. " The resident told an NYPD officer that she would jump if he came near her. Then the resident swung her feet over the 4 foot wall of the patio and stood on the roof of the rolling garage door. The HPC stated that the NYPD officer moved towards the resident, and then the resident fell back onto the pavement. On 8/22/13 at 8:40 AM an interview was conducted with the Construction Manager (CM). The CM stated that on 8/21/13 at 7:10 AM, he got a call from a construction staff that there was a woman straddling the wall at the edge of the patio. The CM stated that he went to the patio and witnessed the resident jumping backwards and landing on the concrete. He stated that an elevator operator has been placed on the freight elevator for monitoring between 7:00 AM to 3:30 PM, during construction hours. He stated that prior to 8/21/13, the freight elevators were not locked for the night when the construction staff went home. The CM was not able to explain why the patio door was not locked. During a subsequent interview on 8/22/13 at 4:13PM, the CM stated that the Security/Fire Watcher is responsible to ensure that the building is secure from outside intruders and to check for fire risk. The CM stated that he did not recall having any discussion in the Transition Meetings concerning how resident safety would be managed after the construction crew left for the day. On 8/22/13 at 10:15 AM, an interview was conducted with the Chief Operating Officer (COO). The COO stated that the Transition Team, composed of approximately 40 staff members, meets to discuss the impact of construction on a weekly basis. The COO stated that there was no formal discussion about the after hour freight elevator access when the 1st floor space was turned over to the construction staff 2 weeks ago. During a subsequent interview on 8/23/13 at 4:00PM, the COO stated that prior to the 1st floor construction, the freight elevator led to an outside exit. The COO stated that the facility did not consider that the residents would be placed in " harm ' s way " when the freight elevator was stopping on the 1st floor construction area. On 8/22/13 at 4:30 PM an interview was conducted with the Associate Director for Facilities Management (ADFM). The ADFM stated that the department heads and the construction firm have conducted the Transition Meetings since the project commenced more than 4 years ago to alert the staff of service interruptions that could impact resident care. The team designated the need for freight elevator operators to accommodate facility deliveries and construction staff services during construction work hours. He stated that a dedicated Security/Fire Watcher is based on the 1st floor construction site during off hours but that this watcher also has the hourly responsibility to make rounds around the building and observe for fire safety. The ADFN stated that it was " understood " that no resident should be on the freight elevator or enter the construction area. He stated that he would have expected the Plant Maintenance Oiler who saw the resident in the elevator to " engage " the resident. He stated that the Nursing and Security staff members are responsible for monitoring the residents ' safety and whereabouts. He further stated that the Security/Fire Watcher is responsible to ensure no one enters the construction site. The ADFM was not able to explain how the Security/Fire Watcher could be monitoring on the 1st floor construction site and make rounds in the building simultaneously. The facility implemented corrective actions to remove the immediacy prior to the arrival of the New York State Department of Health surveyors. This resulted in an Immediate Jeopardy-Past Non-Compliance designation. On 8/21/13, the facility implemented a new policy titled " Freight Elevator Car Use, " which documented that the freight elevators will have an operator at all times between the hours of 6:30 AM and 5:30 PM and that construction workers operating the freight elevator will be trained to ask for identification if it is not displayed. The policy also documented that between the hours of 5:30 PM and 6:30 AM, the freight elevator will be locked to the lower level, requiring the operator to manually insert a key to operate the elevators. 415.12(h)(l)