Every finding on record at New York Center For Rehabilitation & Nursing

Based on observation, record review, and interviews conducted during an Abbreviated Survey (NY00348238 and NY00348669), the facility failed to provide adequate supervision to a resident to prevent accidents. This was evident for two (2) out of five (5) residents (Resident #2 and Resident #5). Specifically, 1. On 07/15/2024 at 3:28 PM, Resident #2 was observed on the floor into the dining room after being left unsupervised by Certified Nursing Assistant #3. Resident #2 was assessed by Registered Nurse #1 and was observed with an abrasion to the right elbow and right hip. 2. On 08/24/2024 at 3:20 AM, Resident #5, who was at high risk for fall, was observed on the bathroom floor after being left unattended in the bathroom. Resident #5 reported that they hit their head. Resident #5 was assessed by Registered Nurse Supervisor #2 with no visible injuries. Resident #5 was transferred to the hospital emergency room for further evaluation. Resident #5 was admitted to the hospital with diagnosis of left frontal acute subdural hematoma (bleeding inside the head). Additionally, on 09/08/2024 at 4:10 PM, Resident #5 was observed on the floor in the dining room after being left unsupervised. Resident #5 did not sustain any visible injuries. The findings include: The facility's policy titled Fall Prevention dated 08/18/2020, documented it is the policy of the facility to provide a safe environment for all residents. The Fall Prevention protocol documented dining room/television room assignment to ensure supervision of residents while positioned in the said areas. The facility's policy titled Resident Safety Program dated 02/08/2024, documented that an Accident is defined an unexpected, unintended event that can cause a resident injury. Examples of accidents include, but are not limited to the following: fractures, lacerations, burns, hematoma, ecchymosis greater than four centimeter and head injuries. An Incident defined as an unexpected, unintended event that can cause a resident superficial or no injury. Examples of incidents may include but not limited to the following falls with no injury or minor injury, soft tissue injury or hematoma less than four-centimeter, superficial scratches, scrapes, blisters resulting from actual occurrence and altercation with another resident with or without injury. The facility's policy titled Dining Room Assignment dated 03/2024, documented Certified Nursing Assistant assigned shall be responsible for maintaining a safe environment in the dining area to prevent falls, injuries, or other incidents during mealtime assignments and fulfilling dining room watch duty for a-30-minute period, as assigned by the charge nurse, to actively monitor and support resident safety. Resident #2 was admitted to the facility with diagnoses including Dementia, Mood Disorder and Anxiety Disorder. The Minimum Data Set, a resident assessment tool, dated 06/28/2024, documented Resident #2 had severely impaired cognition. A Fall Care plan dated 06/21/2024, documented interventions to place Resident #2 in the dining room/television room with staff supervision. The Resident Nursing Instructions dated 06/21/2024 documented Resident #2 was on monitoring for fall precaution, safety, and behavior every day at 6:00 AM to 8:00 AM, 2:00 PM to 4:00 PM, and 10:00 PM to 12:00 AM. An Alteration in Behavior Care Plan dated 06/24/2024, documented Resident #2 had agitation with restlessness. The interventions documented to use behavioral monitoring flow record to document behavior. A Fall Risk assessment dated [DATE] documented showed that Resident #2 was assessed for fall and scored 19 denoting high risk for fall. According to the form a score of seven (7) or greater - the resident is at High Risk. A Behavior/Mood progress notes dated 07/07/2024 through 07/15/2024 documented Resident #2 observed with restlessness, attempting to get up from their wheelchair multiple times, and attempting to walk without assistance. An Accident Report dated 07/15/2024, documented Registered Nurse #1 responded to a chair alarm in the dining room and observed Resident #2 laying on the dining room floor on their right side. Resident #2's wheelchair was also laying on its side on floor in the dining room. Resident #2 was unable to provide details of event due to impaired cognition. Resident #2 was assessed by Registered Nurse #1, Registered Nurse Supervisor #1, and Medical Doctor #1, and was observed with mild redness, swelling to the right elbow area, an abrasion to the right elbow, and right hip. Certified Nursing Assistant #3 was assigned to monitor the residents in the dining room, but Certified Nursing Assistant #3 responded to a call bell on the unit and left the dining room unsupervised. Resident #2 had fallen on to the floor. An x-ray of the right elbow was performed, -and the result revealed no acute fracture. The investigation concluded that there was no abuse or neglect occurred. The Nursing Situation Background Assessment Recommendation notes dated 07/15/2024 at 4:25 PM, by Registered Nurse Supervisor #1 documented that Registered Nurse #1 and them responded to the chair alarm and observed Resident #2 lying on the floor on their right side in the dining room. The wheelchair was also laying on its side. Resident #2 was assessed with abrasions to right elbow and right hip. During an interview on 05/05/2025 at 10:35 AM, Certified Nursing Assistant #3 stated they do not recall the incident. During an interview on 05/05/2025 at 11:57 AM, Registered Nurse #1 who worked on 07/15/2024 on the day shift (8:00 AM-4:00 PM), stated they were at the nursing station when they heard a chair alarm in the dining and responded. Registered Nurse #1 stated they observed Resident #2 and their wheelchair lying on the floor on the right side. Registered Nurse #1 stated that Certified Nursing Assistant #3 was assigned to monitor the residents in the dining room, but Certified Nursing Assistant #3 left the dining room to answer a call bell. Registered Nurse #1 stated that Certified Nursing Assistant #3 should not have left the residents in the dining room unsupervised. Registered Nurse #1 stated that Registered Nurse Supervisor #1 and them assessed Resident #2 and observed with a bruise and abrasions to right elbow and right hip. During an interview on 05/05/2025 at 12:46 PM, the Director of Nursing stated they were notified by Registered Nurse Supervisor #1 of the incident on 07/15/2024 (unsure of the time). The Director of Nursing stated that Resident #2 had severe cognitive impairment and behavioral problems, and that Certified Nursing Assistant #3 left the dining room unsupervised. The Director of Nursing stated they do not know why Certified Nursing Assistant #3 left the dining room unsupervised to answer a call bell. The Director of Nursing stated the incident was investigated and concluded that neglect did not occur because Certified Nursing Assistant #3 answered the call bell for a resident that they were assigned to and when they returned to the dining room Resident #3 had fallen onto the floor. The Director of Nursing stated they had enough staffing in the unit. During an interview on 05/05/2025 at 2:20 PM, the Administrator stated they were notified of the incident by the Director of Nursing on 07/15/2024 (unsure of the time). The Administrator stated that Certified Nursing Assistant #3 received dining room assignment in-service in 07/2023 and that the dining room should always have a Certified Nursing Assistant monitoring the residents. The Administrator stated Certified Nursing Assistant #3 should have had another staff monitor the dining room. The Administrator stated Certified Nursing Assistant #3 was not suspended because they felt it was not intentionally done. Resident #5 was admitted to the facility with diagnoses including Non-Alzheimer's Dementia, Hypertension and Depression. The Minimum Data Set, a resident assessment tool, dated 07/24/2024 documented Resident #5 had severely impaired cognition. A Fall Risk assessment dated [DATE] documented Resident #5 was high risk for fall. A Fall Care Plan dated 07/17/2024 documented interventions for staff to provide assistance with activities of daily living, provide appropriate footwear, and provide bed/chair alarm. A Resident Nursing Instructions dated 07/17/2024 documented instructions for extensive assistance of one-person for toileting. An Accident Report dated 08/24/2024 at 3:20 AM, documented Certified Nursing Assistant #4 left Resident #5 into the bathroom by themself to get an incontinent brief. When Certified Nursing Assistant #4 returned to the bathroom they observed Resident #5 lying on the bathroom floor next to the toilet. Resident #5 was assessed by Registered Nurse Supervisor #2 with no visible injuries, no change in level of consciousness, or range of motion. Resident #5 reported that they hit their head. The Primary Medical Doctor was informed and ordered to transfer Resident #5 to the hospital for further evaluation. The facility concluded that there was no reasonable cause to believe any alleged resident abuse, neglect or mistreatment occurred. A Nursing Progress note dated 08/24/2024 at 4:11 AM, by Registered Nurse Supervisor #2 documented Resident #5 had an unwitnessed fall. There was no visible injury noted. Resident #5 claimed they hit their frontal head with complaints of headache. Tylenol 650 milligram was given. The Medical Doctor was informed and ordered to transfer Resident #5 to the hospital to rule out head injury. Resident #5 left on 08/24/2024 at 4:10 AM with the emergency medical technicians. A Nursing Progress note dated 08/24/2024 at 5:28 AM, written by Registered Nurse Supervisor #2 documented received a call from the emergency room reporting that Resident #5 had slight bleeding on the brain. A Physical Therapy Acute Care Evaluation and Treatment Plan (Hospital Summary) dated 08/27/2024, documented a computed tomography scan of the head revealed left frontal 4-millimeter convexity acute subdural hematoma (blood between the brain and covering). An Accident Report dated 09/08/2024 at 4:10 PM, documented Registered Nurse #2 responded to Certified Nursing Assistant #5's cry for help and observed Resident #5 lying on the floor in the dining room next to their wheelchair. Resident #5 was assessed with no visible injury at the time. Resident #5 complained of headache. The Primary Medical Doctor #1 was informed and ordered to transfer Resident #5 to the hospital for further evaluation. Resident #5 was admitted at the hospital for subdural hematoma. The facility concluded that there was no reasonable cause to believe any alleged resident abuse, neglect or mistreatment occurred because Resident #5 has poor safety awareness due to their impaired cognition. A Nursing Progress note titled, Situation, Background, Assessment, and Recommendation Documentation dated 09/08/2024 at 7:08 PM, written by Registered Nurse #3 documented Resident #5 was found lying on the floor in the dining room. Resident #5 was assessed with no injuries noted. Resident #5 was alert and oriented with confusion and could not relate to what happened. Resident #5 stated they wanted to get up from their wheelchair. There were no changed to Resident #5's level of consciousness or range of motion. Resident #5 complained of headache. The Primary Medical Doctor #1 was notified and ordered to send Resident #5 to the hospital for further evaluation. Resident #5 left the unit with emergency medical technicians at 5:30 PM. A statement dated 09/08/2024, by Certified Nursing Assistant #5 documented they were in front of the dining room arranging their linen cart when they heard a scream and an alarm sound. They entered the dining room and observed Resident #5 lying on the floor. The 6th floor Assignment 4:00 PM-12:00 AM shift dated 09/08/2024, documented Certified Nursing Assistant #5 was on Assignment 1 and dining/television room coverage was scheduled for 4:00 PM-4:30 PM. After Visit Summary (Hospital Summary) dated 09/09/2024-09/11/2024, documented issues that were addressed were frequent falls and subdural hematoma. Summary documented recommendations to follow up with Neurosurgeon on 11/06/2024. During a telephone interview on 05/12/2025 at 10:16 AM, Certified Nursing Assistant #4 stated they were assigned to Resident #5 and at approximately 3:20 AM on 08/24/2024, they assisted Resident #5 onto the toilet and left them there to get an incontinent brief. They stated Resident #5 was observed on the floor when they returned. They stated they check the Resident Instructions and read the plan of care for all residents but cannot recall if Resident #5 was a fall risk. During a telephone interview on 05/12/2025 at 3:15 PM, Registered Nurse Supervisor #2 stated they assessed Resident #5 and there were no visible injuries, however, Resident #5 was complaining of headache and was transferred to the hospital. Resident #5 had history of falls and the facility's protocol was for the staff to stand by the bathroom door to provide Resident #5 privacy while in the bathroom. They stated Certified Nursing Assistant #4 should not have left Resident #5 unattended. During a telephone interview on 05/12/2025 at 2:46 PM, Registered Nurse #2 stated Resident #5 had an unwitnessed fall on 09/08/2024 at approximately 4:10 PM. They stated while they were receiving endorsement report Certified Nursing Assistant #5 informed them that Resident #5 was on the floor in the dining room. They stated Resident #5 was assessed and there were no visible injuries or changes in range of motion or consciousness, but Resident #5 was sent to the hospital for further evaluation. During a telephone interview (regarding the fall on 08/24/2024)348 on 05/12/2025 at 1:33 PM, Assistant Director of Nursing stated on 08/24/2024 at 3:20 AM, Resident #5 had periods of restless and was getting out of bed unassisted. They stated Certified Nursing Assistant #4 was monitoring Resident #5 in the dining room when Resident #5 requested to use the bathroom. The Assistant Director of Nursing stated Certified Nursing Assistant #4 assisted Resident #5 to the bathroom and left them there briefly to get an incontinent brief. They stated Certified Nursing Assistant #4 observed Resident #5 on the floor when they returned. They stated Resident #5 was transferred to the hospital because they complained of headache and was admitted with a hematoma. Assistant Director of Nursing stated the investigation revealed that abuse and neglect did not occur. Regarding the fall that occurred on 09/08/2024, the Assistant Director of Nursing stated on 09/08/2024 at 4:10 PM, Certified Nursing Assistant #5 was assigned to monitor the dining room from 4:00 PM-4:30 PM, but instead they were packing their linen cart outside of the dining room. Certified Nursing Assistant #5 overheard an alarm, responded and observed Resident #5 on the floor in the dining room. Assistant Director of Nursing stated Certified Nursing Assistant #5 received verbal counseling for not being attentive during their schedule dining room coverage. They stated Resident #5 was transferred to the hospital and admitted for intracranial hemorrhage. They stated they are not certain if the hemorrhage is from the previous fall. They stated the facility concluded abuse and neglect did not occur. 10 NYCRR 415.12(h)(2)

Based on interviews and record review conducted during the Recertification survey from 4/17/2023 to 4/24/2023, the facility did not ensure all alleged violations involving injuries of unknown source were reported immediately, but not later than 2 hours after the allegations were made to the State Survey Agency. This was evident for 1 (Resident # 197) of 5 residents reviewed for Falls out of 38 sampled residents. Specifically, the facility did not report an injury of unknown source for Resident #197 to the New York State Department of Health (NYSDOH). The findings are: The facility policy titled Abuse Prohibition Program with effective date March 2003 and last reviewed date 12/2022 documented it was the policy of the facility to maintain an environment free of abuse and neglect. The policy documented that abuse and neglect definitions included physical abuse, verbal abuse, sexual abuse, emotional abuse, mental abuse, neglect, misappropriation, and involuntary seclusion. The Reporting section documented that substantiated and/or confirmed abuse is to be reported to New York Department of Health as well as licensing/certification boards if applicable for further action. The Procedure section documented that confirmed cases of abuse will be reported to Center of Complaints Intake Program within 24 hours of completion of investigation. The policy did not mention how concerns involving injuries of unknown source would be reported. Resident #197 was admitted to the facility with diagnoses which included Unspecified Dementia, Altered Mental Status, and Other reduced mobility. The Quarterly Minimum Data Set (MDS) 3.0 dated 12/31/22 documented Resident #197 had severely impaired cognition, did not walk in the room and corridor, and was total dependent with 1 person for locomotion on unit and off unit. The MDS also documented that Resident #197 had no fall since admission/entry or reentry or the prior assessment. The Accident Report dated 3/11/23 documented the CNA (Certified Nursing Assistant) responded to the bed alarm at about 5:00 AM on 3/11/23 and found Resident #197 lying on the floor to the left side of bed. The report also documented that Resident # 197 was observed with a swelling to the forehead and that the physician ordered Resident #197 be transferred to the emergency room for a head scan. The report further documented that Resident #197 was confused and not able to tell what happened. The hospital discharge summary dated 3/20/23 documented Resident # 97's CT c-spine showed Resident #197 had a transverse oriented fracture through the dens (cervical bone). The Comprehensive Care Plan related to Falls/Injury initiated on 3/20/2023 documented interventions which included keep bed in low position and locked, visual check to assess comfort and toileting needs hourly, and keep immediate necessities within easy reach. Resident # 197's Face Sheet documented Resident # 197 had new diagnoses included Unspecified nondisplaced fracture of second cervical vertebra, Unspecified displaced fracture of first cervical vertebra, and Unspecified injury of head with onset date 3/20/23. The medical note dated 3/21/23 documented Resident # 197 was found lying on floor by nursing staff at the facility and the hospital CT of c-spine showed Resident had a transverse oriented fracture through the dens, type II. There was no HERDS report or other documented evidence in the medical chart that the facility reported the injury of unknown source that occurred on 3/11/2023 to NYS DOH. On 04/20/23 at 10:14 AM, Registered Nurse (RN) #1 was interviewed and stated Resident # 197 was found lying on the floor in their room on 3/11/23 and the incident was not witnessed. RN #1 further stated Resident #197 was not able to verbalize what happened and was observed with a bump on the forehead and the physician ordered Resident #197 be transferred to the hospital for a CT scan. RN #1 also stated they notified the DON and ADON of the incident immediately. On 04/21/23 at 09:58 AM, the Director of Nursing (DON) was interviewed and stated they were notified by the unit nursing supervisor that Resident # 197 was found lying on the floor on the day and had a bump at the forehead. The DON also stated Resident #197 had a history of falls and they thought Resident #197 had fallen again in their room. The DON stated the fall was not witnessed by anyone and Resident #197 was not able to verbalize what happened. Resident #197 had a bump on the forehead and the hospital discharge paper documented Resident #197 had a fracture to their neck. The DON also stated that a discussion is held with the Assistant Director of Nursing (ADON), Medical Director, Administrator, Director of Social Services to determine if an incident is reportable to the New York State Department of Health (NYSDOH) and they did not think that they had to report this fall incident to NYSDOH. The DON further stated the Administrator, ADON and themselves had access to HCS for reporting to NYSDOH and the ADON was responsible for submitting the report through HCS to NYSDOH. The DON then stated that based on the fall being unwitnessed, they should have reported this incident to NYSDOH within 2 hours of their awareness as it was an injury of unknown source. On 04/21/23 at 11:56 AM, the Assistant Director of Nursing (ADON) was interviewed and stated they were responsible for reporting incidents to NYSDOH through HCS or hotline. The ADON also stated they knew they had to report incidents involving injury of unknown source to NYSDOH within 2 hours of awareness, and they did not report the incident with Resident #197 to NYSDOH as they believed Resident #197 had fallen when they tried to get out of bed. The ADON further stated they did not think Resident #197 had an unknown source of injury at that time. The ADON stated the incident was unwitnessed and Resident #197 was cognitively impaired and unable to tell what happened. The ADON further stated they should report this incident to NYSDOH within 2 hours as it was considered as an injury of unknow source. 415.4 (b)(2)

Based on record review and staff interviews conducted during a Recertification survey from 4/17/2023 to 4/24/2023, the facility did not ensure that baseline care plan was completed within 48 hours and the resident and/or their representative were provided with a written summary of the baseline care plan. This was evident for 1 (Resident #129) of 2 residents reviewed for Care Planning out of 38 sampled residents. The findings are: The facility policy titled Baseline Care Plan (BCP) with effective date 1/17/2019 and last reviewed date 1/16/2023 documented that the baseline care plan will be completed within 48 hours of the residents admission. The policy did not document that the facility will provide a written summary of BCP to residents and/or their designated representatives. Resident #129 was admitted to the facility on [DATE] with diagnoses that included Altered Mental Status, Unspecified Dementia, and Unspecified Depression. The Admission Minimum Data Set (MDS) dated [DATE] documented Resident #129 had Brief Interview of Mental Status (BIMS) score 12 out of 15, had no behavioral symptoms, and did not reject care. The MDS also documented only Resident #129 participated in the assessment. On 04/17/23 at 11:37 AM, Resident #129 was interviewed and stated they had been admitted to the facility for about 5 to 6 months now. Resident #129 also stated they made decision themselves. Resident #129 further stated they did not recall if they were provided a hard copy of a baseline care plan since their admission to the facility. The Baseline Care Plan (BCP) was documented as created on 12/30/2022 and the sections for the Social Worker, Speech Therapy, and OT were completed on 1/2/2023, 1/5/2023, and 4/18/2023 respectively and were beyond 48 hours of admission. There was no acknowledgement of receipt section in the BCP for Resident #129 and /or their designated representative. Review of progress notes from 1/2/2023 to 4/10/2023 in the EMR and the hard copy chart revealed no documented evidence that Resident #129 and/or their designated representative were provided with a copy of or signed the baseline care plan. On 04/20/23 at 12:18 PM, Registered Nurse (RN) #2 was interviewed and stated the EMR created the baseline care plan (BCP) for all disciplines when the residents were admitted , and they were responsible to complete the nursing section in the BCP within 48 hours of admission. RN #2 also stated they were not sure which staff was responsible to provide the residents and/or their designated representative the hard copy of baseline care plan and oversees the completion of whole baseline care plan. On 04/20/23 at 12:38 PM, the Social Worker (SW) was interviewed and stated they were not sure which staff was responsible to provide the hard copy of baseline care plan to residents and/or their designated representatives. The SW also stated they had to complete the BCP within 48 hours of admission. The SW further stated they did not do the BCP for Resident #129 and was not able to explain why the social worker section of BCP was not completed within 48 hours of admission. On 04/20/23 at 02:23 PM, the Director of Social Services (DSS) was interviewed and stated each department head was responsible to make sure their staff completed their respective section in the baseline care plan within 48 hours of admission. The DSS also stated the MDS department was responsible to oversee the completion of whole BCP and give a hard copy of BCP to the residents and/or their designated representatives. The DSS completing the social worker section in the BCP for Resident #129 stated they were not able to explain why it was completed on 1/2/23 and not within 48 hours of admission. On 04/20/23 at 02:34 PM, the MDS Coordinator (MDSC) was interviewed and stated the floor RN supervisor was responsible to make sure the whole BCP was completed in 48 hours of admission. The MDSC also stated the medical record staff was responsible to provide the resident and/or their designated representative the copy of baseline care plan only if they requested it. The MDSC stated they did not know that they had to provide the residents and/or their designated representatives the hard copy of the BCP without their request of it. The MDSC also stated they did not provide a hard copy of the BCP to Resident #129 and/or their designated representative because they did not request it. On 04/24/23 at 10:23 AM, the Director of Rehab (DR) was interviewed and stated they assigned staff to complete the therapist sections including OT and SLP in the BCP when the EMR created the assessments. The DR also stated they checked the census and made the assignments for the BCP daily. The DR further stated they monitored once a month if the BCP assessments were completed or not. The DR stated they knew the BCP had to be completed within 48 hours of resident admission to the facility. The DR also stated they were not able to explain for the late completion of therapist sections in the BCP. On 04/21/23 at 09:48 AM, the Director of Nursing (DON) was interviewed and stated each department head was responsible to make sure their discipline completed their respective sections in the BCP within 48 hours of admission. The DON also stated the MDS coordinator was responsible to make sure the whole BCP was completed within 48 hours. The DON further stated they did not know they had to provide a hard copy of BCP to the residents and/or their designated representatives and therefore they did not provide Resident #129 and/or their representative a hard copy of BCP. The DON stated they were not able to explain why the BCP for Resident #129 was not completed within 48 hours. 415.11 (c) Based on record review and staff interviews conducted during a Recertification/Complaint Survey from 4/17/2023 to 4/24/2023, the facility did not ensure that baseline care plan was completed within 48 hours and the resident and/or their representative were provided with a written summary of the baseline care plan. This was evident for 1 (Resident # 129) of 2 residents reviewed for Care Planning out of 38 sampled residents. The findings are: The facility policy titled Baseline Care Plan (BCP) with effective date 1/17/2019 and last reviewed date 1/16/2023 documented that the baseline care plan will be completed within 48 hours of the residents admission. The policy did not document that the facility will provide a written summary of BCP to residents and/or their designated representatives. Resident # 129 was admitted to the facility on [DATE] with diagnoses that included Altered mental status, Unspecified dementia, and Unspecified Depression. The Admission Minimum Data Set (MDS) dated [DATE] documented Resident # 129 had Brief Interview of Mental Status (BIMS) score 12 out of 15, had no behavioral symptoms, and did not reject care. It also documented only Resident # 129 participated in the assessment. On 04/17/23 at 11:37 AM, Resident # 129 was interviewed and stated they had been admitted to the facility for about 5 to 6 months now. Resident # 129 also stated they made decision themselves. Resident # 129 further stated they did not recall they were provided a hard copy of baseline care plan since their admission to the facility. The Baseline Care Plan (BCP) was documented as created on 12/30/2022 and the sections for the Social Worker, Speech Therapy, and OT were completed on 1/2/2023, 1/5/2023, and 4/18/2023 respectively and were beyond 48 hours of admission. There was no acknowledgement of receipt section in the BCP for Resident # 129 and /or their designated representative. Review of progress notes from 1/2/2023 to 4/10/2023 in the EMR and the hard copy chart revealed no documented evidence that Resident # 129 and/or their designated representative were provided with a copy of or signed the baseline care plan. On 04/20/23 at 12:18 PM, Registered Nurse (RN) # 2 was interviewed and stated the EMR created the baseline care plan (BCP) for all disciplines when the residents were admitted , and they were responsible to complete the nursing section in the BCP within 48 hours of admission. The RN # 2 also stated they were not sure which staff was responsible to provide the residents and/or their designated representative the hard copy of baseline care plan and oversees the completion of whole baseline care plan. On 04/20/23 at 12:38 PM , the Social Worker (SW) was interviewed and stated they were not sure which staff was responsible to provide the hard copy of baseline care plan to residents and/or their designated representatives. The SW also stated they had to complete the BCP within 48 hours of admission. The SW further stated they did not do the BCP for Resident # 129 and was not able to explain why the social worker section of BCP was not completed within 48 hours of admission. On 04/20/23 at 02:23 PM, the Director of Social Services (DSS) was interviewed and stated each department head was responsible to make sure their staff completed their respective section in the baseline care plan within 48 hours of admission. The DSS also stated the MDS department was responsible to oversee the completion of whole BCP and give a hard copy of BCP to the residents and/or their designated representatives. The DSS completing the social worker section in the BCP for Resident # 129 stated they were not able to explain why it was completed on 1/2/23 and not within 48 hours of admission. On 04/20/23 at 02:34 PM, the MDS Coordinator (MDSC) was interviewed and stated the floor RN supervisor was responsible to make sure the whole BCP was completed in 48 hours of admission. The MDSC also stated the medical record staff was responsible to provide the resident and/or their designated representative the copy of baseline care plan only if they requested it. The MDSC stated they did not know that they had to provide the residents and/or their designated representatives the hard copy of BCP without their request of it. The MDSC also stated they did not provide a hard copy of BCP to Resident # 129 and/or their designated representative because they did not request it. On 04/24/23 at 10:23 AM, the Director of Rehab (DR) was interviewed and stated they assigned staff to complete the therapist sections including OT and SLP in the BCP when the EMR created the assessments. The DR also stated they checked the census and made the assignments for the BCP daily. The DR further stated they monitored once a month if the BCP assessments were completed or not. The DR stated they knew the BCP had to be completed within 48 hours of resident admission to the facility. The DR also stated they were not able to explain for the late completion of therapist sections in the BCP. On 04/21/23 at 09:48 AM, the Director of Nursing (DON) was interviewed and stated each department head was responsible to make sure their discipline completing their respective sections in BCP within 48 hours of admission. The DON also stated the MDS coordinator was responsible to make sure the whole BCP was completed within 48 hours. The DON further stated they did not know they had to provide a hard copy of BCP to the residents and/or their designated representatives and therefore they did not provide Resident # 129 and/or their representative a hard copy of BCP. The DON stated they were not able to explain why the BCP for Resident # 129 was not completed within 48 hours. 415.11 (c)

Based on observations and interviews the facility did not ensure that food was stored to prevent potential food-borne illness. Specifically:1) adequate ventilation was not maintained in the walk-in refrigerator and 2) Cold food holding temperatures did not meet the standards This was evident during the the Initial Brief Tour and follow up observations of the Kitchen. The findings are: 1) On 12/28/15 at 10:00 AM, a tour of the kitchen was conducted and the following was observed: In the freezer, seven boxes of foods were stacked up to the ceiling with a 1 (inch) space from ceiling; Refrigerator temperatures readings were: between 32F (Fahrenheit) and 40 F On 12/28/15 at 10:15 AM, the Kitchen Supervisor was interviewed and stated that the boxes would be removed right away, and added that she was aware it the food storage boxes should be has to be stored with adequate air circulation from the ceiling. 2) On 12/30/15 at 12:10 PM the trayline temperatures were observed. Cold food temperature readings were as follows: Apple sauce 51 F Sliced peaches 52 F Regular milk 44 F On 12/30/15 at 12:15 PM, the FSS (Food Service Supervisor) was interviewed and stated that they were aware that the temperatures are a little high, even though the food was chilled in the reach in refrigerator. 415.14(h)

The facility did not ensure that refuse was disposed of properly. This was evident during during observation conducted of the outside dumpster area during the Kitchen Tour. The finding is: On 12/28/15 at 12:20 AM the garbage dumpster area was observed as follows: The dumpster door was fully open exposing the garbage in plastic bags. The door was observed held open with a metal string. On 12/28/15 at 10:25 AM the Kitchen Supervisor was interviewed and stated that the dumpster door should be kept closed at all times; The housekeeping staff threw the garbage out this morning and left it in the open position. The Supervisor then untied the metal string that was blocking the door from closing. 415.14(h)

The facility did not ensure that infection control practices were maintained. Specifically, bottles of water for the emergency supply was observed stored directly on the floor. This was evident during observations conducted during the Kitchen Tour. The finding is: On 12/28/15 at 10:00 AM and 12/30/15 at 12:35 PM, a tour of the kitchen conducted and observed the following: Ten Gallons size bottles of water (25 bottles) were stored directly on floor. (First floor). On 12/28/15 at 10:25 AM the Kitchen Supervisor was interviewed and stated that the water stored there is overseen by the Administrative Secretary. On 12/31/15 at 11:55 AM the Secretary in charge of the emergency water supply storage area was interviewed and stated that the water bottles were stored on a rack and that a couple of weeks ago the rack collapsed. I did not get a chance to replace the rack during the holidays and that is why they were on the floor, I know the bottles have to be on a rack. 415.19(a)(1-3)

Based on record review and interview, the facility did not ensure that a Comprehensive Care Plan (CCP) for behavior was developed for a resident who was refusing supplements and medications. This was evident for 1 of 1 residents reviewed for Behavior and Emotional Status. (Resident #257). This resulted in no actual harm with potential for more than minimal harm. The finding is: Resident #257 is an [AGE] year-old, readmitted to the facility 10/1/14, with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had moderately impaired cognition. Physician order [REDACTED]. Vitamin C 500 mg (milligrams) Tab (Tablet) - 1 Tab PO (by mouth) daily Aspirin 81 mg Tab- 1 Tab PO daily [MEDICATION NAME] 125 mcg (micrograms) Tab- 1 Tab PO daily [MEDICATION NAME] 325 mg (65 mg iron) Tab- Give one Tab PO daily [MEDICATION NAME] 20mg Tab - 1 Tab PO OD...Multivitamin Tab - 1 Tab PO daily Potassium Chloride ER (extended release) 20 mEq (milliequivalents) Tab ER- 1 tab PO with food [MEDICATION NAME] 20mg Tab - 1 Tab PO OD Zinc Sulfate 220mg(50mg) Cap- 1 tab PO OD... " . Physician order [REDACTED]. The Medication Administration Record (MAR) dated October 2014 documented that the resident refused the following medications and supplements: LPS Critical Care TID - for 77 of 86 opportunities Aspirin 81 mg (milligrams) - for 2 out of 30 opportunities [MEDICATION NAME] for 1 out of 31 opportunities Multivitamin Tablet 4 out of 30 opportunities [MEDICATION NAME] 325 mg Tab for 4 out of 30 opportunities Vitamin C 500mg for 4 out of 30 opportunities. Weekly Behavior and Mood Logs dated 10/9/14, 10/16/14 and 10/30/14 documented the resident exhibited rejection of care 1 to 3 days. The logs further documented resident refused meds at sometimes. A Physician order [REDACTED]. The MAR dated November 2014 documented the following medication refusals from 11/1/14 to 11/13/14: LPS Critical Care for 34 out of 37 opportunities [MEDICATION NAME] 2.5 mg for 2 out of 9 opportunities Zinc Sulfate 220 mg (50mg) capsule for 1 out of 13 opportunities Aspirin 81 mg tablet for 2 out of 13 opportunities [MEDICATION NAME] 20 mg for 3 out of 13 opportunities Potassium Chloride ER 20 mEq tablet for 1 out of 13 opportunities Multivitamin tablet 2 out of 13 opportunities [MEDICATION NAME] ([MEDICATION NAME]) 20 mg 1 out of 13 opportunities [MEDICATION NAME] sulfate 2 out of 13 opportunities [MEDICATION NAME] for 1 out of 13 opportunities Vitamin C for 4 out of 13 opportunities The Weekly Behavior and Mood Log dated 11/6/14 documented the resident exhibited rejection of care 1 to 3 days. The logs further documented resident refused meds at sometimes. A Nursing Note dated 11/6/14 documented the resident was non-compliant with taking her medication for 2 days. The note further documented the nurse explained the risks and benefits of taking her medications, especially [MEDICATION NAME], and made 3 attempts to administer the medications. The note documented that the RN Supervisor was made aware. A Nursing Note dated 11/7/14 documented the resident refused [MEDICATION NAME] x 2 days and the PMD (primary care doctor) was notified with no new orders made. The note further documented the physician will check the resident later. A Nursing Note dated 11/7/14 documented that resident refused to take her medications despite explanation of the risks and benefits. There was no documented evidence that a Comprehensive Care Plan (CCP) was developed to address the resident ' s supplement and medication refusals. On 11/17/14 at 2:31 PM and 11/19/14 at 9:59 AM, the Licensed Practical Nurse (LPN #1) was interviewed and stated the resident has had multiple refusals of the protien supplement and medications. She further stated that this has been an ongoing issue, and she informed the Registered Nurse Supervisor (RNS) who is responsible for informing the Physician and Dietician. She also stated that she does not have to make a progress note when informing the Supervisor about the refusals because the refusals are documented on the MAR in the Electronic Medical Record (EMR). LPN #1 added that the behavior is also captured in the weekly behavior notes documented by the LPNs. On 11/18/14 at 5:22 PM, LPN #2 (4p-12p shift) was interviewed and stated that he informed the day shift RNS of the [MEDICATION NAME] refusal when the resident refused [MEDICATION NAME] 2 days in a row, and the RNS informed him that all refusals should be reported to the RNS on the shift immediately. He further stated that he spoke to the day shift LPN about the LPS refusals, and he was informed that the resident consistently refused LPS and the RNS had already been informed. He stated that the resident has refused different medications sporadically, and he captured this in the weekly behavior note. LPN #2 further stated he spoke to the resident and the resident's representative about the [MEDICATION NAME] refusal, and the resident told him that she refused the medication because she thought she was receiving it twice per day and feared taking too much. LPN #2 stated that after ensuring her the [MEDICATION NAME] was only given in the evening, he had no further [MEDICATION NAME] refusals. On 11/17/14 at 2:40 PM, 11/18/14 at 4:48 PM, and 11/19/14 at 9:55 AM, the RNS was interviewed and stated that she is responsible for initiating the CCPs. She stated that she was not aware of the LPS refusals until the surveyor pointed out the refusals on 11/13/14. The RNS further stated that upon admission, she believed the resident was compliant with medication and did not feel a Behavior CCP was needed. She stated that when she was informed of the [MEDICATION NAME] refusal, she should have created a Behavior CCP at that time. The RNS stated that she is responsible for reviewing the weekly behavior notes, but they are only reviewed quarterly unless the resident has a known behavioral issue. The RNS also stated that she is responsible for reviewing the MARs, but the MAR reviews are done randomly. On 11/19/14 at 12:58 PM, the Director of Nursing (DON) was interviewed and stated that the RN Supervisors should review the behavior notes weekly and as needed. She further stated that behaviors and interventions are discussed at the interdisciplinary morning meeting. The DON stated that she believes the resident was discussed, but she could not recall when. 415.11(c)(1)

Based on record review and interview, the facility did not ensure that the comprehensive care plan was reviewed and revised for a resident who was refusing a nutritional supplement. This was evident for 1 of 2 residents reviewed for Nutrition (Resident #257). This resulted in no actual harm with potential for more than minimal harm. The finding is: Resident #257 is an [AGE] year-old, readmitted to the facility 10/1/14, with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had moderately impaired cognition. The MDS further documented the resident had three stage 1 pressure ulcers, two stage 2 pressure ulcers, and two Unstageable pressure ulcers present upon admission. The MDS documented the resident received nutrition/hydration intervention. The Comprehensive Care Plans (CCPs) for "Skin Impairment - Actual R (Right) Heel" and "Skin Impairment -Actual Left Heel" dated 10/2/14 documented the intervention: "Nutritional supplement per MD (Physician ' s) order" and Vitamin/mineral supplement per MD order. The CCP for "Nutritional Status" dated 10/3/14 included the intervention: "Provide dietary supplement/nourishment as ordered". The Dietary Readmission note dated 10/3/14 documented: "Noted with multiple pressure ulcers: St (Stage) 1, 2, and unstageable. Recommend LPS(Liquid Protein Supplement) Critical Care 30 ml (milliliters) TID (three times per day) (300 cal (calories), 51 g (grams) pro (protein)) to help aide wound healing and for [MEDICATION NAME]. Monitor intake, weight, skin integrity, and pertinent nutrition related labs. Follow up as needed". The Physician's (MD) Orders dated 10/3/14 and 10/26/14 and 11/12/14 documented LPS Critical Care 30ml TID. The Medication Administration Record [REDACTED]. The Dietary Note dated 10/15/14 for significant change documented: "Diet order NAS Diet; Snacks or supplements LPS Critical Care 30ml TID...estimated nutritional needs 1650-1925 kcal(kilocalories)/day, 66-77 gm (grams) protein/day, and 1375 - 1650 cc (cubic centimeters) fluid/day...intake 50-75%...Labs as of 10/2/14: ... Alb ([MEDICATION NAME]) 2.1 L (Low)... Noted with lt (left) heel unstageable, rt (right) heel st 2, and sacrum unstageable PU (pressure ulcer). Resident is on LPS critical care 30ml TID to help aide wound healing and for [MEDICATION NAME]". There was no documented evidence that the Dietician reviewed and revised the care plan to address the resident's refusal of LPS or other supplement options. The MAR indicated [REDACTED]. The LPS was administered 3 times from 11/1/14 to 11/13/14. There was no documented evidence that the Dietician discussed and explored supplement options with the resident in an attempt to review and revise the plan of care. On 11/17/14 at 2:40 PM, the Registered Nurse Supervisor (RNS) was interviewed and stated that she became aware of the LPS refusals on 11/13/14 when the surveyor brought them to her attention. She further stated that if she had known about the refusals, she would have contacted the Physician and Dietician so that they could address the refusals and decide whether to discontinue or change the supplement. On 11/17/14 at 3:07 PM, the Clinical Dietician was interviewed and stated that when assessing the resident, he reviews the weights, consumption of meals and supplements on the MAR, and pertinent labs. He further stated that he could not explain why he did not become aware of the resident's refusals of LPS when he did the significant change assessment. He stated that he should have identified the refusals and reviewed options with the resident for alternative supplements and nourishments in order to revise the plan of care. The Dietician stated that he did not become aware of the LPS refusals until 11/13/14, when the RNS informed him. 415.11(c)(2)(i-iii)

Based on interviews and record review during an abbreviated survey, the facility did not ensure that services provided met professional standards of quality. This was evident for one of three sampled residents (Resident #1). Resident #1 demonstrated risk factors for elopement, which were not captured on his ongoing elopement risk assessments or addressed in the development of his plan of care. Resident #1 successfully eloped from the facility overnight and was located 0.6 miles away from the facility by the Emergency Medical Services (EMS). This resulted in no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. Complaint #NY 769 Resident #1 was an [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 10/10/13 Minimum Data Set (MDS) 3.0 documented that the resident ' s cognitive skills were moderately impaired and required limited assistance with his activities of daily living (ADL). The Elopement Risk Assessments dated 11/5/10, 4/2/11, 10/1/11, 1/1/12, 4/7/12, 10/6/12, 4/7/13 and 7/6/13 were not scored for any risk factors, noting the resident was " ADL dependent and unable to move without assistance. " The Elopement Risk Assessments completed on 7/2/11, 7/7/12 and 1/5/13 documented that the resident was scored " 3 " (low risk) for elopement based on his independent wheelchair mobility. These assessments did not address other risk factors including impaired decision making or moving freely throughout the facility. A 9/20/12 Medical Director ' s note documented " ...non-cooperative with care, often refuses medication, wheels self out of building and now wants to go to a storage facility for some stuff of his ...Our concern is his safety. He wants to use Access A Ride to go to the storage facility by himself. He may disappear if he goes alone or he may get frustrated enough to elope somehow ...Staff to observe closely to prevent elopement at night. " The 7/24/13 Falls/Injury Comprehensive Care Plan (CCP) documented that Resident #1 was at risk for falls secondary to his impaired judgment, impaired cognition, poor balance, amputation, use of assistive devices, and [DIAGNOSES REDACTED]. The review of the resident ' s CCPs had no documented evidence that the resident ' s elopement risks were addressed. The Accident Report dated 11/18/13 documented that the resident was not located on the unit during rounds at 2:00AM. The front desk Security informed the nursing staff that the EMS called the facility at 1:45AM to inform that Resident #1 was found in the street. When the resident returned to the facility, the resident stated that he went out to " get his prosthetic leg and to watch a soccer game. " The 1/2007 facility policy titled " Elopement Prevention-the Bluebird Program " documented that the resident ' s risk for elopement will be assessed by using the " Elopement Risk Assessment Template. " The policy documented that the risk factors are based on the resident ' s history of actual or attempted elopement, wandering behavior, cognitive impairment or demonstration of poor decision making, verbalization of desire to leave the unit or building, and independence in mobility. During a 12/2/13 1:15PM interview with the Certified Nursing Assistant (CNA), she stated that the resident demonstrated forgetful behavior, such as leaving the faucet on or forgetting to lock his wheelchair brakes. The CNA stated that the resident was allowed to go downstairs and remained downstairs for variable periods of time. She stated that during the summer he " spent hours in the yard. " The CNA stated that on the day of the incident on 11/17/13 at approximately 10:00PM, the resident opened the alarmed exit door leading to the stairs and complained when the staff redirected him. She also stated that the resident had demonstrated this behavior in the past. During a 12/16/13 10:35AM interview with the Registered Nurse Supervisor (RNS), he stated that the resident did not score for " wandering " behavior because his movements throughout the facility were purposeful in nature. The RNS also stated that the resident ' s cognition was intact prior to the incident. During a 12/2/13 5:00PM interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON), they stated that the resident was the subject of many focus meetings for his need for supervision. The DON and ADON were not able to state what formal plans were put in place based on the focus meetings for the resident ' s supervision needs. Resident #1 ' s elopement risk assessments were reviewed. The DON and ADON were not able to explain why the resident was classified as " ADL dependent " on the elopement risk assessments or why his cognitive status was not addressed on the risk assessment. 415.11 (C)(3)(i)

Based on interviews and record review during an abbreviated survey, the facility did not provide adequate supervision to a resident to prevent elopement. This was evident for one of three sampled residents (Resident #1). Resident #1 was not visualized by the staff for over two hours. The resident was able to leave the facility undetected by staff. The resident was located by the Emergency Medical Services (EMS) 0.6 miles away from the facility at approximately 2:00AM. This resulted in no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. Complaint #NY 769 Resident #1 was an [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 10/10/13 Minimum Data Set (MDS) 3.0 documented that the resident ' s cognitive skills were moderately impaired and required limited assistance with activities of daily living (ADL) The Elopement Risk Assessments dated 11/5/10, 4/2/11, 10/1/11, 1/1/12, 4/7/12, 10/6/12, 4/7/13 and 7/6/13 were not scored for any elopement risk factors, noting that Resident #1 was " ADL dependent and unable to move without assistance. " The Elopement Risk Assessments completed on 7/2/11, 7/7/12 and 1/5/13 documented that the resident scored " 3 " (low risk) for elopement based on his independence in wheelchair mobility. The assessment did not address risk factors such as impaired decision making or moving freely throughout the facility. The 9/20/12 Medical Director ' s notes documented " ...non-cooperative with care, often refuses medication, wheels self out of building and now wants to go to a storage facility for some stuff of his ...Our concern is his safety. He wants to use Access A Ride to go to the storage facility by himself. He may disappear if he goes alone or he may get frustrated enough to elope somehow ...Staff to observe closely to prevent elopement at night. " The 7/24/13 Falls/Injury Comprehensive Care Plan (CCP) documented that Resident #1 was at risk for falls secondary to his antidepressant use, impaired judgment , impaired cognition, poor balance, amputation, use of assistive devices, and [DIAGNOSES REDACTED]. The Medical Doctor (MD) ' s order dated 10/12/13 included that the resident may go out on pass with a responsible party and that the resident may go off the unit or in front of the building after advising appropriate staff. The MD also instructed to provide 30-minute visual checks to assess safety, comfort and toileting needs. The 30-minute visual checks for 11/17/13 documented that the resident was on the unit between 12:00AM and 11:30PM. The visual checks documented that on 11/18/13 the resident was off the unit from 12:00AM to 3:30AM and that the resident stayed on the unit for the remainder of the day. The EMS Ambulance and Fire Department of New York (FDNY) call report dated 11/18/13 documented that a call was received at 1:55:03AM on 11/18/13. A male (Resident #1) in a wheelchair with altered mental status was reported as dizzy and disoriented and refused all work-up, treatment and hospitalization on 24th Avenue & 27th Street. The resident stated " I need to get back to the nursing home. " The facility investigative findings for the 11/18/13 incident documented that the nurse on the unit observed that the resident was not in his room at 1:45AM. When the staff was " about to announce a Bluebird Alert (code for Missing Resident) " at 2:00AM, the FDNY-EMS notified the facility that Resident #1 was found in the community by the EMS in the street. The EMS staff advised the supervisor that the resident refused to go to the hospital and dispatched facility staff members to retrieve him. The resident was assessed with [REDACTED]., adding the resident ' s name to the Bluebird program for Elopement Risk, providing a psychiatric consultation, notifying the family and counseling the resident that " leaving the facility without authorization is unacceptable for safety reasons. " The 3/2003 policy titled " Monitoring Resident " documented that the ways of monitoring residents' location include conducting a head count at the beginning and end of the shift, conducting hourly rounds by Certified Nursing Assistants (CNA) and providing visual checks during medication pass and meal times. The policy also documented that the nursing staff will call the front desk receptionist/security if the resident is on the way to go to the lobby and that other team members will advise nursing staff if the resident is on the way back to the unit. The 1/2010 policy titled " CNA Daily Assignment " documented that CNA staff will provide hourly rounds for the entire unit to ensure safety of all residents, especially those in bed and the residents who are able to wheel themselves or ambulate on the unit. During a 12/2/13 1:15PM interview with CNA #1, who was assigned to the resident during the 4PM-12AM shift on 11/17/13, she stated that the resident demonstrated forgetful behavior, such as leaving the faucet on or forgetting to lock his wheelchair brakes. CNA #1 stated that the resident was allowed to go downstairs and remained downstairs for variable periods of time. She stated that during the summer he " spent hours in the yard. " She stated that if he was not on the unit for more than half an hour she called downstairs to " see if he was okay. " CNA #1 stated that on 11/17/13 at approximately 10:00 PM, the resident opened the alarmed exit door leading to the stairs and complained when the staff redirected him. She also stated that the resident had demonstrated this behavior in the past. CNA #1 stated that she visualized the resident at the nurse ' s station across from the elevator at 11:30PM. CNA #1 stated that the resident was not on the unit at 11:50PM and stated that she did not see him for a formal visual check at 12 midnight. CNA #1 stated " that one time I did not check. " During a 12/3/13 6:45AM interview with CNA #2, who was assigned to the resident during the 12AM-8AM shift on 11/18/13, she stated the resident was not in the habit of telling them when he was going downstairs. CNA #2 stated that the resident was usually downstairs when she started her shifts, but she did not see him there on the night of the incident. CNA #2 stated that when the resident returned to the facility, he only had a tee shirt and a hat, without any pants. During a 12/3/13 6:32AM interview with the Licensed Practical Nurse (LPN), who was on duty during the 12AM-8AM shift on 11/18/13, she stated that during the initial rounds she observed that Resident #1 ' s bed was empty. She stated " It was my mistake for not checking in the bathroom or the lobby. " She stated that it was not unusual for Resident #1 to be downstairs, and about 1:30AM she realized that she had not seen him on the unit. She stated that the unit staff " made the assumption " that he was downstairs. The LPN stated that she was not made aware of his earlier attempt to open the stairwell door and felt that she would certainly have checked further if she had known about it. During a 12/2/13 3:42PM interview with the Registered Nurse (RN), who was on duty during the 4PM-12AM shift on 11/17/13, she stated that another resident had an acute need at 11:45PM and she was distracted from performing her usual end-of-the-shift rounds. She stated that she did not perform the end-of-the-shift bed check. The RN stated that she was aware the resident had attempted to open the exit door when the RN supervisor was present. The RN stated that the supervisor redirected Resident #1 to the elevator where he went downstairs and returned approximately 15 minutes later. The RN stated that the resident usually told staff when he wanted to leave the unit. During a 12/23/13 9:30AM interview with the front desk Security (#1), who was on duty during the 4PM-12AM shift on 11/17/13, he stated that he saw the resident at 11:00PM when the resident was sitting to the right of the door under the awning. Security #1 stated that he got distracted by visitors, answering phone calls and other duties that demanded his attention that night. He stated that he did not see the resident outside at the end of his shift and " thought he had gone back upstairs. " During a 12/2/13 4:50PM interview with Security#2, who was on duty during the 12AM-8AM shift on 11/18/13, he stated that the resident normally came down to sit in the lobby area or went out to the ramp where he could be visualized from the reception desk. Security #2 stated that when he arrived for the shift at approximately 11:50PM on 11/17/13, there was no discussion with the outgoing 4PM-12AM shift Security regarding Resident #1. He stated that he received a telephone call from the EMS at approximately 1:30AM stating that they had the resident. He stated that he notified the RNS of the phone call. He stated that since his tenure he never received a call from a nursing unit attempting to verify the location of a resident. During a 12/3/13 6:20AM interview with an orderly who assisted in returning the resident to the facility, he stated that he observed the resident surrounded by the EMS staff on 27th Street & 23rd Avenue wearing a blue shirt and shorts, covered with sheets by the EMS. The orderly stated that it was drizzling outside and the resident " could have used a jacket. " During a 12/23/13 9:29AM interview with the Registered Nurse Supervisor (RNS) #1, she stated that on 11/17/13 she had directed the resident to the elevator at about 10PM and did not recall what he was wearing. When she was notified that the resident was found in the community, she was in the process of notifying the security to call a " Bluebird " alert. During a 12/2/13 11:00 AM interview with RNS #2, she stated that although the CNAs are responsible to document the 30-minute visual checks, all of the staff needs to be watchful. She added that it is routine for the charge nurse and CNAs to account for all of the residents at the start and the end of the shift, as well as during meals, medication pass and toilet routines. During a 12/2/13 4:00PM interview with the MD, he stated that the resident often sat on the porch outside. The MD stated that the resident presented " no indication of risk. " The MD stated that he was not aware of the resident ' s attempt to open the stairwell door earlier in the evening on 11/17/13. The MD stated that in the past, the resident always returned to the unit and did not present any triggers to suggest that he would try to elope. The MD stated that the staff may have " become complacent, " but took immediate corrective action when the resident was missing. During a 12/2/13 9:10AM interview with the Director of Nursing (DON), she stated that Resident #1 was the only resident with a special accommodation to go outside for air. The DON stated that the resident had been at the facility for three years without being considered at risk for elopement. 415.12(h)(l)

Based on record reviews and interviews the facility did not ensure that the resident was provided with choices that were significant to the resident. Specifically,a resident who made a request for showers more than twice a week was not accomodated. (Resident # 326 ).This was evident for 1 of 4 residents reviewed for Choices. This resulted in no actual harm with the potential for more than minimal harm. The findings is: 1) Resident #326 was admitted to the facility with [DIAGNOSES REDACTED]. The Admission MDS 3.0 (Minimum Data Set) dated 9/6/13 assessed the resident with a BIMS (Brief Interview for Mental Status) score of 15, indicating intact cognition and extensive assistance of one person for bathing. The resident interview for daily preferences documented that the ability to make choices about her daily actvities and care are important to her. On 11/15/13 at 9:05 AM the resident was interviewed and stated that she was not given a choice of days or the number of showers she could have per week. She further stated that she voiced her preferences of wanting more frequent showers and was told that the nursing staff can only give her showers twice a week. On 11/19/13 at 11:04 AM, the assigned CNA (Certified Nursing Assistant) was interviewed. The CNA stated that when a resident was due for a shower,it is documented on the shower schedule posted at the nurse's station.She further stated that the residents are showered twice a week and that if a resident requests more frequent showers, she let's the charge nurse know and awaits further instructions and did not recall this resident making a request for additional showers. The CNA also stated that she had not given a resident a tub bath,and that no resident had ever asked her for a tub bath. On 11/19/13 at 11:50 AM the Registered Nurse Supervisor (RNS) assigned to the unit was interviewed and stated that the RNS on each unit develops the shower schedule. When the residents are admitted they are automatically assigned to take a shower two times a week. She further stated that the shower days are assigned by room numbers, shift and time. The RNS stated that every resident is showered twice a week. The RNS stated that upon admission the resident and or their family informed about their shower days The RNS was asked how are residents assessed to determine if the schedule accomodates there needs. She stated that if a resident or family member voices a preference for a shower on a different day, or shfit they will be accomodated. She further stated that although there are two tubs on the unit they have not been in use for [AGE] years. She does not recall any residents requesting a tub bath. The RNS stated that the residents used to complain about the power of the jets in the tub so there was very little request for tub baths; and added the tubs have not been in use and are not offered to residents as a preference. The shower schedule posted at the nurse's station was reviewed and documented the showers were assigned by shift and resident room number. The schedule further documened that this resident is assigned a shower twice a week, on Sundays during the 8A-4P shift and on Wednesdays during the 4P-12AM shift. An interview was conducted with the Registered Nurse Supervisor (RNS) on 11/20/13 at 11:50 AM. The RNS stated that when the residents are admitted to facility they are assigned to take showers two times per week. This is documented in the bathing section of the PDA- as far as baths are concerned- We dont use the century tub-Since I worked here, the tub has not been used- the reason was said but I dont recall why the tub is not in use.if a res wants to take a tub bath I dont think that will be possible and are not provided with the choices related to taking a tub bath, shower or bed bath- only choices r/t a shower or bed bath. 415.5(b)(1-3)

Based on observation, interview and record review, the facility did not report a significant medication error to the Department of Health as soon as the error was discovered. This was evidenced in 1 of 3 sampled residents. (Resident is #1). This resulted in no actual harm with potential for more than harm that is not Immediate Jeopardy. Complaint # NY 4990 The findings are: Resident #1 was admitted on [DATE], transferred to the hospital on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment 3.0 dated 08/11/11 noted that her cognition is moderately impaired. The resident requires total care in all activities of daily living. The facility investigation report dated 08/08/11 documented that the Licensed Practical Nurse (LPN) #1 gave an excessive dose of Regular insulin by error on 08/05/11 at 10:45 PM. Resident #1, a diabetic, had a finger stick (FS) of 598mg/dl reading (normal range 80-120mg/dl). The Primary Medical Doctor (PMD) ordered a STAT dose of 12 unit ' s Regular insulin at 9:00 PM. The LPN #1 gave 100 units Regular insulin. She realized immediately that she gave a wrong dose. She told the Charge Nurse (RN) and the supervisor was notified. The resident was asymptomatic, was given sugar by mouth and was sent to the hospital for evaluation. The resident was sent back next day (08/06/11) as stable but remains with elevated blood sugar (BS). She has a new [DIAGNOSES REDACTED]. The interim MD order dated 08/05/11 at 10:31 PM documented [MEDICATION NAME] R 100 unit/ml injection inject 12 units by injection route now. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] The nursing medication incident report dated 08/05/11 signed by the Medical Director dated 08/12/11 documented that on 08/05/11 at around 10:15 PM resident ' s FS was reported to be 596mg/dl (normal range 80-120mg/dl). PMD ordered 12 units of Regular insulin. LPN #1, the primary medication nurse on duty, injected 100 units of Regular insulin by mistake. RNS was immediately notified and resident was transferred to the hospital. The facility policy and procedure on " Medication Error " revised 02/2011 does not include reporting medication errors or occurrences to the Department of Health. The Director of Nursing was interviewed on 08/12/11 at 11:00 AM. She stated that she discussed the medication error with the interdisciplinary team (IDT) and the LPN #1 on 08/08/11. When asked why she waited until 08/11/11 to report the incident to the Department of Health, she stated that it is still within the five (5) working day window to investigate and to report. She stated that it is an " isolated incident and the resident was not harmed as a result of medication error. 415.4(b)(1)(ii)