Every finding on record at Northern Manor Geriatric Center Inc

Based on observation and interview conducted during the recertification and abbreviated (NY00340747) surveys from 12/3/24 to 12/10/24, the facility did not ensure residents' rights to a safe, clean, comfortable and homelike environment on 4 units. Specifically, 1) Center 3 Unit, walls were chipped in 3 rooms, holes were observed in 2 rooms, wallpaper was peeling in one room, and paint was peeling in 11 rooms, 2)Resident #578 on the Center 1 Unit stated when showered they sat on a shower chair with a torn seat and wet exposed wood and 3) a dust covered fan was blowing on Resident #42 with a tracheostomy. The findings are: The facility policy, Homelike Environment dated 9/2022 documented residents were provided with a safe, clean, comfortable and homelike environment. The facility policy, Maintenance Services Operations dated 10/12 documented Maintenance Department was responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Functions of the maintenance personnel included maintaining the building in good repair and free from hazards. 1). During observation conducted on the Center 3 Unit on 12/04/24 from 10:35 AM until 10:51 AM, the following was observed: room [ROOM NUMBER] walls were chipped, and paint was peeling off the walls behind the door. room [ROOM NUMBER] wall was chipped, and paint was peeling off the wall behind the door. room [ROOM NUMBER] paint was peeling behind the door. room [ROOM NUMBER] paint was scratched behind the door and under the TV by the bed near the window. room [ROOM NUMBER] paint was peeling behind the door. room [ROOM NUMBER] wall had a hole and paint was peeling behind the door. room [ROOM NUMBER] wallpaper was peeling behind the bed/near the sink and the window blind was twisted. room [ROOM NUMBER] paint was peeling behind the door. room [ROOM NUMBER] paint was peeling behind the door and under the TV. room [ROOM NUMBER] paint was peeling behind the door and under the TV, room [ROOM NUMBER] paint was peeling behind the door and there was a hole in the doorway wall. During interview on 12/09/24 at 3:44 PM the Director of Maintenance stated they were not aware of all the concerns on the Center 3 Unit. They stated they completed environmental rounding in resident rooms approximately every 7 weeks, and last completed environmental rounds on unit Center 3 Unit about a month ago. They stated nursing staff should report damage in resident rooms and common areas. During interview on 12/09/24 at 3:57 PM Certified Nurse Aide #6 stated they usually worked in rooms 310-314. They stated they did not observe the above listed damage to the rooms. They stated they would have reported any damage to the nurse manager. During interview on 12/09/24 at 3:59 PM Certified Nurse Aide #7 stated they usually worked in rooms 301-305. They stated they did not observe the above listed damage to the rooms. They stated they would have reported any damage to the nurse. During interview on 12/09/24 at 4:02 PM Registered Nurse Unit Manager #8 stated they did not observe any damage to the rooms on the unit. They stated they would report to the maintenance department either in person or document in the maintenance book. During interview on 12/10/24 at 8:23 AM the facility Administrator stated the maintenance department was responsible to complete environmental rounds on the units and complete the repairs timely. 2). During observation n 12/03/24 at 11:23 AM, 12/05/24 at 2:12 PM, and 12/06/24 at 10:46 AM on the Center 1 Unit, a shower chair was observed with a torn seat and dark- colored, wet exposed wood. During interview on 12/06/24 at 10:46 AM, Resident #579 stated yesterday during their shower they were on a torn shower chair. They stated they tried not to have contact with the torn dark-colored wet exposed wood, but there was no way to avoid their skin coming in contact with the torn seat. During interview on 12/06/24 at 11:09 AM Certified Nurse Aide #17 stated the shower chair with the torn seat and dark- colored, wet, exposed wood was used for residents when they were given showers. During interview on 12/06/24 at 11:19 AM Certified Nurse Aide #18 stated they used the shower chair with the torn seat and dark- colored, wet, exposed wood, when giving resident showers. During interview on 12/06/24 at 11:24 AM Registered Nurse Unit Manager #10 observed the shower chair with the torn seat and dark- colored, wet, exposed wood and stated the Certified Nurse Aides should have told them about it. During interview on 12/06/24 at 11:25 AM the Infection Preventionist/Assistant Director of Nursing stated they were aware of the shower chair with the torn seat and dark- colored, wet, exposed wood, had told administration, but did not take the chair out of service. They stated the shower chair should have been removed from the unit as soon as it was identified. During interview on 12/09/24 at 01:23 PM during an interview, the facility Administrator stated the shower chair should have been taken off the unit. 3) During observation on 12/06/24 at 11:17 AM the fan in room [ROOM NUMBER] was dusty and blowing on Resident #42 with a tracheostomy. During observation and interview in room [ROOM NUMBER] on 12/06/24 at 11:33 AM the Infection Preventionist /Assistant Director of Nursing stated housekeeping was supposed to clean the fans and stated they had already been told to do so. They stated it was concerning for the Resident #42 with a tracheostomy to have a dusty fan blowing on them. 10 NYCRR 415.29 41666

Based on interview and record review during the recertification survey conducted 12/3/24-12/10/24, the facility did not ensure each staff and resident was screened, offered the COVID-19 vaccine and provided education regarding the benefits, risks and potential side effects associated with the vaccine for 1 of 5 residents (Resident # 193) and 10 of 10 staff reviewed for COVID vaccines. Specifically, there was no documented evidence of immunization records for COVID vaccine for Resident #193. Additionally, there was no documented evidence of immunization records for COVID vaccine for the Director of Admissions, Certified Nurse Aide #6/#19/#21, Licensed Practical Nurse #22/#23, Occupational Therapist #24, Registered Nurse #25/#10 and Cook, #20. Findings include: The facility policy titled COVID-19 Vaccination for Residents and Staff last revised 11/27/24 documented the facility follows guidance from The Centers for Disease Control as well as Federal and State requirements among residents, staff and others. The facility shall provide education about the importance of receiving the COVID-19 vaccine to residents, resident representatives and staff. Upon admission/readmission the facility shall obtain COVID-19 history to the extent possible. Upon hire, the facility shall obtain COVID-19 vaccine history of new staff. COVID-19 vaccine shall be offered, promoted and encouraged to all eligible residents and staff initiated within 14 of admission and within 14 days of hire for staff. Resident #193 had diagnoses of intracranial injury with loss of consciousness, respiratory failure and tracheostomy. There was no documented evidence the resident/resident representative received education, was offered the vaccination, or declined the COVID vaccine. During the recertification survey the facility was asked to provide the vaccination status for staff for flu, pneumococcal and COVID vaccines. There was no documented evidence the facility had documentation of screening, education offering or current COVID 19 status for the Director of Admissions, Certified Nurse Aide #6,#19 and #21, Licensed Practical Nurse #22, and #23, Occupational Therapist #24, Registered Nurse #25 and #10 and [NAME] #20. During an interview on 12/10/24 at 1:33 PM Registered Nurse Unit Manager #10 stated upon admission vaccines were supposed to be offered to the resident and/or resident representative and education was to be provided. They stated they should have gotten the resident's vaccine status back in April when they were admitted , but they missed Resident #193. During an interview on 12/10/24 at 2:06 PM the Infection Preventionist stated nursing collected the vaccine status from records during the admission process. They stated they did not have a record of vaccine status for all in house residents on paper or electronic medical record. The Infection Preventionist stated they did not have a system to track which residents were vaccine eligible or who had declined the vaccine. During an interview on 12/10/24 at 3:23 PM the Director of Nursing stated vaccines were important, as they were the first line of defense for preventing disease. The Director of Nursing stated the Infection Preventionist was asked during morning report about resident vaccine eligibility, administration and education and had reported there were no problems. The Director of Nursing stated they were not aware vaccine tracking was not being done. 10NYCRR 415.19 (a)(1-3)

Based on observation, interview, and record review conducted during the recertification and abbreviated (NY00340747) surveys from 12/3/2024 to 12/10/2024, the facility did not ensure each nurse aide received twelve hours of in-service education per year based on their individual performance review. Specifically, 1.) One of five Certified Nurse Aides (#12) did not have the required 12-hour mandatory in service education per year, and 2.) Four of five Certified Nurse Aides (#12, 13, 14 and 15) annual performance reviews were not up to date. Finding Include: Review of Certified Nurse Aides # 12, #13, #14, 15 and #16 in - service records revealed: Certified Nurse Aide #12 was hired 3/30/1998 and there was no documented evidence that inservice was provided in 2023. Review of Certified Nurse Aides # 12, #13, #14, 15 and #16 annual performance evaluations revealed: Certified Nurse Aide #12 was hired 3/30/1998, and there was no documented evidence that a performance evaluation was completed. Certified Nurse Aide #13 was hired 7/11/1993, and their performance evaluation was undated. Certified Nurse Aide #14 was hired 5/20/2023, and their performance evaluation was undated. Certified Nurse Aide #15 was hired 11/6/2012, and their last performance evaluation was dated 11/16/2012. On 12/10/24 at 1:40 PM, the Assistant Director of Nursing stated they were responsible for providing Certified Nurse Aide education. On 12/10/24 at 1:55 PM, the Director of Nursing stated a system had been in place as of 11/1/24 and Certified Nurse Aides should be completing the 12-hour mandatory training in the system. The Director of Nursing stated they were still working on figuring out who was not up to date with their training. The Director of Nursing stated Certified Nurse Aide evaluations should be completed annually and stated they were not up to date. 10 NYCRR 415.26

During observation and interview during the Recertification Survey conducted from 12/3/24 through 12/10/24 the facility did not ensure each resident was treated with respect and care in a manner and environment that promoted dignity while dining. Specifically, the facility did not avoid daily use of disposable cutlery and/or dishware for residents on [NAME] 1 and North 1. Residents were observed eating meals from styrofoam plates and/or using plastic utensils on 3 separate days. The findings are: During observation on 12/03/24 at 12:32 PM, of the lunch meal in [NAME] 1 Unit Dining Room, Residents #20, #19, #201, and #180 were served their food on styrofoam plates. During observation on 12/04/24 at 1:09 PM, of the lunch meal in the [NAME] 1 Unit Dining Room, Residents #201, #19, #17, and #180 were served their food on styrofoam plates and were given plastic utensils During observation on 12/06/24 at 8:46 AM, of the breakfast meal on the [NAME] 1 Unit, Resident # 45,#10, #202, #23, and #130 were served their food in styrofoam containers. During observation on 12/06/24 at 8:50 AM, in the hallway outside the North 1 Unit, all breakfast trays had styrofoam containers and plastic utensils. During observation on 12/06/24 at 12:46 PM, in the [NAME] 1 Unit dining room, Residents #19, #17, #201, and #180 were served their meals on styrofoam plates. During interview on 12/06/24 at 1:09 PM, Registered Nurse Unit Manager #1 stated they were unsure of the reason styrofoam dishware was being used for some residents, and stated there was no pattern of use of styrofoam dishware. During interview on 12/06/24 at 3:36 PM, the Dietitian stated the facility was short on regular/non disposable plates and plastic utensils. The Dietitian stated the kitchen was responsible for ordering dishes. During interview on 12/09/24 at 10:32 AM, the covering Food Services Director stated the facility should have had backup dishware. During interview on 12/09/24 at 3:02 PM, the facility Administrator stated they were aware of the facility dish shortage. 10 NYCRR 415.5

Based on record review and interview during the recertification survey conducted 12/3/24 to 12/10/24, the facility did not ensure each resident was offered pneumococcal immunizations and received education regarding the benefits and potential side effects of the immunizations for 1 of 5 residents (Residents #193) reviewed. Specifically, there was no documented evidence Resident #193 was offered, declined, or educated on the pneumococcal immunization. Findings include: The facility policy dated 8/22/24 and titled Resident Vaccines documented the facility will offer immunizations to the residents, following their consent to aid in the prevention of infectious conditions in accordance with the Centers for Disease Control (CDC) and the Advisory Committee for Immunization Practices. Prior to receiving vaccines, the resident will be provided information and education regarding the potential side effects of the vaccination. The facility should collect vaccination history on admission. A provision of education shall be documented in the resident medical record. Historical information data should be entered into the resident's electronic medical record. Resident #193 had diagnoses including intracranial injury with loss of consciousness, respiratory failure and tracheostomy. There was no documented evidence the resident/resident representative received education, was offered the vaccination, or declined the pneumococcal vaccine. During an interview on 12/10/24 at 1:33 PM Registered Nurse Unit Manager #10 stated upon admission vaccines were supposed to be offered to the resident and/or resident' representative and education was to be provided. They stated they should have gotten the resident's vaccine status back in April when they were admitted , but they missed Resident #193. During an interview on 12/10/24 at 2:06 PM, the Infection Preventionist stated nursing collected the vaccine status from records during the admission process. They stated they did not have a record of vaccine status for all in house residents on paper or electronic medical record. The Infection Preventionist stated they did not have a system to track which residents were vaccine eligible or who had declined the vaccine. During an interview on 12/10/24 at 3:23 PM, the Director of Nursing stated vaccines were important, as they were the first line of defense for preventing disease. The Director of Nursing stated the Infection Preventionist was asked during morning report about resident vaccine eligibility, administration and education and had reported there were no problems. The Director of Nursing stated they were not aware vaccine tracking was not being done. 10NYCRR 415.19 (a) (1-3)

Based on record reviews and interviews conducted during the recertification and abbreviated (NY00348289, NY00348920) surveys from [DATE] to [DATE], the facility did not ensure the Medical Director fulfilled their responsibility for the implementation of resident care when a resident died . This was evident for 1 of 1 residents (Resident #379) reviewed for death. Specifically, the Medical Director was designated as the individual to sign the death certificate for Resident #379. In accordance with State Public Health Law 4041, this was required within 72 hours of death. Resident #379 died on [DATE] and the Medical Director signed the death certificate on [DATE]. Findings include: The facility policy titled - Death- documented for Resident Pronouncement and Release to Mortuary, the primary healthcare provider (or designee) will complete and sign a death certificate in accordance with state or county law (e.g., as soon as possible but not to exceed 72 hours). Resident #379 had diagnoses including subdural hematoma, atrial fibrillation, and coronary artery disease. The Minimum Data Set (an assessment tool) dated [DATE] documented Resident #379's cognition was severely impaired. A progress note dated [DATE] at 10:25 PM documented Resident #379 was found without carotid pulse, pupillary reflex or respirations. In accordance with the Do Not Resuscitate order, no Cardiopulmonary Resuscitation was initiated. Resident #379 was pronounced dead at 9:30 PM and the Medical Director was notified. Next of kin was also notified and stated they would contact the funereal service, and call the facility back with the information. The Director of Nursing and Administrator were made aware. Resident #379's Death Certificate documented the resident died on [DATE] and was signed electronically on by the Medical Director on [DATE]. During a telephone interview on [DATE] at 3:27 PM, Registered Nurse #5 they stated they notified the Medical Director and called the family when the resident died . During an interview on [DATE], the Medical Director stated they looked at the death certificate for Resident #379 and saw that it was signed 7 days after the death. They stated it was an anomaly and had not happened before. During a telephone interview on [DATE] at 12:05 PM, the Director of the funeral home stated they had to call the facility multiple times to get the death certificate signed for Resident #379. They stated the death certificate had to be filed in order to process the body and without a signature, the body of the deceased remained in the freezer at the funeral home. They stated it took 7 days to get the death certificate signed. 10 NYCRR 415.15(a)

Based on observation and interview conducted during the recertification survey from 12/03/24 to 12/10/24, the facility did not ensure food was stored in accordance with professional standards for food safety practice. Specifically, there was undated food stored in the walk-in refrigerator and in 1 of 3 unit food refrigerators. Findings include: The facility policy titled Food Storage: Refrigerator Food Storage revised May 2024 documented all foods should be covered, labeled, and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates or frozen (where applicable) or discarded. The facility policy titled Unit Food Storage revised April 2023 documented all resident food items will be dated with a use by date. During observation and interview on 12/03/24 at 9:43 AM, the walk-in refrigerator contained two undated sandwiches on a tray. The Food Service Director stated the sandwiches were made today, and that was the reason there was no date on the sandwiches. Approximately five single cheese slices were observed on a plate with clear wrap which was not dated. The Food Service Director stated they were unable to provide information as to when the cheese was placed in the refrigerator. During an observation/interview on 12/03/24 at 1:00 PM with Certified Nurse Aide #11, an undated, wrapped ham sandwich was observed in the unit refrigerator. Certified Nurse Aide #11 stated they did not know how long the sandwich had been in the refrigerator. 10NYCRR 415.14 (h)

Based on observation, record review and interview conducted during the recertification survey from 12/3/24 to 12/10/24, the facility did not ensure all drugs and biologicals in 2 of 4 medication storage rooms were labeled and stored in accordance with professional standards. Specifically, one bottle of over-the-counter medication and two bottles of tube feeding formula had past due expiration dates. The findings include: The revised-on January 2019 facility policy titled Medication- Storage documented expired, discontinued and/or contaminated medications will be removed from the medication storage areas and disposed of in accordance with facility policy. During observation on 12/05/24 at 1:28 PM, a bottle of Aspirin 325 mg tablets with an expiration date of 10/24 was on the shelf in the Center 1 Unit medication storage room. During an interview on 12/5/24 at 1:28 PM, Licensed Practical Nurse #2 stated the nurse manger was responsible for checking the medications in the medication storage room. During an interview on 12/05/24 at 2:02 PM, Registered Nurse Unit Manager #3 stated they were responsible for checking medications in the medication storage room. They stated all nurses were supposed to check medication/s each shift prior to transferring them from the storage room to their medication carts. During observation on 12/05/24 at 2:25 PM Vital tube feeding formula with a 12/1/24 expiration date and Jevity tube feeding formula with an expiration date of 5/1/24 were observed in the Center 1 North [NAME] Unit medication room. During an interview on 12/05/24 at 2:25 PM Licensed Practical Nurse #9 stated the 2 expired tube feeding formulas were no longer in use and should have been discarded, as the facility currently utilized a different brand of tube feeding. They stated nursing staff were responsible for discarding expired tube feeding formulas. During an interview on 12/06/24 at 10:36 AM the Director of Nursing stated all nurses were responsible for checking medication carts each shift and medication storage rooms should be checked by the nurse managers weekly. They stated Pharmacy should check the medication room and medication carts quarterly to ensure there were no expired medications. They stated the Dietician was responsible for checking tube feeding formulas, but would not check the medication storage rooms. They stated unused medications/ tube feedings should have been discarded by the nurses. 10 NYCRR 415.18(e)(1-4)

Based on record review and interview during the recertification and abbreviated (NY00360711) surveys from 12/3/24 to 12/10/24, the facility did not ensure residents or resident representatives were notified in writing of the facility bed hold policy for 4 of 4 residents (Residents #529, #179, #169, and #148) reviewed for hospitalization . Specifically, residents were transferred to the hospital and the facility was unable to provide evidence that written notice of facility bed hold policy was given to the residents or their representatives. The findings are: The facility Bed Hold policy dated 3/2018 documented, 'prior to or at the time of a transfer (or as soon as practicable following an emergency transfer), written information (bed hold information and agreement) will be given to the resident and/or the resident representative that explains in detail: the rights and limitations of the resident regarding bed-holds, reserve bed payment policy as indicated by the resident's primary insurance policy, the resident/representative's option to pay privately to reserve their bed if their primary insurance policy does not provide bed hold coverage. 1). Resident #529 was admitted with diagnoses including cerebral infarct, hemiplegia affecting left non dominant side, and hypertensive heart disease with heart failure. The 11/13/24 Discharge/ Return Anticipated Minimum Data Set Assessment documented Resident #529 was discharged to the hospital. The 11/13/24 Physician Order documented transfer to hospital for evaluation post fall. The 11/13/24 Registered Nurse note documented send Resident #529 to the emergency room for evaluation. There was no documented evidence a written notice of the facility Bed Hold Policy was given to the resident or their representative. During an interview on 12/06/24 at 1:28 PM the Director of Social Work stated nurses were to provide written notice of the facility Bed Hold Policy to the resident and/or resident representative. The Director of Social Work stated there was no documented evidence a written notice of the facility Bed Hold Policy was given to the resident or their representative. 2). Resident #179 was admitted with diagnoses including anemia, urinary tract Infection, schizophrenia. The 9/20/24 Quarterly Minimum Data Set documented the resident had severely impaired cognition. The 10/3/24 Discharge/ Return Anticipated Minimum Data Set Assessment documented Resident # 179 was discharged to the hospital. The 10/3/24 Situation Background Assessment Recommendation Note documented change in condition: behavior symptoms of agitation, throwing objects at staff, kicking furniture, making loud noises, very disruptive to the unit. Nurse Practitioner ordered to send to Hospital for evaluation. On 12/10/24 at 4:07 PM during an interview, the Director of Social Work stated they did not provide a written notice of the facility Bed Hold Policy to Resident # 179 or their representative. 3). Resident #169 was admitted with diagnoses including chronic respiratory failure, muscle wasting and atrophy, and dependence on ventilator. The 9/20/24 Quarterly Minimum Data Set documented Resident # 169 had severely impaired cognition. The 10/22/24 Discharge/ Return Anticipated Minimum Data Set documented Resident # 169 was discharged to the hospital. The 10/22/24 Respiratory Therapist note documented Resident # 169 was transferred to the hospital for fever. During an interview on 12/09/24 at 12:16 PM the Administrator stated they were made aware that the facility had not been providing written notice of the facility Bed Hold Policy to residents or representatives when they were discharged or transferred to the hospital. On 12/10/24 at 2:46 PM, during a follow-up interview with the Assistant Administrator, they stated they did not provide written notice of the facility Bed Hold Policy to any resident or representative prior to 12/9/24. 10NYCRR 415.3 (i)(3)(i)(a) 51214

Based on record review and interview during the recertification survey from 12/3/24 to 12/10/24, the facility did not ensure residents and/or their designated representative were fully informed of their right to an expedited review of a service termination. Specifically, for one of three residents (Resident #300) reviewed for Beneficiary Protection, the facility did not ensure the Notice of Medicare Non-Coverage form (CMS-10123) was provided to the resident and/or representative at a minimum of two days prior to the end of Medicare Part A covered services. The findings are: There was no documented evidence of a policy specific to the Notice of Medicare Non-Coverage, and the two-day requirement to provide notice to the beneficiary or representative. The 8/27/24 progress note documented Notice of Medicare Non-Coverage was not provided to Resident #300 and family representative. There was no documented evidence the Notice of Medicare Non-Coverage was provided to the designated representative/contact person for Resident #300. During an interview on 12/6/24 at 3:58 PM, the Minimum Data Set Coordinator stated when a resident was going to be discharged , they were supposed to receive prior notice from the Social Worker verbally or by email. They stated they reminded the Social Worker the Notice of Medicare Non-Coverage must be presented to the resident two days prior to discharge. They stated they checked resident's Brief Interview for Mental Status assessment, or received input from the Social Worker to determine whether the resident was able to understand the notification. If the resident lacked capacity, the family or representative would be notified in person or by telephone, if they were notified by telephone the notification would be sent by certified mail. They stated they were not aware of the pending 8/28/24 discharge for Resident #300 until 8/27/24. They stated they did not issue the Notice of Medicare Non-Coverage because it would not have been received in the required time frame of two days prior. During an interview on 12/6/24 at 4:26 PM the Director of Social Work stated they met with Resident #300's spouse on 8/20/24 to discuss discharge. The resident was cleared for discharge by the doctor on 8/26/24 and discharged on [DATE]. They stated they did not know why the Minimum Data Set Coordinator was not aware of the resident's pending discharge until 8/27/24. During an interview on 12/10/24 at 11:57 AM the Regional Director of Nursing stated the facility did not have a separate policy for the Notice of Medicare Non-Coverage. 10 NYCRR 415.3 (g)

Based on observations and interviews during an abbreviated survey (NY00343390, NY00339693), the facility did not ensure the environment was functional, sanitary, and comfortable for residents, staff, and the public. Specifically, the kitchen floor by the washing machine had about 2 inches of water pooled, and staff were actively working in the area, multiple areas of the building had chipped paint, scratched paint, scuff marks, visible dirt and stains on the walls and floors, peeling wallpaper and foul odors. Finding include: During an observation in the kitchen on 9/6/2024 at 10:20AM, surveyor observed a pool of water about 2inches on the floor by the wash machine. During an interview on 090/06/2024 at 10:20 AM, the Dietary Aide stated an outside vendor was called to repair the leak from the wash machine which had been leaking for a week. The vendor came in on 9/4/2024 with their supervisor and the repairs was not completed. There was still water on the floor after they left. During a walk through on the units on 09/12/2024 from 10:00 AM until 11:39 AM, the following was observed: -In room [ROOM NUMBER]W, there were scratches along the molding around the walls and holes along with scratched -paint underneath the paper towel dispenser. -In room [ROOM NUMBER]W, there was a black smudge with missing paint on the wall next to the resident's bed. -In room [ROOM NUMBER]W, the molding was off the wall around the entire perimeter of the room behind the resident's beds. -At the Center 2 hallway, the lower portion of the wall and the rubber baseboards had visible dirt, scuff marks and stains. - At the dining room, the walls were dirty with some chipped paint on the walls and around the windows. -Along the corridor of Center 2, observed chipped paint on the walls. -At the Center 1 hallways, the walls had visible debris, dirt, and scuff marks. - At the Center 1, the floor by the elevator was visibly dirty and had chipped paint on the walls as well as dirty baseboards -In room [ROOM NUMBER], the wallpaper was peeling, and paint chipped at room entry During a walk through on the 3rd floor unit on 09/13/2024 from 11:53 AM until 11:56 AM the following was observed: - At the 3rd floor unit, there was an odor of urine and multiple visible stains on the floor. - At the 3rd floor unit, walls of the corridor were visibly soiled and had chipped plaster and paint. - At the 3rd floor unit, below the handrail down the entire hallway the paint was scratched off. - At the 3rd floor unit, the radiator in the hallway had paint scrapped off and a piece of duct tape was in place holding the panel in place -Outside of room [ROOM NUMBER], there was bubbled up wallpaper with a brown stain going down the wall - At the 3rd floor unit, emergency exit door had chipped paint around the window and was visibly dirty with stains - At the 3rd floor unit, the base board of unit manager's office door had visible dirt and stains - At the 3rd floor unit, there was a brown stain on the wall near the treatment cart. - At the 3rd floor unit, the paint was scrapped off sections of the handrail. - At the 3rd floor unit, there was a large area of paint peeled off the wall by the radiator, and the wall behind the radiator was visibly dirty on the 3rd floor unit During a walk-through on the unit 2 North [NAME] on 9/16/2024 at 1:35 PM the floor was noted to be sticky, and the hall smelled of feces and urine. During an interview on 09/10/2024 at 10:14 AM, the Director of Maintenance stated each unit and the kitchen have a book for work order requests. The Director of Maintenance stated their staff check the book daily and sign off the sign in sheet. The Director of Maintenance stated throughout the day the facility staff will call them to inform them of any environmental issues in the facility and they or their staff will respond. The Director of Maintenance stated they follow up with repairs within the next day or if it is something that can be handled immediately, then they will address it right away. The Director of Maintenance stated if a room needed to be painted then they let the nurse manager know and request the resident be moved out the room, for the room to be painted. The Director of Maintenance stated they make environmental rounds with the staff and the Administrator weekly to see if the rooms need to be repainted or refreshed. The Director of Maintenance stated they know some of the rooms need touch up paint jobs, but the residents are in the rooms and that they are working on it right now, but it is a work in progress and that they work on about 2 rooms per week. The Director of Maintenance stated the last time they did any work in the kitchen was last week, the sink was dripping, and they had to change the entire unit. The Director of Maintenance stated they were unaware of the pool of water on the floor in the kitchen by the dishwashing area. After walkthrough with surveyor through the kitchen, the Director of Maintenance stated they never received a work order request for that and that they would call the vendor and have someone come out right away to repair. During an interview on 9/17/2024 at 3:10 PM, the Director of Nursing stated they are part of the environmental rounds. The Director of Nursing stated they go around and check the rooms to ensure the resident is safe, that there are no smells and if any safety issues are observed, they are addressed by the department it belongs to. The Director of Nursing stated they will follow up before the end of the day to ensure they are in compliance. The Director of Nursing stated if it is something out of their control then they bring it to the administrator. The Director of Nursing stated they text the department head immediately if they see something. During a telephone interview on 10/31/2024 at 9:25 AM, the Administrator stated environmental rounds are done in the facility daily for the past year and a half and that they take the facility very seriously. The Administrator stated they have been working on keeping the facility up and making it aesthetically appeasing. The Administrator stated the Director of Nursing, Director of Housekeeping and the Maintenance Director make the environmental rounds with them. The Administrator stated that they pick certain units weekly with maintenance and housekeeping and they make thorough rounds on the units and with that schedule, the entire building should be covered at least once a month. The Administrator stated when a repair is needed sometimes it takes a day or 2 for the work to get completed. The Administrator stated a reasonable time for repairs to be done is within 24 hours and that sometimes residents need to be moved from rooms for repairs to be made. The Administrator stated sometimes a repair may require more time, for example if a wall needs to be plastered. The maintenance department would have to allow time for the plaster to dry before they could re-paint. The Administrator stated identified concern areas were probably in the process of being repaired and that they would go and inspect the areas, but a lot have been addressed. The Administrator stated they were informed of the water on the floor in the kitchen, and they went down and saw it, and the vendor came and fixed it. 10 NYCRR 415.29

Based on record reviews and interviews during an abbreviated survey (NY00333515, NY00331035, NY00327139, NY00321114) the facility did not ensure the resident representative was immediately informed of a significant change in the resident's physical status or a need to alter treatment significantly. This was evident for 3 out of 4 residents (Residents #17, #19, #20) reviewed for notification of changes. Specifically, (1) Resident #17 had an electrocardiogram on 12/22/2023 in the facility which revealed a low heart rate, and their anti-hypertension medication was discontinued, Resident #17's guardian was not informed. (2) Resident #19 on 10/05/2023 was discontinued from the tracheostomy collar oxygenation and was placed on a ventilator, Resident 19's daughter was not notified. (3) Resident #20 had an episode of respiratory distress with decreased oxygen saturation on 07/29/2023, and on 07/30/2023 they vomited x 1 and had decreased oxygen saturations and was placed on a ventilator. There was no documented evidence of Resident #20's family being informed of the resident's change in status/condition. Findings include: The facility Notifications policy dated 04/2019 documented except in a medical emergency, the facility must consult with the resident immediately if the resident is competent and notify the resident's physician and designated representative when there is: (1) a significant improvement or decline in the resident's physical, mental, or psychological status or a need to alter treatment significantly; (2) when there is a significant alteration in treatment a nurse will promptly notify the resident and/or their representative of any changes in the residents care and treatment initiated by nursing measure or a physicians order. Examples of alteration in treatment are change in medication, treatment, and equipment. Notification of a change is documented in the nurse's progress notes and reflects the name of the person notified and the change in condition and/or treatment. 1) Resident #17 and had diagnoses including but not limited to Vascular Dementia, Atherosclerotic Heart Disease and Bradycardia. A Comprehensive Minimum Data Set, dated dated dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of 07/15, associated with severe cognition impairment (00-07 severe impairment, 08-12 moderate impairment and 13-15 cognitively intact). Review of the electrocardiogram results dated 12/22/2023 documented sinus bradycardia, first degree atrioventricular block, right bundle branch block. If clinically warranted 24-hour [NAME] monitor could be obtained for further evaluation. Review of a nursing progress note dated 12/23/2023 documented Metoprolol discontinued due to bradycardia, electrocardiogram done, pending results. Review of Nurse Practitioner #2's progress note dated 12/25/2023 documented Resident #17 was seen and examined for follow up electrocardiogram done, results stable. Metoprolol discontinued due to bradycardia and staff to monitor blood pressure. There was no documented evidence of Resident #17's representative being notified of their new diagnosis of bradycardia and the changes made to their medication regimen. During a telephone interview on 09/13/2024 at 12:17 PM, Resident #17's representative stated in December of 2023, Resident #17 was found to have a significant low heart rate and they were never notified of this. Resident #17's representative stated they found out about the diagnosis reading the paperwork they were provided to take with them to a doctor's appointment scheduled for the resident. Resident #17's representative stated communication was nonexistent in the facility. They asked the facility in January 2024 if the follow up dental, cardiology and neurology appointments had been scheduled. They were informed it had not been done and Resident #17's guardian stated they scheduled an appointment in February 2024 for the follow up with cardiology, and they brought the resident to the appointment. During the appointment, the cardiologist stated the residents heart rate was very low at 30 and the resident needed to be admitted for further review. The resident was brought to the hospital by the representative and was admitted and a pacemaker was placed to regulate the heart rate. 2) Resident #19 was admitted and had diagnoses including but not limited to Acute and Chronic Respiratory Failure, Dependence on Respirator and Dementia. Review of a Significant Change Minimum Data Set, dated dated dated [DATE] documented the resident is rarely/never understood and was severely cognitively impaired for daily decision making. No behaviors noted. The family was involved in care discussions about resident preferences. The resident was on oxygen and suctioning, tracheostomy care and invasive mechanical ventilation. Review of a progress note dated 10/24/2022 at 8:36AM documented on 10/05/2022 revealed that Resident #19 was placed on a ventilator and the tracheostomy collar was discontinued. Review of a progress note dated 10/19/2022 documented Resident #19 was tolerating ventilator settings, and no acute respiratory distress was noted. Review of a pulmonary consult note dated 10/19/2022 documented Resident #19 was very short of breath a few days ago and was attached to the ventilator on assist/control mode, and now they are comfortable. Review of a Minimum Data Set progress note dated 10/20/2022 at 6:19AM documented the nurse in charge reported that Resident #19 is now on a ventilator. Order for vent 10/19/2022, interdisciplinary team made aware. There was no documented evidence that Resident #19's family was made aware of the need to be placed on a ventilator for oxygenation assist/control for respirations. Resident #19's family stated they found the resident on a ventilator and no longer using a tracheostomy collar when they visited the resident. During a telephone interview on 09/17/2024 at 9:34 AM, Resident #19's daughter stated Resident #19 was on a breathing tube to assist them with their breathing and once Resident #19 was changed to 100% ventilator assistance, the facility did not inform them, they came to the facility and found Resident #19 on the ventilator. During an interview on 09/17/2024 at 11:50 AM, the Director of Social Services stated they spoke with the resident's daughter numerous times but it's the physician's or the nurse who should have had informed the family of the change in the resident's condition. 3) Resident #20 had diagnoses but not limited to Contusion and Laceration of Cerebrum, Nontraumatic Intracerebral Hemorrhage and Acute Respiratory Failure with Hypoxia. A 5-day Minimum Data Set, dated dated dated [DATE] documented the resident was rarely/never understood and was severely cognitively impaired with daily decision making. The resident had a feeding tube and was receiving oxygen, suctioning, tracheostomy care and IV medication. Review of an impaired cognition care plan initiated 07/27/2023 documented related to non-traumatic intracerebral hemorrhage disease process Resident #20, would maintain their current function. Interventions listed included ask yes/no questions to determine their needs and communicate with the resident or family representative regarding the residents' capabilities. Review of an alteration in respiratory system care plan initiated 07/27/2023 documented Resident #20 had a tracheostomy and would be free of respiratory distress and receive adequate oxygenation through the review period. Interventions listed included administer nebulizer treatments and medications as per the physician's order and educate on interventions to improve gas exchange. Review of a progress note dated 07/29/2023 documented Resident #20 was having a period of respiratory distress during the shift with fluctuating oxygen saturations. The Nurse Practitioner was informed and ordered labs, antibiotics, and a chest x-ray. Review of a respiratory therapist note dated 07/30/2023 at 7:55AM documented Resident #20 vomited on 7/29/2023 around 8:30 PM and their oxygen saturation level was 75%. The resident was bagged with 100% oxygen. After 10 minutes, Resident #20 was placed back on the tracheostomy collar and oxygen saturation still fluctuated in the 80's. Physician made aware, and physician's assistant ordered to place Resident #20 on the ventilator if the oxygen saturation remains below 90%. Review of Nurse progress note dated 7/30/2023 at 5:44PM documented per physician's order, Resident #20 was transferred to the hospital for further evaluation. There was no documented evidence of Resident #20's family being informed of the resident's change in status/condition with vomiting and decreased oxygen saturation on 7/29/2023. During an interview on 09/17/2024 at 3:10 PM, the Director of Nursing stated family notification should be done right away when there is a change in a resident's status or condition. The Director of Nursing stated the physician should be made aware and a progress note should be written to document the notifications. This incident occurred before their tenure. The Director of Nursing stated now they will also schedule a meeting with the family to discuss the changes in condition in person to address issues in real time. 10 NYCRR 415.3(f)(2)(ii)(b)

Based on record reviews and interviews during an abbreviated survey (NY00339693, NY00341303, NY00343390, NY00333515,) the facility did not ensure resident's right to be free from misappropriation of resident property. This was evident for 3 out of 3 residents (Resident #14, #16, #17) reviewed for personal property. Specifically, Resident #14's advocate stated the resident's glasses went missing during one of their hospitalization s and they have not been returned yet. 2) Resident #16's cell phone was not returned to the family after they expired in the facility on [DATE]. Resident #16's family stated the cell phone was being used by someone in the facility after they expired, and they have since had the service turned off. 3)Resident #17's guardian stated the resident's wallet was missing after their admission to the facility. They discovered a charge from the facility on the debit card shortly after their admission to the facility. There was no documented grievances or investigations, or local enforcement referrals initiated into all concerns regarding residents' properties above. Findings include: The facility Personal Property policy dated ,d+[DATE] and last revised [DATE] documented residents are permitted to retain and use personal possession as space and safety regulations may allow. The facility will inventory the residents' personal possessions upon admission. The facility will keep resident's property securely stored for 30 days while the resident is in the hospital or if they are discharged . If the resident has not returned to the facility after 30 days, the facility will contact the resident's representative to make arrangements for the resident's property to be picked up. If a resident is discharged the facility will securely store their property for 30 days, during which time attempts will be made to contact the resident/representative to arrange for their property to be picked up. The facility will promptly investigate any complaints of misappropriation or mistreatment of resident property. 1) Resident #14 was admitted with diagnosis including but not limited to Multiple Sclerosis, Acute Kidney Failure and Acute and Subacute Endocarditis. A Significant Change Minimum Data Set, dated dated dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of ,d+[DATE], associated with severe cognition impairment (,d+[DATE] severe impairment, ,d+[DATE] moderate impairment and ,d+[DATE] cognitively intact). No behaviors noted. The resident required a wheelchair for locomotion, supervision for eating and bed mobility and maximal assistance for toileting and transfers. The resident had a foley catheter and was frequently incontinent of bowels. Review of Resident #14's admission progress note dated [DATE] revealed the resident was admitted wearing glasses, there was no documented description of the glasses. Review of inventory binder at the receptionist desk on [DATE], revealed no inventory form for Resident #14. During a telephone interview on [DATE] at 2:10 PM, Resident #14's advocate stated during one of the resident's hospitalization s their glasses went missing, and they have not been returned yet. Resident #14's advocate stated when the resident returned from the hospital there were glasses on the windowsill, which did not belong to the resident. The facility gave those glasses to the resident, and they are not sure who those glasses belong to because they do not belong to Resident #14. During an interview on [DATE] at 11:40 AM, the Director of Social Work stated they handle the grievances, and they must be completed within 5 days. The Director of Social Services stated the actions that they take are documented on the grievance forms. and they follow up with the resident and the family regarding the outcomes of the grievances. During a follow up interview on [DATE] at 12:14 PM, the Director of Social Services stated they do not have any investigations on file for Resident #14 regarding their glasses. The Director of Social Services stated the receptionist or the nurse on the unit are responsible for the inventory for the residents' personal belongings and if something was to go missing then social work would be involved and investigate. The Director of Social Work stated the inventory list would either be in the resident's chart or uploaded in the miscellaneous section of point click care. The Director of Social Work stated they do not have any investigations on file for Resident #14 regarding missing glasses. During an interview on [DATE] at 12:05 PM, the Receptionist stated when residents are admitted to the facility, and they have personal belongings they are given a clothing inventory checklist to fill out. The Receptionist stated after the form is completed, they are told to take a picture of the form and a copy of the form goes into the clothing inventory book kept at the front desk and the other copy goes down to the laundry department with the clothing. The form has blank areas to add other items besides clothing, and the forms are all kept at the front desk by the receptionist. The Receptionist stated this is the only place the forms would be located. The Receptionist stated if a resident stated their property was missing the first thing they would do is inform the Director of Housekeeping. 2) Resident #16 was admitted with diagnosis including but not limited to Cirrhosis of Liver, Type 2 Diabetes Mellitus and Fracture of Left Femur. Review of a 5-day Minimum Data Set, dated dated dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS score of 15 associated with intact cognition and required supervision for eating and dependent for toileting and transfers. The resident expired in the facility on [DATE]. Review of inventory binder at the receptionist desk on [DATE], revealed no inventory form for Resident #16. During a telephone interview on [DATE] at 12:30 PM, Resident #16's family representative stated after Resident #16 passed someone in the facility was using the residents cell phone. To date, the cell phone is still in use and the facility had not returned it. Resident #16's representative stated they have now had the cell phone service turned off. When the resident passed the phone was being used for a while. During a telephone interview on [DATE] at 12:46 PM, Resident #16's daughter stated someone stole the residents cell phone in the facility and they were using it after the resident passed away. Resident #16's daughter stated the only thing of value the resident had was their cell phone and they tried to reach out to the facility about the cell phone and never got a return call. During an interview on [DATE] at 11:20 AM, the Director of Social Services stated they were never informed about Resident #16's cellphone being missing and there was no investigation on file regarding the cell phone. During an interview on [DATE] at 1:45 PM, the Director of Social Services stated they are not sure if Resident #16 had a cellular phone with them in the facility and that the resident was in the facility for a short time. The Director of Social Services stated they would look into it and reach out to Resident #16's family about the cell phone. 3) Resident #17 was admitted with diagnoses including but not limited to Vascular Dementia, Atherosclerotic Heart Disease and Bradycardia. A Comprehensive Minimum Data Set, dated dated dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS score of 7 indicating severe cognitive impairment. The resident required supervision for eating and bed mobility and maximum assist for toileting. Resident #17's guardian stated Resident #17's wallet was missing, and they found fraudulent charges on Resident #17's debit card shortly after being admitted in the facility, and that there was a charge from the facility on the debit card after their admission to the facility. Review of the inventory binder at the receptionist desk on [DATE], revealed inventory form for clothing which did not include Resident #17's wallet. During an interview on [DATE] at 11:20 AM, the Director of Social Services stated they were never informed about Resident #17's wallet being missing and there were no grievances or investigations on file regarding the wallet. During an interview on [DATE] at 3:10 PM, the Director of Nursing stated they have developed and will be implementing a new inventory log sheet for the residents' personal possessions and that the form will be completed by the nurse during the resident's admission. The Director of Nursing stated the form will be signed by the resident or family and the nurse will have them filed in the resident's chart once completed. The Director of Nursing stated the new form will itemize all belongings as soon as the resident enters the facility, with a detailed description of the items. During a telephone interview on [DATE] at 9:25 AM, the Administrator stated they are involved in all grievances, and they are responsible to sign off on them. The Administrator stated they were never made aware of Resident #17's wallet missing, or any fraudulent charges being made on the resident's debit card from the facility. The Administrator stated they believe a friend got involved with Resident #17 and was requesting reimbursement for somethings at the facility, but it was a fishy case. The Administrator stated they are always cautious when a friend gets involved because they have to look out for the best interest of their residents. The Administrator stated if something like this was brought to their attention, then this would be misappropriation of funds and would be reported and they would have taken it seriously. The Administrator stated if this was something that occurred, they would have remembered, but they do no recall this incident. The Administrator stated they do not recall Resident #16's cell phone being reported missing, and they do not recall speaking with the residents' daughter at any time. 10 NYCRR 415.4(b)

Based on record reviews and interviews during an abbreviated survey (NY00343390, NY00339693, NY00345193, NY00341303, NY00331035, NY00325315) the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice for 6 out of 7 residents (Residents #1, #14, #15, #16, #19, #21) reviewed for quality of care. Specifically, (1) Resident #1's certified nurse assistant accountability documentation revealed that in a 2-month period, there were no signatures for bladder/incontinence care being provided on 9 occasions; (2) On 090/06/2024 Resident #14 was observed lying in bed with a catheter draining leg bag in place Review of Resident #15's certified nurse assistant accountability record revealed that in a 3-month period there were no signatures for bladder/bowel incontinence care being provided on 25 occasions; (4) Resident #16's certified nurse assistant accountability report for April 2024 revealed on 5 occasions there was no signature indicating bladder/bowel incontinence care was rendered. (5) Review of Resident #19's certified nurse assistant accountability report for October 2022 revealed no signatures, indicating task completed for the application of heel booties on 3 occasions and turning and positioning on 2 occasions. Review of Resident #19's certified nurse assistant accountability report revealed in a 2-month period there were no signatures for the application of heel booties on 7 occasions and turning and positioning on 6 occasions (6) Resident #21's certified nurse accountability report revealed that in a 2-month period the following tasks were not signed off as completed: bowel/bladder continence, toileting, and skin observation on 7 occasions. Findings include: The facility Activities of Daily Living Care and Support policy dated 08/2016 and last revised 03/13/2024 documented the facility shall provide residents with Activities of Daily Living care and support in accordance with current standards of practice, State and Federal regulations and are based on the resident's assessed needs, personal preference, and goals. Activities of Daily Living care and support will be provided for residents who are unable to carry out Activities of Daily Living independently, with the consent of the resident and in accordance with the resident's assessed needs, personal preferences, and individualized plan of care, that includes but is not limited to supervision and assistance with hygiene and elimination. Nail care should be provided as needed for the resident and may require a licensed nurse to perform if certain medical conditions are present. Toileting/Perineal care/Incontinence care will be provided with care and as needed. 1) Resident #1 was admitted with diagnoses including but not limited to Sickle Cell Disease with Crisis, Chronic Obstructive Pulmonary Disease and Chronic Pain Syndrome. An Admission Minimum Data Set, dated dated dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS used to determine attention, orientation, and ability to recall information) score of 15/15, associated with intact cognition). The resident required supervision for eating, dependent for toileting, bed mobility and transfers. Review of a bladder incontinence care plan dated 05/21/2024 documented interventions listed as apply incontinence devices as identified as appropriate for resident, monitor for signs and symptoms of urinary tract infection, bladder/bowel incontinence. Review of a bowel incontinence care plan dated 06/04/2024 documented the resident had bowel incontinence. The goal was the resident would not have any skin breakdown due to incontinence. Interventions listed included check and provided incontinence care every 2-4 hours as tolerated and toilet every 2-4 hours as tolerated during waking hours and assist with toileting as needed. Review of a grievance form dated 06/12/2024 documented Resident #1 was interviewed by Registered Nurse Manager #1 and complained that Certified Nurse Assistant #1 was not providing them with activities of daily living care in a timely manner. Certified Nurse Assistant #1 was in-serviced on customer service and activities of daily living time. Review of Resident #1's certified nurse assistant accountability record for May of 2024 revealed there was no documented evidence of Resident #1 receiving bladder/bowel incontinence care on 3 occasions . Review of the certified nurse aide accountability record for June of 2024 revealed there was no documented evidence of Resident #1 receiving bladder/bowel incontinence care on 9 occasions. During an interview on 09/06/2024 at 4:00 PM, Certified Nurse Assistant #2 stated they were the only certified nurse assistant on Resident #1's unit the night of 06/09/2024, so it was a little harder to get the residents cares done. Certified Nurse Assistant #2 stated when there is one certified nurse assistant it is rough with 36 residents. Certified Nurse Assistant #2 stated they tried their best to do what they could that night, because it is hard to take care of 36 people , and they got to the resident when they could. During an interview on 9/13/2024 at 11:33 AM, Registered Nurse Unit Manager #1 stated they did an in-service with Certified Nurse Assistant #2 because Resident #1 complained that they were not changing them timely. Registered Nurse Unit Manager #1 stated the issue was regarding customer service, and that Resident #1 had complained, and the social worker had written a grievance, because Certified Nurse Assistant #2 was not changing their adult diaper or their sheets on time. 2) Resident #14 was admitted with diagnosis including but not limited to Multiple Sclerosis, Acute Kidney Failure and Acute and Subacute Endocarditis. A Significant Change Minimum Data Set, dated dated dated [DATE] documented the resident had a Brief Interview for Mental Status score of 6/15 associated with severe cognitive impairment. The resident required maximal assistance for toileting and transfers. The resident had a foley catheter and was frequently incontinent of bowels. A Quarterly Minimum Data Set, dated dated dated [DATE] documented the resident had a Brief Interview for Mental Status score of 9/15 associated with moderate cognitive impairment. The resident required moderate assistance for toileting and bed mobility and maximal assistance for transfers. The resident had a foley catheter and was frequently incontinent of bowel. Review of an Indwelling Foley Catheter for obstructive uropathy care plan initiated 03/11/2024 and last revised 07/30/2024 documented the resident will show no signs and symptoms of urinary tract infection and will remain free from catheter related trauma through the review date. Interventions listed included catheter/perineal care, change catheter as ordered, ensure catheter tubing is anchored to prevent pulling, maintain privacy bag, maintain urine collection bag below the level of the bladder, monitor and document output as per facility policy, monitor/document for pain/discomfort due to catheter, monitor/record/report to physician any signs and symptoms of urinary tract infection, Urology consult as ordered and voiding trail as ordered. During an interview on 09/06/2024 at 10:44 AM, Licensed Practical Nurse #1 stated Resident #14 has a leg bag in place. Licensed Practical Nurse #1 stated Resident #14 is going to be taken out of bed for therapy that is why they have a leg bag on in bed. Resident #14 was observed lying in bed with the leg bag in place in bed in their gown on 09/06/2024 at 10:40AM. During an interview on 09/09/2024 at 1:25 PM, Nurse Practitioner #1 stated as soon as they try to take Resident #14's urinary catheter out, the resident cannot urinate. Nurse Practitioner #1 stated Resident #14 is not mentally able to state they cannot urinate and when they are assessed they are found with a distended abdomen. Nurse Practitioner #1 stated they had to change the resident's urinary catheter the other day because it was not draining and clogged with sediment. Nurse Practitioner #1 stated they do not normally check the status of the urinary catheter to see if it is draining, but the nurses on the unit had not checked it and Resident #14 had started showing signs of an impending infection. Nurse Practitioner #1 stated Resident #14 is followed by Urology and that the resident will drink fluids if they are provided to them. During an interview on 09/09/2024 at 1:30 PM, the Registered Nurse Unit Manager #1 stated the certified nurse assistants empty the Foley catheters and change the bag from a drainage bag to a leg bag when the resident is out of bed. Registered Nurse Unit Manager #1 stated when a resident is going to or coming from therapy, they are always supposed to have a leg bag in place and that the staff are good with changing the bag. 3) Resident #15 was admitted with diagnoses including but not limited to Chronic Respiratory Failure, Chronic Obstructive Pulmonary Disease with Acute Exacerbation and Anxiety Disorder. A Comprehensive Minimum Data Set date 05/28/2024 documented the resident had a Brief Interview for Mental Status score of 15/15, associated with intact cognition. The resident required moderate assistance for toileting and bed mobility and dependent for transfers. A Significant Change Minimum Data Set, dated dated dated [DATE] documented the resident had a Brief Interview for Mental Status score of 14/15, associated with intact cognition. The resident required moderate assistance with toileting, bed mobility and transfers. Review of a bladder incontinence care plan dated 05/23/2024 documented Resident #15 would remain free from skin breakdown related to incontinence and brief use. Interventions listed included apply incontinence devices as identified appropriate for the resident, monitor for signs and symptoms of urinary tract infection and monitor/document/report to physician as needed any changes in incontinence. Review of an impaired gastrointestinal function care plan initiated 6/4/2024 documented related to constipation Resident #15 will have regular bowel movements throughout the review date. Interventions listed included administer medications as ordered by the physician, evaluate bowel status with any change in behavior or mental status. During an interview on 9/10/2024 at 4:30 PM, Resident #15 stated they ring their call bell and no one comes in, the staff ignore the call bell and are not attentive to the residents, taking their time to change them. Resident #15 stated they are made to sit in their wet/soiled diaper until the staff are ready to put them back to bed. Resident #15 stated they are afraid to have a bowel movement, because when they ring the call bell no one comes, and they do not want to sit in feces all night. Resident #15 stated it is so bad that they have to get enemas from holding their stool for so long and that they got a urinary tract infection from sitting in their dirty diaper. Resident #15 stated the staff change their diaper for the last time at 6 PM and then they do not get changed again until 5 AM. Review of Resident #15's certified nurse assistant accountability record revealed bladder/bowel incontinence was not signed as being completed as follows: June 2024- 8 occasions, July 24- 7 occasions and in August 24-7 occasions. During an interview on 9/16/2024 at 12:04 PM, Nurse Practitioner #1 stated Resident #15 is monitored well during the day shift, but they may have an issue with having their diaper changed during the evening and night shifts. 4) Resident #16 was admitted with diagnoses including but not limited to Cirrhosis of Liver, Type 2 Diabetes Mellitus and Fracture of Left Femur. Review of a 5-day Minimum Data Set, dated dated dated [DATE] documented the resident had a Brief Interview for Mental Status score of 15 associated with intact cognition. No behaviors noted. The resident required supervision for eating and was dependent for toileting and transfers and moderate assistance for bed mobility. Review of a self-care and mobility care plan initiated 4/18/2024 documented the goal was Resident #16's status will improve through the review date. Interventions listed included encourage to participate to the fullest extent possible with each interaction, monitor for changes in status and notify interdisciplinary team as needed, lying to sitting on side of bed dependent with 2 or more staff assistance, toilet transfer with 2 person assist and mechanical lift and bed mobility with substantial assist of 2 staff. During a telephone interview on 9/12/2024 at 12:30 PM Resident #16's family representative stated Resident #16 would lay for hours ringing their call bell, to be changed and no one would come and help them. Resident #16's family representative stated Resident #16 was a clean person and they kept themselves clean and at the facility they just put diapers on the resident and leave them. Resident #16's family representative stated Resident #16 did not like the feeling of being wet and they had wounds that were painful from sitting in wetness. During a telephone interview on 9/12/2024 at 12:46 PM, the Resident #16's daughter stated Resident #16 was unable to get out of bed and sat in soiled diaper for 3 hours. Review of Resident #16's certified nurse assistant accountability report for April 2024 revealed on 5 occasions there was no signature indicating that bladder/bowel incontinence care was rendered. 5) Resident #19 was admitted with diagnoses including but not limited to Acute and Chronic Respiratory Failure, Dependence on Respirator and Dementia. Review of Resident #19's certified nurse assistant accountability report for November 2022 revealed no signatures, indicating task completed for the application of heel booties on 4 occasions and turning and positioning on 4 occasions. Review of an alteration in skin integrity care plan initiated 1/9/2023 documented an actual pressure ulcer to the posterior head. The goal was Resident #19's wound would show improvement appropriately through the review period. Interventions listed included assess wound weekly and document measurements and appearance, monitor dressing daily to ensure clean, dry and intact, monitor wound daily for signs and symptoms of infection and wound care consult as needed. Review of an alteration in skin integrity care plan initiated 1/10/2023 documented an actual pressure ulcer to the left elbow stage 4. The goal was Resident #19's wound would show improvement appropriately through the review period. Interventions listed included assess wound weekly and document measurements and appearance, monitor dressing daily to ensure clean, dry and intact, monitor wound daily for signs and symptoms of infection and wound care consult as needed. Review of an alteration in skin integrity care plan initiated 1/26/2023 documented an actual pressure ulcer right heel blister 2x2.5 cm. The goal was Resident #19's wound would show improvement appropriately through the review period. Interventions listed included monitor dressing daily to ensure clean, dry and intact, and monitor wound daily for signs and symptoms of infection. Review of an alteration in skin integrity care plan initiated 1/26/2023 documented an actual pressure ulcer to the left lateral foot 4x2.5 cm. The goal was Resident #19's wound would show improvement appropriately through the review period. Interventions listed included monitor dressing daily to ensure clean, dry and intact, and monitor wound daily for signs and symptoms of infection. Review of an alteration in skin integrity care plan initiated 1/26/2023 documented an actual pressure ulcer to the left inner heel 2.5x 3 cm. The goal was Resident #19's wound would show improvement appropriately through the review period. Interventions listed included monitor dressing daily to ensure clean, dry and intact, and monitor wound daily for signs and symptoms of infection. Review of Resident #19's's certified nurse accountability report for January 2023 revealed no signature for heel booties, pillows for positioning and turning and positioning on 4 occasions and was not consisitently signed offf. During a telephone interview on 9/17/2024 at 9:34 AM Resident #19's daughter stated Resident #19 was not being turned and positioned while in the facility and had large wounds because of this. Resident #19's daughter stated Resident #19's equipment such as the feeding tube and the tracheostomy were dirty, as well as the heel booties, which were not placed properly. 6) Resident #21 was admitted with diagnoses including but not limited to Unspecified Cord Compression, Peripheral Vascular Disease and Muscle Weakness. A Quarterly Minimum Data Set, dated dated dated [DATE] documented the resident had a BIMS score of 9 with no behaviors noted. The resident required extensive assistance with bed mobility and toileting by 2 people, totally dependent for transfers and supervision for eating. Review of a bladder incontinence care plan initiated 8/23/2023 documented related to Type 2 Diabetes Mellitus the goal was Resident #21 would maintain incontinence through the waking hours through the review date. Interventions listed included apply incontinence devices as identified as appropriate for resident, monitor for signs and symptoms of urinary tract infection, monitor/document/report as need to physician any changes in incontinence. Review of a bowel incontinence care plan initiated 8/26/2023 related to medication side effects documented Resident #21's incontinence would be managed in a timely manner through the review period. Interventions listed included bowel retraining program, check resident every 2 hours and assist with toileting as needed, provide peri-care after each incontinence episode. Review of an activities of daily living care plan initiated 8/26/2023 documented the goal was Resident #21's activities of daily living status would improve, and they would maintain the current status through review date. Interventions listed included encourage to participate to the fullest extent possible with each interaction, encourage to use call bell for assistance. Review of Resident #21's certified nurse accountability report for September 2023 revealed tasks were not signed as completed for the following activities: bowel/bladder continence, toileting, and skin observation on 6 occasions. Review of Resident #21's certified nurse accountability report for October 2023 revealed tasks were not signed as completed for the following activities: bowel/bladder continence, toileting, and skin observation on 1 occasion. During an interview on 9/6/2024 at 11:00 AM, Registered Nurse Unit Manager #1 stated on the certified nurse assistant accountability sheet reflects each task a resident is to be provided and that states if a task is scheduled for every shift, then each box should have a signature in the box. Registered Nurse Unit Manager #1 stated if there is no signature in a box, then it means the task was not done. During an interview on 9/16/2024 at 1:12 PM Licensed Practical Nurse Unit Manager #1 stated in the certified nurse assistant accountability record if a task is scheduled for every shift, then there should be a entry at least one time per shift that the task was completed. Licensed Practical Nurse Unit Manager #1 stated this documentation is monitored via the dashboard, and if everything is completed then it will appear green. During an interview on 9/17/2024 at 3:10 PM the Director of Nursing stated the call bell response is an issue, staff were not responding in a timely manner. The Director of Nursing stated they are addressing leadership styles and ensuring hand off is effective and incorporating teamwork. The Director of Nursing stated the residents were complaining of not being changed in a timely manner and their call bell response has not been in a timely manner. The Director of Nursing stated the staff have been in serviced on incontinence care and call bell response. Stated they have checked all the call bells to ensure they are working appropriately. The Director of Nursing stated they are also making off hour rounds to ensure the residents are cared for properly. 10 NYCRR 415.12

Based on record review and interviews during an abbreviated survey (NY00343390, NY00345193, NY00341303, NY00339693, NY00333515, NY00331035, NY00327139, NY00321114, NY00325315), the facility did not ensure residents were free from significant medication errors. This was evident for 13 (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13) out of 19 residents reviewed for medication administration. Specifically, the Residents on the Center 2 Unit did not receive their scheduled medications on 06/09/2024 during the 7:30 AM to 3:30 PM shift. There was no evidence in the Medication Administration record that the scheduled physician prescribed medications were administered to the residents and no notification to the physician the medications were missed or not administered. Findings include: The Facility Medication Administration policy dated 09/2015 and last revised 08/2019 documented Licensed Nurses must ensure that prior to the end of their shift all medications administered/refused/held etc., are properly documented on the Medication Administration Record. Failure to do so is considered an omission in the medical record. When the medication pass is complete, the nurse is to recheck the Medication Administration records to make sure all medications have been administered and documented appropriately. The Nurse will follow up and document appropriately on medications that were administered but not documented. The facility will utilize the Clinical Dashboard electronic medication administration record completion report during daily clinical meeting for review of potential omissions of documentation. Nursing Management will follow up with the nurse within 24 hours to correct documentation if applicable. 1) Resident #1 had diagnoses including but not limited to Sickle Cell Disease with Crisis, Chronic Obstructive Pulmonary Disease and Chronic Pain Syndrome. The Physician's order dated 6/4/2024 documented Hydrocodone-Acetaminophen 5-325 milligram tablet give 1 tablet by mouth every 6 hours for pain. Review of Resident #1's medication administration record for June 2024 revealed no documented evidence of the pain medication being administered on 06/09/2024 or signed out as administered on the narcotic log sheet for Resident #1's scheduled 12:00 PM dose. 2) Resident #2 had diagnoses including but not limited to Chronic Obstructive Pulmonary Disease, Major Depressive Disorder and Anxiety Disorder. The Physician's order dated 4/21/2024 documented Buspirone HCL 5 mg- 1 tablet by mouth 3 times daily for anxiety. Review of Resident #2's medication administration record for June 2024 revealed the 9 AM and 1 PM doses were not signed as administered on 06/09/2024. 3) Resident #3 had diagnoses including but not limited to Type 2 Diabetes Mellitus, Embolism and Thrombosis of Arteries of the Lower Extremities and Cerebral Infarction. The Physician's order dated 6/5/2024 documented Ceftriaxone 2 gm intravenously daily for 26 days for infection. Review of Resident #3's medication administration record for June 2024 revealed dose omissions on 06/09/2024. The Physician's order dated 6/5/2024 documented Gabapentin 100 mg capsule give 1 capsule by mouth 3 times daily for pain. Review of Resident #3's medication administration record for June 2024 revealed the medication was not signed out as administered 9 AM or 12 PM on 6/9/2024. The Physician's order dated 6/5/2024 documented Levetiracetam 500 mg 1 tablet by mouth 2 times daily for seizures. Review of Resident #3's medication administration record for June 2024 revealed the medication was not signed out as administered at 9 AM on 6/9/2024. The Physician's order dated 6/7/2024 documented Lovenox injection solution 120mg/0.8 ml inject 0.8 ml subcutaneously daily for cerebral vascular accident and atrial fibrillation. Review of Resident #3's medication administration record for June 2024 revealed the medication was not signed out as administered at 9 AM on 6/9/2024. The Physician's order dated 6/5/2024 documented Humalog Kwikpen subcutaneous solution 100U/ml inject as per sliding scale. Review of Resident #3's medication administration record for June 2024 revealed no documented evidence of the resident's blood sugar being logged or insulin signed out as being administered at 8 AM and 12 PM on 6/9/2024. 4) Resident #4 had diagnoses including but not limited to Dementia, Schizophrenia and Anxiety disorder. The Physician's order dated 5/2/2024 documented Lamotrigine 200 mg 1 tab let by mouth 2 times a day for seizures. Review of Resident #4's medication administration record for June 2024 revealed the medication was not signed out as administered on 6/9/2024 at 9 AM. The Physician's order dated 6/5/2024 documented Tramadol 100 mg 1 tab let by mouth every 12 hours for pain. Review of Resident #4's medication administration record for June 2024 revealed the medication was not signed out as administered at 9 AM on 6/9/2024 or signed out as administered on the narcotic log sheet for Resident #4's scheduled 12:00 PM dose. The Physician's order dated 5/2/2024 documented Enoxaparin Sodium 40mg/0.4 ml inject 40 mg subcutaneously every 12 hours to prevent blood clots. Review of Resident #4's medication administration record for June 2024 revealed the medication was not signed out as administered at 9 AM on 6/9/2024. 5) Resident #5 had diagnoses including but not limited to Metabolic Encephalopathy, Type 2 Diabetes Mellitus and Parkinson's disease. The Physician's order dated 6/4/2024 documented Humalog injection solution 100U/ml inject as per sliding scale. Review of Resident #5's medication administration record for June 2024 revealed no documented evidence of the resident's blood sugar being logged or insulin signed out as being administered at 8 AM and 12 PM on 6/9/2024. The Physician's order dated 6/4/2024 documented Carbidopa-Levodopa 25-100 tablet 1 via gastrostomy tube 4 times daily for Parkinson's. Review of Resident #5's medication administration record for June 2024 revealed the medication was not signed out as administered at 9 AM and 1 PM on 6/9/2024. 6) Resident #6 had diagnoses including but not limited to Myasthenia Gravis, Secondary Parkinsonism and Spinal Stenosis. The Physician's order dated 4/17/2024 documented Carbidopa-Levodopa 25-100 tablet 1 tablet by mouth 3 times daily for Parkinson's Disease. Review of Resident #6's medication administration record for June 2024 revealed the medication was not signed out as administered at 10 AM and 2 PM on 6/9/2024. The Physician's order dated 4/17/2024 documented Gabapentin 600 mg 1 tablet by mouth every 8 hours for back pain. Review of Resident #6's medication administration record for June 2024 revealed the medication was not signed out as administered at 2 PM on 6/9/2024. 7) Resident #7 had diagnoses including but not limited to Fracture of Right Femur, Pain in Leg and Low Back Pain. The Physician's order dated 6/6/2024 documented Oxycodone-Acetaminophen 5-325 mg 1 tablet by mouth every 12 hours for pain. Review of Resident #7's medication administration record for June 2024 revealed the medication was not signed out as administered at 9 AM on 6/9/2024 or signed out as administered on the narcotic log sheet for Resident #7's scheduled 9 AM dose. 8) Resident #8 had diagnoses including but not limited to Displaced Subtrochanteric Fracture of Left Femur, Type 2 Diabetes Mellitus and Venous Insufficiency. The Physician's order dated 2/23/2024 documented Eliquis 5 mg 1 tablet 2 times daily for deep vein thrombosis. Review of Resident #8's medication administration record for June 2024 revealed the medication was not signed out as administered at 9 AM on 6/9/2024. 9) Resident #9 had diagnoses including but not limited to Fracture of Unspecified Part of Neck of Left Femur, Primary Hypertension and Schizophrenia. The Physician's order dated 5/20/2024 documented Eliquis 5 mg 1 tablet 2 times daily for deep vein thrombosis. Review of Resident #9's medication administration record for June 2024 revealed the medication was not signed out as administered at 9 AM on 6/9/2024. 10)Resident #10 had diagnoses including but not limited to Convulsions, Fracture of Unspecified Part of Neck of Left Femur and Severe Intellectual Disabilities. The Physician's order dated 4/11/2024 documented Carbamazepine ER 12 Hour 400 mg 1 tablet by mouth 2 times daily for Seizures. Review of Resident #10's medication administration record for June 2024 revealed the medication was not signed out as administered at 9 AM on 6/9/2024. The Physician's order dated 4/11/2024 documented Gabapentin 300 mg 1 capsule by mouth 2 times a day for pain. Review of Resident #10's medication administration record for June 2024 revealed the medication was not signed out as administered at 9 AM on 6/9/2024. The Physician's order dated 4/11/2024 documented Methocarbamol 750 mg 1 tablet by mouth 3 times a day for pain. Review of Resident #10's medication administration record for June 2024 revealed the medication was not signed out as administered at 9 AM or 1 PM on 6/9/2024. 11)Resident #11 had diagnoses including but not limited to Muscle Weakness, Other Cervical Disc Degeneration and Opioid Abuse. The Physician's order dated 3/6/2024 documented Gabapentin 300 mg 1 capsule by mouth every 8 hours for neuropathy. Review of Resident #11's medication administration record for June 2024 revealed the medication was not signed out as administered at 2 PM on 6/9/2024. 12)Resident #12 had diagnoses including but not limited to Unspecified Intellectual Disabilities, Hydrocephalus and Anxiety Disorder. The Physician's order dated 5/8/2024 documented Clonazepam 0.5 mg 1 tablet by mouth every morning and at bedtime for anxiety. Review of Resident #12's medication administration record for June 2024 revealed the medication was not signed out as administered at 9 AM on 6/9/2024 or signed out as administered on the narcotic log sheet for Resident #12's scheduled 9 AM dose. 13) Resident #13 had diagnoses including but not limited to Intervertebral Disc Disorders with Radiculopathy, Low Back Pain and Spinal Stenosis. The Physician's order dated 9/17/2022 documented Gabapentin 300 mg 2 capsules by mouth 3 times a day for pain. Review of Resident #13's medication administration record for June 2024 revealed the medication was not signed out as administered at 9 AM or 1 PM on 6/9/2024. Review of the daily staffing sheet for 6/9/2024 revealed Licensed Practical Nurse #1 was a no show for the 7 AM- 3 PM shift and was scheduled to work on the Center 2 unit. Licensed Practical Nurse #1 was noted on the staffing schedule as working the 3PM-11PM shift on 6/9/2024. During an interview on 9/6/2024 at 12:00 PM the Nurse Practitioner stated they were never called and informed that Resident #1 never received any of their daytime medication, including their narcotic on 6/9/2024. The Nurse Practitioner stated that the nurses in the facility have been better with informing them about refused or missed medications in general, but they were not informed about the missed doses on 6/9/2024. During an interview on 9/5/2024 at 12:32 PM Licensed Practical Nurse #1 stated they do not recall Resident #1 or working with the resident on 6/9/2024. Licensed Practical Nurse #1 stated that a blank spot on the medication administration record would indicate that the medication was not given. If a narcotic is not administered, they would have to let the physician and the supervisor know. Licensed Practical Nurse #1 stated they would also document that the medication was not given in the medication administration record and in a progress note. During an interview on 9/9/2024 at 1:30 PM the Registered Nurse Unit Manager #1 stated they do not remember an alert that 19 residents on their unit, Center 2, did not get their medications on 6/9/2024.The Registered Nurse Unit Manager #1 Stated when they came in on Monday, 6/10/2024, they were not going to sign for any missed medication, but they did not alert the administration either. During a telephone interview on 9/20/2024 at 2:52 PM the Medical Director stated they were not informed on 6/9/2024 that 19 residents did not receive their medications. The Medical Director Stated they are in the facility on the weekends, and they know that the facility is short staffed. The Medical Director Stated they the nurses will let them know if they are not able to give all medications. The Medical Director stated some medications being missed is not a big deal and no harm is done. It is not best practice, but there is no harm. The Medical Director stated if any medications are missed and they are informed, they will tell the nurse to ensure the residents receives all medications they need. The Medical Director stated they are aware of residents missing some medications at times or delay in administration but best practice is to make sure all residents get their medications timely. The medical director stated there are times when they have been informed that the facility did not have a nurse to administer medications as scheduled, and when a nurse arrives the residents would receive their medications. They were not aware of missed medications for 19 residents on 6/9/2024. During a telephone interview on 9/24/2024 at 12:41 PM the Registered Nurse Supervisor stated they do not recall there being no nurse working on Center 2 unit on 6/9/2024. The Registered Nurse supervisor stated if a nurse did not show up, They would call other staff until they find someone to work. The Registered Nurse Supervisor stated they would also pull another nurse, from another unit to cover the floor that had missing staff. The Registered Nurse supervisor stated they have access to the dashboard which shows if residents did not receive their medications and if the dashboard showed residents had not received their medications, then they would talk to the nurse that was on duty to see why they did not document giving the medication. Registered Nurse supervisor stated they do not recall any of the residents on Center 2 unit missing their medications on 6/9/2024 and if there was no nurse for the unit, then they would give the medications to the resident themself. 10 NYCRR 415.12(m)(2)

Based on record review and interviews during an abbreviated survey (NY00341303) the facility did not ensure that services being provided meet professional standards of quality in clinical practice for 1 out of 16 residents (Resident #16) reviewed for medication administration. Specifically, Resident #16 was noted to have an elevated Prothrombin time (which measures the time it takes for liquid portion of blood to clot) and INR (International Normalizing Ratio (a blood test that measures how long it takes the blood to clot) PT/INR of 71XXX,d+[DATE].4(seconds) on [DATE] with a reference range of (PT-9XXX,d+[DATE].7/INR-0XXX,d+[DATE].1) indicating the blood is taking longer than normal to clot. Resident #16 was ordered to receive 10mg Vitamin K (vitamin needed for blood clotting) to be administered intramuscularly by the physician on [DATE] at 4:47PM. The Vitamin K was not readily available in the facility. Staff did not notify the physician that the Vitamin K was not available. Resident #16's Vitamin K was not administered until 12:58 AM on [DATE]. Resident #1 was found unresponsive in their bed and pronounced dead at 6:50AM on [DATE]. Findings include: The facility Anticoagulation therapy policy dated ,d+[DATE] and last revised ,d+[DATE] documented all residents requiring anticoagulation therapy will have labs drawn as ordered by the physician to determine effectiveness of therapy and subsequent dosages. Clinical staff will monitor Residents as needed for safety of medication therapy. The physician will order appropriate lab testing to monitor anticoagulant therapy and potential complications. The physician will help review the progress of individuals who are being anticoagulated, monitor for potential complications and manage related problems. Resident #16 was admitted with diagnoses including but not limited to Cirrhosis of Liver, Type 2 Diabetes Mellitus and Fracture of Left Femur. Review of a 5-day Minimum Data Set, dated dated dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of ,d+[DATE], associated with intact cognition. No behaviors noted. Ambulated with a walker previously with lower extremity impairment on one side. The resident required supervision for eating, dependent for toileting and transfers and moderate assistance for bed mobility. Review of a risk for bleeding care plan initiated [DATE] documented Resident #16 is at risk for bleeding secondary to Non Steroidal Anti-Inflamatory Drugss/anticoagulant use/status post Deep Vein Thrombosis. The goal was Resident #16 would be free of signs and symptoms of abnormal bleeding through the review date. Interventions listed included handle the resident gently during activities of daily living care and support the extremities under joints during movement, monitor for abnormal signs of bleeding. Review of a Nurse Practitioner #1's progress note dated [DATE] at 4:25PM documented Resident #16's labs were reviewed, and the Prothrombin Time was 71.6/INR was 7.4. Warfarin discontinued and will give Vitamin K 10 mg IM x 1.Will repeat bloodwork in the morning. Resident #16 is stable no signs of bleeding, will start Eliquis to prevent frequent needlesticks. Review of a nurse's progress note dated [DATE] at 11:06PM documented PT/INR abnormal and warfarin on hold. Waiting for Vitamin K to be administered, monitored for bleeding. There was no documented evidence of the Physician being made aware of Vitamin K intramuscular injection not being readily on hand. Review of the pharmacy delivery log dated [DATE] revealed the Vitamin K injection (Phytonadione) 10mg/ml was delivered and signed for on [DATE] at 12:38 AM. Review of a nurse's progress note dated [DATE] at 2:55AM documented Vitamin K 10 mg injected subcutaneously one time only for elevated PT/INR, no adverse reaction noted. Review of the Medication Administration record revealed the Vitamin K was administered at 12:58AM on [DATE]. During an interview on [DATE] at 12:04 PM, Nurse Practitioner #1 stated they were on their way out the building when they were informed about Resident #16's lab results. They ordered for Resident #16 to receive Vitamin K intramuscularly now, and the nurse was supposed to give the Vitamin K to the resident stat, but no one called them and told them the facility did not have it available in the automated dispensing machine system. Nurse Practitioner #1 stated they would have ordered an oral dose if they knew the intramuscular dose was not available. Nurse Practitioner #1 stated they do not believe Resident #16 received the dose of Vitamin K in timely. They were informed in the morning that the resident had expired. Nurse Practitioner #1 stated asked the staff if the resident got the Vitamin K and they stated there was none in the automated dispensing machine, and they asked why they were not notified. Nurse Practitioner #1 stated if they have been informed, they would have sent the resident to the hsopital. They have now resolved to send residents to the hospital. Nurse Practitioner #1 stated the evening and the night shifts do not monitor the residents or communicate about them the way they should. During an interview on [DATE] at 4:06 PM, Licensed Practical Nurse #10 stated they have been working in the facility for 1 year and they remember the resident from Unit 2 west the last time they met them. Licensed Practical Nurse #10 stated the order for Vitamin K arrived/was received in the middle of the night between 12AM and 2AM. The medication was administered to Resident #16, and they did not have any signs of bleeding or adverse effects after the administration. During an interview on [DATE] at 3:10 PM the Director of Nursing stated if staff is given an order for a medication and the medication is not on hand, the nurse is expected to check the automated dispensing machine to see if the medication is available and if the medication is not in the automated dispensing machine, then the nurse needs to call the pharmacy for delivery and notify the Physician to see if there is an alternative medication that can be given. During a telephone interview on [DATE] at 2:52 PM, the Medical Director stated the Vitamin K should have been given when ordered as it is not a routine medication. The Medical Director stated if the resident is not actively bleeding or having any symptoms then an oral dose could be given. The oral dose takes longer to be digested hence the choice to order the medication for intramuscular administration or subcutaneous. The Medical Director stated residents could die with an INR of 3 but that Resident #16 had a history of cirrhosis, and they always had a high INR and no bleeding. The Medical Director stated they do not feel that the delay in treatment caused the resident to expire. The Medical Director stated the INR is usually checked once a week and if the Vitamin K was given right away, and the lab was not drawn within a certain time, there is no way to tell if the medication would have reversed the levels or not. 10 NYCRR 415.11(c)(3)(i)

Based on record review, and interviews conducted during an abbreviated survey (NY00339051), the facility did not ensure residents right to be free from abuse for 2 of 4 residents reviewed for abuse. Specifically, on 4/12/2024, Resident #3 was transferred to a different unit due to verbal aggression with their roommate. The receiving unit was not notified of the incident of verbal aggression with their roommate which prompted the transfer. Resident #3 punched Resident #4 in the face and was transferred to the hospital and was admitted for psychosis. Findings include: The facility policy, 'Abuse' revised 12/2022 documented the facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation of resident/patient property by anyone including but not limited to staff, family, friends and residents of the facility. The facility prohibits any exploitation of the mentally and physically disabled resident in the facility. The facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation of property. Resident #3 had diagnoses including but not limited to schizophrenia, hypertension, and hyperlipidemia. The Quarterly Minimum Data Set (resident assessment tool) dated 2/8/2024 documented that the resident had intact cognition. The assessment documented Resident #3 required supervision with eating, transfers, ambulation in room and corridor. The Behavior Symptoms care plan dated 2/8/2024 documented behavior symptoms such as restlessness, paranoia, delusions, noncompliance with their medication regimen. Interventions included to administer psychoactive medications as ordered, determine cause of the behavior, and maintain resident's safety. The Psychoactive Medications related to Schizophrenia care plan dated 12/12/2023 documented interventions which included to administer medications as ordered by physician, monitor/record/report refusal to eat and behavior symptoms not usual to the person, monitor/record occurrence of target behavior symptoms and document per facility protocol. The Psychiatry Consult dated 1/11/2024 documented recommendation given Resident #3 history of schizophrenia per chart review and Resident #3s' report of previous psychotic symptoms keep medications as prescribed, no gradual dose reduction indicated at this time. The Psychiatry Consult dated 1/18/2024 documented gradual dose reduction not indicated at this time. The Physician's orders included Haldol 2 mg, 1 tab twice a day for schizophrenia, and Invega Sustenna Intramuscular 156 mg every 30 days for schizophrenia, The April 2024 Medication Administration Record was blank on 4/11/2024 for all prescribed medications on the day shift, and no reason was documented. There was no nurse's note on 4/11/2024 documenting Resident #3 refusals to take any medications on the day shift, or that the medical provider was notified. The April 2024 Medication Administration Record documented on 4/11/2024 at 5 PM, under comment that Resident #3 refused Haldol and all other medications on the evening shift and there was no nurse's note documenting that the provider was notified of Resident #s's refusal or his behavioral symptoms. There was no Physician's Note in Resident #3's medical record related to Resident #3's behavioral symptoms on 4/11/2024 and 4/12/2024, or Resident #3's refusal of medication on 4/11/2024. The Nurse's Note dated 4/11/2024 at 11:43PM written by Licensed Practical Nurse (Staff #20), documented Resident #3 was alert with confusion, refused all medications this evening and his meal and claimed that staff are trying to poison him. Resident #3 put their snack in the garbage. Resident #3 continues to refuse care despite encouragement. The Nurse's Note dated 4/12/2024 at 10:32 AM written by Registered Nurse Unit Manager (Staff #10), documented that at 7:45 am staff overheard Resident #3 and roommate in a verbal altercation in their room and Resident #3 stating, F you I will kill you. On assessment Resident #3 stated I was talking to myself because they are trying to give me poison, I curse them. Resident #3 was provided emotional support and transferred to another unit. The Nurse's Note dated 4/12/2024 at 11:57 AM written by Registered Nurse Unit Manager (Staff #10), documented Resident #3 displayed verbal outbursts, refusal of care, hallucinations / delusions, refused food and medications, resident stated they are trying to poison me. Resident #3 was able to be redirected with some effect and received food and medications. Haldol 2 mg was last administered 4/12/2024 at 9:23 AM. Non-Pharmacological Interventions: Resident was redirected to less stimulating environment. Result of intervention: better. The Nurse's Note dated 4/12/2024 at 9:49 PM written by Licensed Practical Nurse (Staff #9), documented Resident #3 was observed verbally and physically abusive to roommate. Non-Pharmacological Interventions- verbal redirection. Result of intervention: unchanged. The Nurse's Note 4/12/2024 at 11:11 PM written by Registered Nurse Supervisor (Staff #22) documented Resident #3 physically assaulted new roommate. Incident was witnessed by Licensed Practical Nurse, who intervened and removed the roommate from the room. Resident #3 was highly agitated, cursing at unit nurse and nurse supervisor. Resident #4 had diagnoses including but not limited to hemiplegia & hemiparesis affecting left side, aphasia, severe depression with psychotic features, dementia with behavioral disturbance, psychosis. Resident #4 Quarterly Minimum Data Set (resident assessment tool) dated 1/22/2024 documented moderately impaired cognition. The resident had delusions, no verbal or physical behavioral symptoms, and wandering behavior 1-3 days. The resident had impairments to upper & lower extremities on one side. The assessment documented the resident required supervision with eating & bed mobility, moderate assistance with bathing & dressing & hygiene & transfers. The 'At risk for Potential Abuse' care plan initiated 05/05/2016 included interventions to provide support and ensure the resident is free from abuse. The 'Impaired Cognitive Function' care plan dated 1/22/2024 documented long term memory loss. Interventions included administer medications as ordered, ask yes/no questions to determine needs, encourage simple activities, consistent routine, monitor/document/report any changes in cognitive function. The 'Self-Care and Mobility' care plan dated 1/10/2024 documented limited mobility, limited range of motion, stroke. Interventions included to encourage resident to participate to the fullest extent possible The Accident &Incident report for Resident #4 dated 4/12/2024 at 9:20 PM documented a Resident-to-Resident Altercation with roommate. The nurse witnessed Resident #3 punching Resident #4 in the mouth, immediately intervened and pulled Resident #4 out of the room. Prior to the incident, they had observed Resident #4 sitting in the hallway. Resident #4 was observed with bruise to right mouth and small internal gum laceration from contact with teeth s/p hit from roommate. Resident immediately separated from his assailant and safety ensured with change in room and assessment. First aid was provided. Resident without any further injuries. Resident assessed by Social Services 4/15/24 with no evidence of anguish 2/2 incident. New York State Department of Health notified of incident due to resident-to-resident status. On 5/21/2024 at 4:21 PM during an interview, Licensed Practical Nurse (Staff #20), stated they worked the evening shift on 4/11/2024. Staff #20 stated they did not notify the medical provider that Resident #3 refused all medications and refused their meal and claimed that staff were trying to poison them, and put their snack in the garbage, and refused care despite encouragement. Staff #20 stated that when they came to work on 4/11/2024, they were informed by the day nurse that Resident #3 refused their medications on the day shift. Resident #3 continued to refuse medications throughout the evening shift. Staff #20 stated that when a resident refuses medication and has unusual behaviors, they are to call the medical provider and make the supervisor aware. Staff #20 stated they did not do so. On 5/21/2024 at 4:43 PM during an interview, the Director of Nursing stated that when a resident refuses medication, the nurse should document the refusal in the Medication Administration Record, notify the medical provider, and write a note. On 5/21/2024 at 5:10 PM during an interview, Registered Nurse Supervisor (Staff #23) who worked on 4/11/2024 on the evening shift stated the unit nurse did not report any concerns with Resident #3 regarding medication refusals or behavioral symptoms. Staff #23 stated they would have notified the medical provider if any concerns had been reported. During an interview on 5/21/2024 at 6:35 PM, the primary physician stated they were not made aware of Resident #3 behavioral symptoms and medication refusals on 4/11/2024. The physician stated they should have had been notified. During an interview on 5/21/2024 at 6:54 PM and at 7:04 PM, the Nurse Practitioner stated they were not made aware of Resident #3 medication refusals and behaviors on 4/11/2024 or on 4/12/2024. The Nurse Practitioner stated they were in the building all day on 4/11/2024 and 4/12/2024 and they would have assessed Resident #3 and documented the assessment if they had been made aware. During an interview on 5/22/2024 at 8:42 AM, Registered Nurse Unit Manager (Staff #10), stated they worked on 4/12/2024 on the Center 2 unit on the day shift. Staff #10 stated they were not made aware that Resident #3 had refused medications on 4/11/2024 or that Resident #3 had stated to the nurse that they thought they are being poisoned, and therefore they did not notify the Nurse Practitioner on duty. During an interview on 5/22/2024 at 8:36 AM, Licensed Practical Nurse (Staff #9) stated they worked on 4/12/2024 on the unit on the evening shift and witnessed the altercation between Resident #3 and their previous roommate. Staff #9 stated they were not given report as to the reason why Resident #3 was transferred to the new unit, they were not made aware of the verbal altercation between Resident #3 and their previous roommate, and they were not made aware that Resident #3 had refused medications the day before and had told staff they thought they were being poisoned. During an interview on 5/24/2024 at 2:44 PM, Licensed Practical Nurse (Staff #24), they stated they worked on the evening shift on 4/12/202024, on the unit Resident #3 was transferred to. They stated they do not remember receiving report as to why Resident #3 was transferred to that unit. During an interview on 5/24/2024 at 2:56 PM with certified nurse aide (Staff #16), they stated they were assigned to Resident #3 on the day and evening shifts on 4/12/2024 on the new unit. They stated they did not receive report as to the reason why Resident #3 was transferred to the unit. They stated they were not informed that Resident #3 had a verbal altercation with their previous roommate or that Resident #3 thought the food was poisoned. During a follow-up interview On 5/29/2024 at 10:59 AM, Registered Nurse Unit Manager (Staff #10) stated they gave a verbal report to the receiving unit nurse when Resident #3 was transferred. Staff #10 stated that the nurse who was responsible for medicating Resident #3 should have brought Resident #3 medications to the receiving unit and give report. During an interview on 5/29/2024 at 1:18 PM, Registered Nurse (Staff #21) stated they worked on the receiving unit on 4/12/2024 on the day shift, but Staff #25 (Licensed Practical Nurse) did not bring Resident #3 medications to the receiving unit. Staff #21 also stated they did not get report as to the reason that Resident #3 was transferred to receiving unit. 10NYRCC 415.4(b)(1)(i)

Based on record review, and interviews conducted during the abbreviated surveys (NY00339051), the facility did not ensure that appropriate behavioral care was provided to address the problem of refusals and delusions for 1 of 4 residents (Resident #3) reviewed for the use of psychoactive medications. Specifically, Resident #3 refused their antipsychotic medication Haldol as ordered by the medical provider at 9 AM and 5 PM on 4/11/24, refused to eat, and stated they thought they were being poisoned, and the medical provider was not notified. The following day, Resident #3 punched their roommate in the face, Resident #3 was transferred to the hospital, and was admitted for psychosis. Findings include: The Facility Policy titled Psychotropic Medication revised 7/2019 documented that the facility supports the goal of determining the underlying cause of behavioral symptoms so the appropriate treatment of environmental, medical and /or behavioral interventions as well as psychopharmacological medications can be utilized to meet needs of the individual resident. The Policy and Procedure Medication Administration revised 12/2019 documented, medications must be administered in accordance with the orders, including any required timeframe. Resident #3 had diagnoses including but not limited to schizophrenia, hypertension, and hyperlipidemia. The Quarterly Minimum Data Set (resident assessment tool) dated 2/8/2024 documented intact cognition. The assessment documented the resident required supervision with eating, transfers, ambulation in room and corridor. The Behavior Symptoms care plan dated 2/8/2024 documented behavior symptoms such as restlessness, paranoia, delusions, noncompliance with his medication regimen. Interventions included to administer psychoactive medications as ordered, determine cause of the behavior, and maintain resident's safety. The Psychoactive Medications related to Schizophrenia care plan dated 12/12/2023 documented interventions which included to administer medications as ordered by physician, monitor/record/report refusal to eat and behavior symptoms not usual to the person, monitor/record occurrence of target behavior symptoms and document per facility protocol. The Psychiatry Consult dated 1/11/2024 documented recommendation given Resident #3 history of schizophrenia per chart review and Resident#3 report of previous psychotic symptoms keep medications as prescribed, no gradual dose reduction indicated at this time. The Psychiatry Consult dated 1/18/2024 documented recommendation gradual dose reduction not indicated at this time. The Physician's orders included Haldol 2 mg, 1 tab twice a day for schizophrenia and Invega Sustenna Intramuscular 156 mg every 30 days for schizophrenia. The April 2024 Medication Administration Record was blank on 4/11/2024 for all prescribed medications on the day shift, and no reason was documented. There was no consistent documented evidence regarding Resident #3 refusals to take any medications on 4/11/2024 or that the medical provider was notified. The April 2024 Medication Administration Record documented on 4/11/2024 at 5 PM, comment 2, Resident #3 refused Haldol. The Medication Administration Record documented on 4/11/2024 documented Resident #3 refused all other medications on the evening shift. The Nurse's Note written by Licensed Practical nurse(Staff #20) dated 4/11/2024 at 11:43PM did not include documentation that the medical provider was made aware of Resident #3's medication refusals or of the Resident's behavioral symptoms. The Nurse's Note documented that the Resident is alert with confusion, refused all medications and their meal this evening and claimed that staff are trying to poison them. They put their snack in the garbage and continues to refuse care despite encouragement. Resident #3 medical record did not document Physician's Notes related to Resident #3 behavioral symptoms on 4/11/2024 and 4/12/2024, or Resident #3 medication refusals on 4/11/2024. The Resident's medical record did not document Physician's notes related to the Resident's behavioral symptoms on 4/11/2024 and 4/12/2024, or the Resident's medication refusals on 4/11/2024. The Nurse's Note dated 4/12/2024 at 10:32 AM documented by Staff #10, (Registered Nurse Unit Manager), documented at 7:45 am staff overheard Resident #3 and roommate on Center 2 unit in room [ROOM NUMBER] in a verbal altercation stating, F you I will kill you. On assessment Resident #3 stated I was talking to myself because they are trying to give me poison, I curse them. Resident was provided emotional support and transferred to a different unit (room [ROOM NUMBER]). The Nurse's Note dated 4/12/2024 at 11:57 AM documented by Staff #10 (Registered Nurse Unit Manager), documented Resident #3 displayed verbal outbursts, refusal of care, hallucinations / delusions. Pharmacological interventions: Haldol 2 mg last administered 4/12/2024 at 9:23 AM. Non-Pharmacological Interventions: Resident was redirected to less stimulating environment. Result of intervention: better. Notification Physician. Resident had a verbal altercation with roommate, transferred to another unit. The Nurse's Note dated 4/12/2024 at 9:49 PM documented by Staff #9 (Licensed Practical Nurse), documented Resident #3 was observed verbally and physically abusive to roommate. Non-Pharmacological Interventions: verbal redirection. Result of intervention: unchanged. The Nurse's Note 4/12/2024 at 11:11 PM documented by Staff #22 (Registered Nurse Supervisor), documented Resident #3 physically assaulted roommate, witnessed by Licensed Practical Nurse, who intervened and removed roommate from the room. Resident #3 was highly agitated, cursing at unit nurse and nurse supervisor. During an interview on 5/21/2024 at 4:21 PM, Staff #20 (Licensed Practical Nurse), stated they worked on the Center 2 unit on 4/11/2024 on the evening shift. Staff #20 stated they did not notify the medical provider that Resident #3 refused all medications and refused their meal and claimed that staff were trying to poison them and put their snack in the garbage and refused care despite encouragement. Staff #20 stated that when they came to work on 4/11/2024, they were made aware by the day nurse that Resident #3 refused their medications on the day shift. Staff #20 stated it was unusual for Resident #3 to refuse medications from them and they thought Resident #3 would take their medications but stated Resident #3 continued to refuse throughout the evening shift. Staff #20 stated that when a resident refuses medication and has unusual behaviors, they should call the medical provider and make the supervisor aware. Staff #20 stated they did not do so. During an interview on 5/21/2024 at 4:43 PM, the Director of Nursing stated that when a resident refuses medication, the nurse should document the refusal in the Medication Administration Record, notify the medical provider, and write a note. During an interview on 5/21/2024 at 5:10 PM, Staff #23 (Registered Nurse Supervisor) who worked on 4/11/2024 on the evening shift stated the unit nurse did not report any concerns with Resident #3 regarding medication refusals or behavioral symptoms. Staff #23 stated they would have notified the medical provider if any concerns had been reported. During an interview on 5/21/2024 at 6:35 PM, the primary physician stated they were not aware of Resident #3 behavioral symptoms and medication refusals on 4/11/2024. The physician stated if they should have had been notified. During an interview on 5/21/2024 at 6:54 PM and at 7:04 PM, the Nurse Practitioner stated they were not made aware of Resident #3 medication refusals and behaviors on 4/11/2024 or on 4/12/2024. The Nurse Practitioner stated they were in the building all day on 4/11/2024 and 4/12/2024 and they would have assessed Resident #3 and documented the assessment if they had been made aware. During an interview on 5/22/2024 at 8:42 AM, Staff #10 (Registered Nurse Unit Manager), stated they worked on 4/12/2024 on the Center 2 unit on the day shift. Staff #10 stated they were not made aware that Resident #3 had refused medications on 4/11/2024 or that Resident #3 had stated to the nurse that they thought they are being poisoned, and therefore they did not notify the Nurse Practitioner on duty. During an interview on 5/22/2024 at 9:53 AM, Staff #21 (Registered Nurse) stated they worked 4/11/2024 on the Center 2 unit on the day shift. Staff #21 stated that Resident #3 refused their medications on the day shift. Staff #21 stated they forgot to sign the Medication Administration Record to document the refusals, and they did not notify the physician or the nurse supervisor. Staff #21 stated they should have notified the physician and the supervisor of the refusals. Staff #21 stated they gave verbal report to the evening nurse about the medication refusals. 10 NYCRR 415.12

Based on record review and interviews during the abbreviated survey (NY00339051), the facility did not ensure that a resident was free of significant medication errors for 1 of 4 residents (Resident #3) reviewed. Specifically, on 4/11/2024 Resident #3 refused their significant medications that included antipsychotic medication, anticoagulant, cardiovascular, and steroid/bronchodilator. There was no consistent documentation on the Medication Administration Record of the refusal and that the medical provider was notified of the missed medications. Consequently, on 4/12/2024, Resident #3 punched their roommate in the face and was transferred and admitted to the hospital with admitting diagnosis of psychosis. The findings are: The facility policy, 'Medication Administration' revised 12/2019 documented medications must be administered in accordance with the orders, including any required timeframe. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall document as such in designated format (hard copy or electronic) space provided for that drug and dose. Resident #3 had diagnoses including but not limited to schizophrenia, hypertension, and hyperlipidemia. The Quarterly Minimum Data Set (resident assessment tool) dated 2/8/2024 documented that Resident # 3 had intact cognition. The assessment documented the resident required supervision with eating, transfers, and ambulation in room and corridor. Resident #3's active Physician's Orders included Haldol 2 mg (antipsychotic medication), 1 tab twice a day for schizophrenia; Invega Sustenna Intramuscular 156 mg every 30 days for schizophrenia; Eliquis 5 mg, 1 tab twice a day for Deep Vein Thrombosis prophylaxis; Sodium Chloride Tab 1 gm, 1 tab twice daily for hyponatremia; Advair Discus 250-50 mcg, 1 inhalation every 12 hours for Chronic Obstructive Pulmonary Disorder and Metoprolol Tartrate 25 mg, 1 tab twice a day for Hypertension. The Physician's note dated 4/7/2024 documented a review of medications and to continue Metoprolol for hypertension, Advair for Chronic Obstructive Pulmonary Disorder, Eliquis for Deep Vein Thrombosis prophylaxis, and Haldol and Invega for schizophrenia. The April 2024 Medication Administration Record on 4/11/2024 on the day shift did not document evidence that any medications were administered, and no reason was documented Registered Nurse (Staff #21) was assigned to administer medications to Resident #3 on 4/11/2024 on the day shift. There was no documented evidence during the day shift on 4/11/2024 pertaining to Resident #3' refusal of their medications and/or that the medical provider was notified. The April 2024 Medication Administration Record on 4/11/2024 at 5 PM documented under comment that Resident #3 refused all medications which included Haldol 2 mg for schizophrenia, Eliquis 5 mg for Deep Vein Thrombosis prophylaxis, Sodium Chloride Tab 1 gm for hyponatremia, Advair Discus for Chronic Obstructive Pulmonary Disorder, Metoprolol Tartrate 25 mg for Hypertension. The Nurse's Note dated 4/11/2024 at 11:43PM written by Staff #20 (Licensed Practical Nurse) documented that Resident #3 was alert with confusion, refused all medications this evening and their meal and claimed that staff are trying to poison them. Resident #3 put their snack in the garbage. Resident #3 continues to refuse care despite encouragement. The Nurse's Note dated 4/11/2024 at 11:43PM did not document evidence that the medical provider was made aware of Resident #3 medication refusals and behavioral symptoms. Review of Resident #3 medical record did not reveal evidence of Physician's Notes related to Resident #3's medication refusals/behaviors on 4/11/2024. During an interview on 5/21/2024 at 4:21 PM, Staff #20 (Licensed Practical Nurse), stated they worked on the Center 2 unit on 4/11/2024 on the evening shift. Staff #20 stated they did not notify the medical provider that Resident #3 refused all medications and refused their meal and claimed that staff were trying to poison them, that Resident #3 put their snack in the garbage and refused care despite encouragement. Staff #20 stated that when they came to work on 4/11/2024, they were made aware by the day nurse that Resident #3 refused their medications on the day shift. Staff #20 stated it was unusual for Resident #3 to refuse medications from them and they thought Resident #3 would take their medications but Resident #3 continued to refuse their medications throughout the evening shift. Staff #20 stated that when a resident refuses medication and has unusual behaviors, they are expected to call the medical provider and make the supervisor aware. Staff #20 stated they did not do that. During an interview on 5/21/2024 at 4:43 PM, the Director of Nursing stated that when a resident refuses medication, the nurse should document the refusal in the Medication Administration Record, notify the medical provider, and write a note. During an interview on 5/21/2024 at 5:10 PM, Staff #23 (Registered Nurse Supervisor) who worked on 4/11/2024 on the evening shift stated the Center 2-unit nurse did not report any concerns with Resident #3 regarding medication refusals or behavioral symptoms. Staff #23 stated they would have notified the medical provider if any concerns had been reported. During an interview on 5/21/2024 at 6:35 PM, the primary physician stated they were not aware of Resident #3 behavioral symptoms and medication refusals on 4/11/24. The physician stated if they should have had been notified. During an interview on 5/21/2024 at 6:54 PM and at 7:04 PM, the Nurse Practitioner stated they were not made aware of Resident #3's medication refusals and behaviors on 4/11/2024 or on 4/12/24. The Nurse Practitioner stated they were in the building all day on 4/11/2024 and 4/12/2024 and they would have assessed Resident #3 and documented the assessment if they had been made aware. During an interview on 5/22/2024 at 8:42 AM, Staff #10 (Registered Nurse Unit Manager), stated they worked on 4/12/2024 on the Center 2 unit on the day shift. Staff #10 stated they were not made aware that Resident #3 had refused medications on 4/11/2024 or that Resident #3 had stated to the nurse that they thought they are being poisoned, and therefore they did not notify the Nurse Practitioner on duty. During an interview on 5/22/2024 at 9:53 AM, Staff #21 (Registered Nurse) stated they worked 4/11/2024 on the Center 2 unit. Staff #21 stated that Resident #3 refused their medications on 4/11/2024 on the day shift. Staff #21 stated they forgot to sign the Medication Administration Record to document the refusals, and they did not notify the physician or the nurse supervisor. Staff #21 stated they should have notified the physician and the supervisor of the refusals. Staff #21 stated they gave verbal report to the evening nurse on 4/11/2024 about the medication refusals. 10NYRCC 415.12(m)(2)

Based on record review and interviews conducted during an abbreviated survey (NY00312813), the facility did not ensure grievances were resolved in a timely manner. This was evident for 1 of 3 resident (Resident # 3) reviewed for grievances/complaints. Specifically, there was no documented evidence that a thorough investigation was completed after Resident #1 and family representative reported missing clothing's. The findings are: The facility Policy and Procedure titled Investigation of Grievance/concerns dated 3/2016, reviewed on 1/18/2023 documented that the facility residents and representatives may submit a grievance orally, in writing and anonymously. The Director of Social Work is the facility's Grievance Officer and is responsible for facilitating the complaint/grievance process, and the corresponding department will investigate the allegation(s) and submit a written report of such findings within 7 business days. Resident # 3 was admitted with diagnoses including but not limited to Urinary tract infection, benign neoplasm of the meninges (brain), and seizures. The Admission Minimum Data Set (MDS, an assessment tool) dated 1/30/2023 documented the resident was cognitively intact and able to make self-understood and understands others. Review of the Social Services Progress Note from 02/01/2023 to 03/31/2023 revealed no documented evidence pertaining to Resident #3 grievance and missing property complaint. During a record review of the clothing inventory log for Resident #3, the property inventory log form dated 2/2/2023 revealed a documentation the residents clothing not logged. During an interview on 4/26/2024 at 2:33 pm, Staff # 1 (certified nurse assistant) stated that resident clothing need to be labeled, goes to the receptionist then it goes to housekeeping. During an interview on 04/30/2024 at 11:04 am, Social Worker # 2 stated they were not aware of missing property, and if a resident or family member is complaining about missing property, they ask them if they want to file a grievance. The family member was in contact with the administrator, and the administrator never told them to complete a grievance form. Social worker #2 stated they are the grievance officer, and any grievance form is returned to them to contact the family with the results within 7 days. All grievances are kept in one binder in the director of social services office; if the form was not initiated, filed or in the binder, no grievance was filed. During an interview on 4/30/2024 at 3:10 pm, the Front Desk Receptionist stated they have been working at the facility for 6 months and when someone brings items in, they give them a form to complete, the yellow copy goes in a bag and kept behind the desk for housekeeping and the white copy is placed in a binder at the front desk. They stated there is a form for Resident # 3 dated 2/2/2023 but clothing not logged was written in marker that is not timed or indicate the person who wrote the information. During an interview on 05/9/2024 at 10:46 am, the Administrator stated the social worker completes a missing property form and missing items are investigated when residents have missing property issues. If they are aware of the missing property themselves then they would ask the social worker to write up a grievance. If a grievance was not documented, then they are not sure why. During an interview on 5/9/2024 at 11:04 am, the Director of Housekeeping and Laundry stated that clothing is logged in on a (triplicate) form at the front desk by the family member and the front desk staff. One copy is placed in the clothing bag; the second copy is given to the family; and the third is placed in a binder at the front desk. There must have been a complaint by Resident # 1 or the family of missing property because the process is that when there is a complaint, they check the laundry and the clothing inventory log form in the binder at the front desk. If there is no form, they write on a new clothing inventory log form clothing not logged. At that point, the social worker would be told by them; however, they do not recall the incident. 10 NYCRR 483.10(j)(2)

Based on observation, record review and interview conducted during an abbreviated survey (Case # NY00289197) completed on 1/14/2022, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 10 residents reviewed. Specifically, Resident #1 was admitted to the facility on [DATE] with diagnoses of Dementia, Anxiety, Psychosis, and Depression and assessed as high risk for elopement, exited the facility unnoticed by staff on 1/5/22 and has not been located to date by the facility and the police department. Resident #1 was assessed for elopement risk on admission and had a score of 17 which indicated resident was high risk for elopement. The Registered Nurse (RN) who completed the assessment documented (on the assessment) the resident was a low risk for elopement. There was no corroborating documentation as to the RN's rationale for lowering the resident's elopement risk. Per directions on the assessment, if a resident is assessed as a high risk, the elopement protocol should be implemented. The Elopement Protocol documented, if a resident was deemed high risk, a wander guard bracelet should be applied, placement of the bracelet should be verified and documented each shift, and the resident should be monitored. The Nursing Assessment evaluation completed on admission documented under history that Resident #31 had made 1+ elopement attempts and had a history of wandering. This resulted in immediate jeopardy with risk for more than minimal harm to resident #1 and the likelihood of risk for more than minimal harm to 18 resident's health and safety. The findings are: The facility policy and procedure for Elopement initiated 7/2014 and updated 2/2021 documented that an elopement risk evaluation must be completed by the nursing staff on all residents upon admission, readmission, quarterly, and change in condition. The initial resident assessment is to be completed on admission using the facility approved risk evaluation scoring tool. If the total score on the elopement risk evaluation tool is 10 or greater, the resident should be considered at risk for elopement and prevention protocols should be followed and documented in the care plan. Interventions for residents at risk for elopement include initiating wander guard bracelet, checking for placement and functionality daily and every shift and document on Medication Administration Record (MAR). Residents' activities should be monitored and recorded in the sign out book located on all units. Resident #1 was admitted to the facility on [DATE] with diagnoses including Dementia, Major Depression, Anxiety Disorder, and Psychosis. The Admission Minimum Data Set (MDS; a resident assessment tool) dated 10/19/2021 documented Resident # 1 had severe impaired cognition, and required supervision in bed mobility, personal hygiene, dressing, and limited assistance in transfer, eating, toilet use and walking on and off the unit. The MDS also documented the resident used a walker as a mobility device. Review of the Facility Investigation Form dated 1/5/2022 revealed Resident #1 was admitted to the facility on [DATE] and was assessed by the former RNUM #1 on admission for elopement risk evaluation with a score of 17. An order was placed to monitor the resident for wandering on and off the unit every shift and document the number of episodes. The investigation documented that on 1/5/2021, around 6:05PM, a CNA #1 placed Resident #1's dinner tray in the resident's room. The CNA returned around 6:15PM to pick up the tray and noticed Resident #1 was not in the room and the meal tray was untouched. A thorough search was conducted, and code for missing resident was activated. The facility Administrator, Director of Nursing (DON), and the neighboring Police department were notified, and continued the search including surrounding areas. All attempts by the facility and the Police department to locate the resident has been ineffective to date. The resident remained unfound. The resident was last seen on 1/5/2022 at 5:30PM by a Licensed Practical Nurse (LPN #1) in the facility walking towards another unit. A Hospital and Community Patient Review Instrument (HC-PRI)/Discharge Summary dated 10/12/2021 documented the resident was recommended for placement for wandering and confusion related to dementia with psychosis. The resident would need a wander guard/locked unit. Resident #1's Admission Elopement Evaluation dated 10/12/2021 documented the resident was alert and oriented to person, place, and time, fully ambulatory, and had a history of one + elopement attempts. The resident scored a 17 on the admission elopement risk evaluation, which indicated the resident was a high risk for elopement. The former RNUM #1 who completed the assessment categorized Resident #1 as a low risk for elopement. There was no documentation or rationale for lowering the resident's elopement risk. The directions on the assessment documented that elopement prevention protocol should be initiated for a score of 10 or greater. Risk for elopement and prevention protocols were not initiated. Wander guard bracelet was not put in place. Comprehensive Care Plan (CCP) for Elopement initiated 10/12/2021 documented Resident #1 was at risk for elopement due to wandering behavior. Goals included to maintain resident's safety through the next review date 1/17/2022. Interventions included for staff to identify wandering behaviors and triggers and document and initiate psychiatric evaluation as needed. There was no documentation for the use of a wander guard bracelet on the CCP. Nursing Admission/Readmission Evaluation dated 10/12/2021 indicated the resident was oriented to person and place, had a history of wandering and fully ambulatory. Physician Orders dated 10/12/2021 and updated 1/5/2022 documented to monitor/identify pattern of targeted behaviors every shift and record the number of episodes interventions were needed. The Certified Nursing Aide (CNA) Task List for 1/2022 included instructions for the use of a rolling walker to bathroom with supervision, and to monitor Resident #1's behavior symptoms every shift as needed. During an interview with the Administrator on 1/10/2022 at 11:53 AM, s/he stated that Resident #1 was assessed for elopement on admission and scored high, but they determined the resident was not at risk for elopement. The resident was not on a lock unit, did not have any exit seeking behavior, and did not have a wander guard in place. The resident remained on his/her unit, except when he/she went to the vending machine. The video monitor was reviewed with the Administrator but did not reveal the incident. During an interview with the Director of Nursing (DON) on 1/10/2022 at 12:40PM, s/he stated that they received a call from the RN supervisor on 1/5/2022 that Resident #1 could not be located. They conducted a unit search and then a code grey for missing person was called. The DON stated s/he was notified that about 6:05PM, CNA #1 brought the resident's dinner tray to their room, and Resident #1 was not in his/her room. At 6:15PM when the CNA #1 returned to Resident #1's room to pick up the tray, the food was untouched, and the resident was still not in the room. The CNA alerted a Licensed Practical Nurse (LPN #1) who notified the supervisor. They continued with the search and the Police were called. The DON stated that Resident #1 was assessed for elopement on admission and scored 17 which indicated high risk, but the former RNUM #1 determined the resident was not at risk for elopement. The resident was last seen by LPN #1 at 5:30 PM. The DON stated that residents who are at risk for elopement, have their pictures posted on every unit at the nurses' station, the reception area on the first floor, and in every facility department. The DON did not provide any evidence that Resident #1's picture was posted in these areas, or that the resident had a wander guard in place. During an interview with the Corporate DON on 1/10/2022 at 1:05PM, s/he stated that the facility elopement policy documented that if the resident was at risk, preventative measures should be in place. S/he stated that the resident scored high for the elopement risk evaluation at 17, but the RN who did the assessment did not determine the resident at risk for elopement. During an interview on 1/10/2022 at 4:23PM with CNA #1, s/he stated that s/he was assigned to Resident #1 on 1/5/2022 which was the first-time taking care of the resident. CNA#1 stated that at the beginning of the shift, s/he only took a glimpse at Resident #1 in their room. At approximately 6:05PM, s/he brought the resident's dinner tray to their room, but the resident was not in the room, so s/he left the tray. Ten minutes later CNA#1 returned for the tray, and noticed the tray was untouched, and the resident was still not in their room. CNA#1 then alerted an LPN #1 who asked her/him to check the recreation room, but the resident was not there. The staff began to search for the resident. CNA #1 stated that s/he knew that residents who are at risk for elopement must be kept within their view and staff needed to make sure the residents do not leave the floor. CNA #1 stated that on 1/5/2022, the evening shift nurse gave CNA#1 report at the beginning of shift, but no one informed her/him that Resident #1 was at risk for elopement. CNA #1 stated that they did not check the CNA Task either. During an interview on 1/10/2022 at 4:56PM with LPN #2, they stated that Resident #1 was alert, oriented and able to make their needs known. LPN #2 stated that they were aware of the documentation in the Medication Administration Record (MAR) that Resident #1 had a history of wandering. The nurses check the resident for wandering behavior and sign the MAR. LPN #2 stated Resident #1 did not have exit seeking behavior and had not verbalized a desire to leave the facility. The resident ambulated independently without assistive device and had a walker that the resident did not use. LPN#2 stated they did not know if Resident #1's elopement risk information was documented on the CNA care guide. LPN#2 stated that the nurses gave report to the CNAs, but they did not know who gave report to the assigned CNA #1 on 1/5/2022 because they had worked the day shift. During a telephone interview on 1/11/2022 at 2:40PM with the former RN Unit Manager (RNUM #1) s/he stated that Resident #1 was admitted to the facility in October 2021, and s/he performed the admission elopement assessment. Former RNUM#1 stated that s/he reviewed the hospital admission record including the Patient Review Instrument (PRI) which documented Resident #1 was at risk for elopement. The PRI documented the resident required a wander guard or be placed on a lock unit. RNUM#1 stated that during the assessment, s/he asked Resident #1 if they were seeking to leave the facility, to which the resident responded no. Former RNUM #1 stated that based on this response, s/he determined that the resident was at low risk. The former RNUM #1 stated that they recommended a psychiatric consult and obtained an order from the physician to assess the resident for signs of wandering and elopement. Former RNUM #1 stated that Resident #1 used a rolling walker on admission, and that the use of the walker, in addition to the resident's response contributed to the determination that the resident was low risk for elopement. Former RNUM #1 stated they could not recall Resident #1's actual admission elopement score or range but remembered documenting the resident was low risk in the resident's behavior care plan and assessment note. Former RNUM#1 stated that if Resident #1 had displayed elopement behavior, s/he would have applied the wander guard. A review of the resident's medical record did not reveal documented evidence of this information. The facility did not provide the documentation upon request. During an interview on 1/12/2022 at 12:02PM with CNA #2, s/he stated that s/he received training on elopement. S/he stated that residents at risk of elopement are monitored every 30 minutes to see what they were doing, and where they were going. S/he stated that the facility doors and elevators have wander guard sensors which would be triggered if a resident tried to leave the facility. In this case, the staff would stop the resident, and bring them back to the facility. During a telephone interview on 1/13/2022 at 1:32PM with the Attending Physician (AP), s/he stated that the resident was new to her/him in the nursing home. The AP was not aware that the resident was at risk for elopement or had any behavior that might have caused the resident to leave the facility. The resident never informed her/him that s/he wanted to leave the facility. The staff did not inform her/him that the resident was at risk for elopement. S/he reviewed the hospital discharge record but could not recall seeing anything that indicated the resident was at risk for elopement. The AP stated that Resident #1 ambulated without an assistive device and was not aware of any exit seeking behavior. In a follow up interview with the Administrator on 1/14/2022 at 12:15PM, they stated that Resident #1 had not been located. During a telephone interview on 1/18/2022 at 5:03PM, with the assigned LPN #1 they stated that Resident #1 was in their room on 1/5/2022 when s/he did rounds at the start of their shift. There were no problems or complaints from the resident, and no problems were reported. LPN#1 stated that at 5:30PM, s/he observed the resident walking to another unit on the same floor wearing a white shirt, short pants, and sneakers. LPN#1 stated they did not stop the resident because that was the resident's routine. LPN #1 stated Resident #1 had never attempted to leave the facility or voiced a desire to leave. Resident #1 ambulated independently without a device or difficulty. LPN #1 stated that they knew the resident was not at risk for elopement. There was nothing going on with the resident prior to 1/5/2022 that would suggest the resident would leave the facility. LPN #1 stated that Resident #1 did not have a picture posted or have a wander guard bracelet in place to prevent elopement. __________________________________________________________________________________ Immediate Jeopardy was removed on 1/14/2022 at 12:44pm based on corrective measures taken by the facility prior to exit. The facility supplied evidence that 94.7% of staff including RN, LPN, CNA, Housekeeping and Dietary was educated on the accurate completion of the elopement risk assessment Facility Staff were interviewed and had knowledge of elopement process, how to accurately complete risk assessment and document interventions and rationale. The facility reviewed their Elopement Policy and facility determined no revisions were needed The Facility presented evidence of completed weekly alarm checks for wander guards and exit door alarms, performed by maintenance. All alarms were functional. All residents admitted in the last 3months were assessed and reassessed to determine risk and all new admissions will be assessed 415.12 (h) (2)

Based on observations, interviews and record reviews conducted during an Abbreviated Survey (Complaint NY 185), the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents. Specifically, Resident #1 was identified as being an elopement risk due to wandering and frequent expressions of desire to leave the facility. The resident was care planned to have 30-minute checks which were not provided on 7/10/2021 from 6am to 7am. The resident subsequently climbed out a window on the third floor and fell on to cement. Resident #1 was discovered by staff at 7:00am, and was hospitalized with a fractured pelvis, a fractured ankle and is on mechanical ventilation. This resulted in IMMEDIATE JEOPARDY with actual harm to Resident #1 and the likelihood for serious harm to thirty-five residents' health and safety. The findings are: Review of the facility's policy titled, Elopement Prevention dated 04/06/2021 documented that the facility strived to promote resident safety and protect the rights and dignity of the residents. An elopement risk assessment was completed by nursing on all residents upon admission, quarterly and at any change of condition. The risk evaluation tool addressed each resident's mobility as well as psychological, behavioral, physical, and cognitive functions. Interventions that may be used included frequent monitoring of resident's whereabouts to assure he/she remains in the facility, implementing a wander bracelet and to promote activities in full view of staff members. The policy also stated that the physical plant was to be secured to minimize the risk of elopement such as: [ .] Restricted window openings. Review of the facility's policy titled, Safety and Supervision of Residents revised 02/2021 documented that the facility strives to make the environment free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents were facility wide priorities. Review of the facility's policy titled, Elopement Prevention Plan Policy last revised on 11/09/2018 documented that an elopement risk evaluation was completed by nursing staff for all residents upon admission, quarterly and at any change of condition. The risk evaluation tool addressed resident's mobility as well as psychological, behavioral, physical, and cognitive functions. Interventions that may be used included frequent monitoring of resident's whereabouts to assure he/she remains in the facility, implementing a wander bracelet and to promote activities in full view of staff members. Review of the facility's Investigation Report dated 07/10/2021 documented that Resident #1 sustained a fall from a Third-Floor window after dislodging the portable A/C duct from the window and going through the hole where it was secured. The report also noted that Resident #1 displayed agitated behaviors during the night shift (11:00PM on 07/09/2021 to 07:00AM on 07/10/2021). Pharmacological and non-pharmacological interventions were provided to Resident #1 with some effect. Additionally, Resident #1 continued to be monitored every 30 minutes for refusal to wear the Wanderguard and exit seeking behaviors. During an interview on 07/10/2021 at approximately 01:15PM, a Maintenance Worker stated that two wooden board encasements were affixed with screws to the window frame of one Third Floor dining room window, and each board (placed on the exterior and interior of the window frame, respectively) had a penetration in the center which measured approximately 20-inches in diameter. The exhaust tube was fed through the two wooden board encasements and was secured with duct tape around the diameter of one side of the exterior board. Resident #1 was admitted to the facility on [DATE] with diagnoses that included Type II Diabetes, Hypertension, Dementia, [CONDITION(S)], and Metabolic [CONDITION(S)]. Resident #1's Minimum Data Set (MDS; a resident assessment tool) dated 04/14/2021 documented a Brief Interview for Mental Status (BIMS) score of 9, indicating severe cognitive impairment. The resident's mood was assessed to have little or no interest in doing things nearly every day and there were no behavior issues identified at the time of the assessment. The MDS documented that Resident #1 ambulated with limited assistance, fed him/herself with tray set up and was frequently incontinent of bladder and bowel. Vision is moderately impaired and additional Medical Doctor's (MD's) documentation supports that Resident #1 was legally blind and palpates (examine via touch) objects to find his way back from the bathroom. Review of a Behavior Care Plan initiated on 10/12/2020 showed that Resident #1's diagnoses included Dementia, Altered Mental Status and Delusional Disorder. Observed behaviors included refusal of medications, hallucinations, stating staff was trying to poison him/her and refusal of meals. Interventions included to administer [CONDITION(S)] medications as ordered, initiate psychiatric evaluation as needed, notify MD of inappropriate behavior and to redirect negative behavior. The care plan was not updated since 10/12/2020. Review of the CNA Accountability Record dated June/July 2021 documented that Resident #1 required limited assistance of one staff for locomotion in the hallway, half hour visual checks for behavior monitoring and Wander-guard placement to be checked each shift. Review of a Nurses' Progress note dated 06/27/2021 08:05AM, documented that Resident #1 was received at the start of the shift in the hallway between S Unit and C2 Unit, sitting on a laundry bag full of clothing. Resident #1 was persistently encouraged to return to the Unit. Redirection was attempted and ineffective. Medical Doctor (MD) returned a call from the previous night shift. MD Orders were to discontinue [MEDICATION(S)] ([MEDICATION(S)]), start [MEDICATION(S)] 1mg as needed every 4 hours for 14 days. Psychiatry consult was ordered, and Resident #1 will be monitored. Review of a Nurses' Progress Note dated 06/28/2021 at 01:40AM, documented that Resident #1 was attempting to elope, talking to him/herself, and stating that someone is waiting for him/her outside. Review of a Nurses' Progress Note dated 06/28/2021 at 11:37AM documented that Resident #1 was exhibiting extreme behaviors of agitation and aggression towards staff, was experiencing delusions, was verbalizing very loud in Creole while entering other residents' rooms and was being disruptive to other residents. Resident #1 was very difficult to redirect and was combative. Resident #1 also refused medications as well as meals. He/she was observed to be walking around while carrying a bag of clothing, wanting to leave. Resident #1 was posing a danger to him/herself and others. The nurse spoke with the MD and the Psychiatrist who provided orders to send Resident #1 to the emergency room for evaluation. Resident #1's son was notified. Review of a Nurses' Progress Note dated 07/01/2021 at 05:01AM written by the Unit LPN documented that Resident #1 was received in bed, awake, verbalizing needs. The call bell was noted to be within reach. Transfer to unit day 3/3, displaying no disruptive behaviors, ambulates as needed, toilets independently. Resident #1 had no complaints of pain. Resident #1's Wander-guard was noted to be in place on the right ankle and he/she has had no attempts to elope. Will monitor. Review of a Behavior Note dated 07/02/2021 at 05:20AM documented that Resident #1 was combative and refused all medications and food. Staff noted that they were unable to reason with Resident #1. Resident #1 was transferred to the hospital for evaluation. Review of a Nursing Progress Note dated 07/04/2021 at 11:00PM documented that Resident #1 returned from the hospital. Review of a Nursing Behavior Note dated 07/05/2021 at 10:32PM documented that Resident #1 was confused and wanted to leave the unit. A snack and [MEDICATION(S)] 1mg tab were given to the resident. Resident #1 remained in his/her room, very confused and awaiting to leave. Review of a Nurses' Progress Note dated 07/06/2021, written by the Unit LPN documented that Resident #1 was observed without the Wanderguard. The Supervisor was made aware. Review of a Psychiatry Consult dated 07/06/2021 at 02:03PM documented that Resident #1 was having auditory hallucinations, depressed mood, behavioral disturbances and was increasingly confused. Resident #1 had diagnoses including Dementia, [CONDITION(S)] and Major Depressive Disorder (MDD). The plan included to continue current treatment, provide support and to monitor behavior. A Gradual Dose Reduction for [CONDITION(S)] medications was noted as clinically contraindicated due to Resident #1's [CONDITION(S)]. Review of a Physician's Progress note dated 07/07/2021 documented that Resident #1 was admitted after a hospital stay on 10/04/2020 for having a blood sugar reading over 600. Resident #1's family stated that the resident, with a sheet tied around him/her and climbing out of bed so he could escape out the window, told his/her son that he/she was going to Haiti by boat. The family added that Resident #1 became less paranoid once his/her sugar level was stabilized. The note also documented that Resident #1 lacked the capacity to understand medical issues and that his/her awareness of his/her medical issues seemed limited. Resident #1 experienced increased agitation over the past week and was sent to the emergency room (ER) for evaluation. The recommendations included for Resident #1 to continue with neuropsychotropic medications ([MEDICATION(S)]). Review of a Nursing Progress Note dated 07/09/2021 at 04:34PM documented that Resident #1 refused to wear a Wander-guard (a technology system with the express purpose of keeping wanderers safe, preventing them from straying too far) and threw it in the garbage. Close monitoring was ordered for every shift due to Resident #1's risk of elopement and refusal to wear the Wander-guard. Resident #1's Care Plan and interventions were updated, and his/her family was notified. Resident #1 was placed on every 30-minute monitoring for 7 days. The 07:00AM to 03:00PM nurse and Certified Nursing Assistant (CNA) were informed. Review of Physician's Orders dated 07/09/2021 documented that staff were to monitor Resident #1 every 30 minutes for 7 days secondary to his/her refusal of the Wanderguard and exit seeking behaviors. Resident #1's Half Hour Behavior Monitoring tool for CNAs was reviewed and documented that on 07/09/2021 at 3:00PM, checks were started and documented that the resident remained in bed until 06:00 PM. On 07/10/2021 it was documented that Resident #1 was observed in the hallway until 02:00AM. From 02:30AM to 05:30AM, Resident #1 was in another resident's room. At 06:00AM and 06:30AM, Resident #1 was observed in the hallway. The form documented that Resident #1 refused toileting as well as snacks and was talking to him/herself. Review of a Nursing Progress Note dated 07/10/2021 at 7:40AM documented that at 11:40PM on 07/09/2021, while performing rounds, Resident #1 was in the hall talking to himself. On 07/10/2021 at 12:00 AM, [MEDICATION(S)] 1mg was administered as ordered with some effect. At 02:00 AM, Resident #1 was walking back and forth in the hallway. At 03:00AM, Resident #1 was in room 310 (not his/her room) talking to him/herself and refused to come out. The supervisor was notified and at 04:00AM, Resident #1 was offered [MEDICATION(S)] 1mg prn (pro re nata - as the occasion arises, as necessary), snacks and fluids but refused. At approximately 06:00AM, while administering medications, Resident #1 was seen on the unit. At 07:00AM, the supervisor informed the writer that Resident #1 was lying on the ground, outside of the facility. During an interview on 07/10/2021 at 10:31AM with a Housekeeping staff member (HK #1), he/she explained that he/she typically starts work at 07:00AM, but punches in a few minutes early. He/she stated that on the morning of 07/09/2021, he/she went to Center 2. His/her priority was the clean the tables and sill in the dining room because the residents eat there. HK #1 explained that as he/she cleaned by the dining room window, he/she looked out of the window and saw a body on the cement. HK #1 stated that he/she saw blood on the cement but could not say where from the body it was coming from. HK #1 did not see anyone in the hallway, panicked and ran downstairs where he/she saw one of the Maintenance Workers (MW #1). HK #1 explained that he/she saw a few people coming into the facility for work, saying there is a body. MW #1 then went outside, returned, and told the Receptionist to call 911 as there is a body outside Center 1. The Receptionist refused and stated that he/she will call a supervisor. HK #1 then called 911 from his/her personal phone as he/she did not want to wait for anybody. HK #1 retrieved the record from the 911 call on his/her phone, showing that the call was at 07:00AM. HK #1 told 911 that he/she was an employee at the facility and saw a body on the ground outside. Meanwhile, the Receptionist called the police and told of the body where he/she was asked if someone could check if the person is breathing, but there was no one around to do so. HK #1 was the first person to approach the body and reported to the police that the chest moved. HK #1 was asked if the person was a resident, but she could not see the person's face. HK #1 stated that the bleeding appeared to be from the feet. HK #1 then saw the police arrive and they took over care. At that time, a nurse and a supervisor arrived at the body's location. During an interview with the Director of Nursing (DON) on 07/10/2021 at 11:15AM, he/she explained that any resident at risk for elopement will be on 30-minute safety checks as a precaution. For the change of shift monitoring (07:00AM, 03:00PM and at 11:00PM) staff will notify the next shift of staff that a resident is on 30-minute checks. It is also communicated to the oncoming shift that Resident #1 has no Wanderguard, so he/she can get onto the elevator without the alarm sounding. The staff were to monitor all 6-inch openings in the facility windows for a period of 6 months. Elopements were to be reviewed monthly and for 6 months. DON explained that Resident #1 had impaired cognition, was purposeful and found his way around, ambulating independently, without any assistive devices. The DON explained that Resident #1 displays periods of maladaptive behaviors followed by no maladaptive behaviors, but upon return from the hospital, he/she was good. Resident #1 displayed no wandering or negative behaviors. The DON noted that Resident #1 started showing wandering behaviors maybe twice during the previous week and 30-minute visual checks were initiated on 07/08/2021. The DON stated that the police have been to the facility for Resident #1's behaviors. Resident #1 was sent to the hospital then returned on 07/06/2021, but he/she was unsure of the exact date. During a follow up interview on 07/10/2021 at approximately 11:30AM, the DON stated that the portable A/C unit was installed in the Third-Floor dining room because the facility wanted to keep the Dementia/Alzheimer's Unit cool. The DON further stated that the facility's normal air conditioning system was not effective. The DON also stated that the portable A/C unit was positioned in the doorframe of the unused dining room, facing into the corridor, with the exhaust duct stretched across the dining room and placed through the window for discharge. Additionally, the DON stated that the facility did not have available staff to monitor the room that housed the portable A/C unit. During interview on 07/10/2021 at 12:50PM, CNA #1 stated that on 07/09/2021 at approximately 11:30PM, he/she began the overnight shift at the facility. CNA #1 stated that the A/C unit was large, heavy, and half in and half out of the dining room at the beginning of his/her shift. CNA #1 stated that on the overnight shift from 07/09/2021 into 07/10/2021, there were two CNAs and one LPN stationed on the Third Floor. CNA#1 explained that the LPN told him/her that he/she had never worked in the unit before. CNA #1 also stated that one RN supervisor was covering the entire building. CNA #1 further stated that he/she was assigned to monitor Resident #1 every 30 minutes on the Third Floor and to document his/her observations on a written monitoring log. He/she explained that Resident #1 was to be asked if he/she was ok and if he/she wanted anything to eat. CNA #1 went on break at 02:00AM. CNA #2 was in the dining room and CNA #1 told them to keep an eye on resident. CNA #1 said they never saw Resident #1 go into the other dining room with A/C unit. CNA #1 stated that at 02:30AM, Resident #1 was observed talking to him/herself, muttering that he/she wants to get out. The resident was in room 310 (a resident room next to the dining room). There were two sleeping residents in that room. CNA #1 reported Resident #1's behavior to the supervisor who instructed him/her to monitor Resident #1. CNA #1 noted that at the completion of the overnight shift, he/she submitted the monitoring log to the Third Floor Licensed Practical Nurse (LPN #1). CNA #1 stated that during the shift, if Resident #1 was not resting in bed, Resident #1 was agitated and pacing the hallway while talking to him/herself. CNA #1 explained that by agitated he/she meant that Resident #1 with an escalating loud voice would state, don't touch me, leave me alone. CNA #1 stated that he/she attempted to redirect Resident #1 by trying to sit down to talk with him/her and offering him/her water and food, but he/she refused all redirection. CNA #1 stated that when Resident #1 was agitated, he/she typically did not accept anything offered to him/her. Furthermore, CNA #1 stated that the last time they observed Resident #1 was on 07/10/2021 at approximately 6:00AM in the hallway walking around while CNA #1 was in the dining room. CNA #1 stated that at that time, he/she had to care for another resident on the unit. CNA #1 stated that CNA #2 was monitoring a different resident in the dining room across the hall from the dining room with the portable A/C unit. CNA #1 said that he/she assumed that CNA #2 would also be watching Resident #1. CNA #1 stated that Resident #1 would routinely go into other residents' rooms and walk back and forth in the hallway. During an interview on 07/10/2021 at approximately 01:15PM, a Maintenance Worker stated that he/she was unsure who installed the wooden boards and exhaust tube in the Third-Floor dining room, but it was not installed by in-house maintenance staff. The Maintenance Worker stated that he/she believed the wooden boards and exhaust tube were installed by a contractor. Furthermore, the Maintenance Worker stated that as per the request of the DON and the Assistant Director of Nursing (ADON), he/she removed the wooden boards and secured the window at around 10:00AM this morning (7/10/2020). Additionally, the Maintenance Worker stated that the facility had an issue with the chiller unit that is housed in the boiler room. The Maintenance Worker further stated that about three to four weeks ago, the chiller system was completely down for approximately two or three days. Additionally, the Maintenance Worker stated that to combat the high temperatures, the facility installed about 13 to 15 smaller window A/C units into resident bedrooms throughout the building. The facility also installed one wheeled portable A/C unit in the Third-Floor dining room. Subsequently, the Maintenance Worker stated that the chiller is currently working at 50% capacity. During an interview with LPN #2 on 07/10/2021 at 01:39PM, he/she stated that he/she knew Resident #1 well. LPN #2 explained that Resident #1 was verbally aggressive, more so lately. LPN #2 further explained that Resident #1 often went into the dining room with the A/C unit but was redirected out. LPN #2 shared that he/she reported that he/she felt that it was a problem to have a big hose in the dining room with dementia residents around. During an interview with CNA #3 on 07/10/2021 at 01:50PM, he/she stated that he/she works mostly on Resident #1's unit. CNA #3 explained that Resident #1 was steady on his/her feet, wanders the unit frequently and often spoke about going home. CNA #3 explained that he/she has received training to report resident behaviors but feels that the facility has not done anything about them. CNA #3 stated that while performing 30-minute visual checks, he/she will observe residents all acting up at once. During interview with CNA #4 on 07/10/2021 at 01:55PM, he/she stated that he/she took care of Resident #1 often who was very agitated some days. He/she stated that Resident #1 had recently attempted to get off the unit and the police had to be contacted. CNA #4 explained that he/she does not typically get much of a report about Resident #1's behaviors; he/she has to figure it out. On Thursday (07/08/2021), Resident #1 was very pleasant, and he/she gave him/her a shower without any issues. During an interview with the DON on 07/10/2021 at 05:50PM, he/she explained that Resident #1's Elopement Risk Assessment was last completed on 03/24/2021. The DON further stated that after the ER visit on 06/28/2021 for 3 elopement attempts with behaviors, there was no need to update the Elopement Risk Assessment. The DON stated that the assessment from 03/24/2021 remained in effect on 06/28/2021. The DON went on to explain that although Resident #1 went to theER on [DATE] and returned on 07/06/2021, no elopement care plan was necessary. During interview with the Registered Nurse Supervisor (RNS) on 07/10/2021 at 06:20PM, he/she explained that he/she performed rounds at approximately 01:30. At the time, Resident #1 was in the dining room talking to him/herself. The RNS explained that he/she knew Resident #1 and that he/she had behavioral issues including wandering around. The RNS stated that Resident #1 does not typically display physical aggression but is very strong and has used his/her hands to scratch others. Resident #1 was to be redirected by offering drinks, food and prn medications. RNS further explained that if staff attempt to force Resident #1 to comply, he/she will become more aggressive. The RNS stated that he/she was aware that Resident #1 was in room 310 during the night. The RNS explained that he/she did not assess Resident #1 because this is his/her typical behavior and he/she would not have found anything new. The RNS stated that he/she directed the CNA to watch and monitor Resident #1, offer him/her something to eat and administer [MEDICATION(S)] 1mg. The CNAs reported to the RNS that Resident #1 would not exit room 310 but that as long as Resident #1 was not agitated, staff should let him/her come out on his own. The RNS explained that he/she did not go to the unit to see Resident #1. The RNS stated that from 03:00AM to 04:00AM, he/she was on another floor and that the nurse had not called back, so he/she thought that Resident #1's behaviors were better with no other bad behaviors. The RNS stated that if Resident #1 had not been redirected, then the unit nurse or CNA would have called. At 07:00AM, a nurse on the ventilator unit reported to the RNS that a resident is outside of the building and on the sidewalk. RNS said that he/she went to ventilator unit, jumped from the window, looked up and saw an open window on the Third-Floor. The RNS explained that the he/she questioned the unit nurse and CNAs who stated that Resident #1 was on the unit, standing in the hallway at the nursing station at 06:30AM. During an interview with CNA #2 on 7/10/2021 at 06:40PM, he/she stated that he/she usually works on the Third Floor. He/she stated that Resident #1 typically goes in and out of other residents' rooms. CNA #2 noted that Resident #1 stated in Creole that he/she was upset and wanted to get out of building to go home. CNA #2 added that Resident #1 says that all the time and talks non-stop. CNA #2 stated that he/she was aware that Resident #1 is to receive every 30-minute checks. CNA #2 stated that at 02:00AM he/she along with the nurse, took over Resident #1's 30-minute checks from CNA #1 as CNA #1 was going on break. CNA #2 stated that at the time, Resident #1 was in another residents' room (room 310) talking to him/herself, but they could not get him/her to exit the room. CNA #2 stated that Resident #1 remained in room 310 with two sleeping women from 02:30AM to 05:30AM. CNA #2 stated that he/she began to provide cares to other residents at 04:15, which takes about 2 hours to complete. CNA #2 noted that he/she finished providing cares around 06:15AM. CNA #2 explained that at that time, while the nurse was in the hallway administering medications, CNA #1 began performing rounds and stated that he/she would call when he/she was leaving. CNA #2 stated that he/she last saw Resident #1 at 05:30AM in the hallway. CNA #2 further stated that he/she remained in the Dining Room from 06:15AM until 07:27AM and Resident #1 did not come in at any time. CNA #2 shared that he/she could not provide 1:1 supervision to Resident #1 and that he/she did not see him/her after 05:30AM. CNA#2 stated he/she signs off the 30-minute increments on the monitoring tool for her/his resident's only even though he/she was responsible for visually monitoring CNA #1 resident's because that's how it goes. During a follow up interview with CNA #1 on 07/12/2021 at 11:15AM CNA #1 stated that the CNAs get their dining room observation time slot based on the rooms assigned at the beginning of the shift. The assignments were posted in the dining room. The monitoring was done at one-hour intervals. According to the Half-Hour Behavior Monitoring Tool, CNAs are to ask if the resident's need anything or wants a snack. The CNAs were then to document the resident's location, the resident's behavior, if the resident was toileted and if the resident was offered snacks. There is an area on the tool for CNA comments but not for CNA signature. The residents' names are manually entered onto the tool. The tool used for Resident #1 documented that he/she was in room at 2:30AM until 5:30AM. At 06:00AM and 06:30AM documentation supported that the resident was in the hallway. CNA #1 was asked why the 06:30AM time slot was completed as checked and CNA#1 stated that he/she last saw Resident #1 at 06:00AM. CNA #1 stated THAT when another CNA makes the observation, they document THAT it was done. This is the way it is done at the facility. A follow up interview was conducted with CNA #2 on 07/12/2021 at 06:40PM who stated that he/she took over for CNA #1 at about 06:15AM so he/she could do his/her rounds. CNA #2 was observing the dining room residents and saw Resident #1 in the hallway walking. CNA #2 explained that when Resident #1 was out of view, he/she did not go looking for him because he/she stayed in the dining room. CNA #2 was unaware of the fall until the RNS told him/her about it at 07:00AM. CNA #2 stated that the CNA assigned to the residents were the ones responsible for completing the form. CNA #2 filled out the form only for his/her assigned residents. During a telephone interview on 07/11/2021 at approximately 10:30AM, the facility Administrator stated that on the resident units there are LPNs and CNAs. The LPNs and CNAs had become complacent. The facility wanted all the nursing staff to be well-rounded and familiar with every resident in the building, so we decided to float the nursing staff. Some of the LPNs stayed on their units because they were exceptional. The change occurred on 07/05/2021 and some of the residents' family members were unhappy because their loved one was used to their caregivers. The Administrator explained that Resident #1 was really up and down. The Administrator added that the portable air conditioning unit that was utilized in the Third-Floor dining room was installed by the corporate maintenance team, not by facility maintenance staff. Additionally, the Administrator stated that the portable A/C unit was placed on the Third Floor approximately one month ago because the Third Floor is closest to the roof and becomes hotter than the other floors in the facility during the warmer months. During an interview on 07/12/2021 at approximately 12:15PM, the facility's Maintenance Director stated that the portable air conditioning unit was positioned in the doorframe of the Third Floor dining room with the corridor door resting on one side of the unit and the exhaust duct extended behind the unit leading towards the window. The exhaust duct traversed an approximate 16-foot distance, across the dining room floor. The facility's Maintenance Director further stated that the facility placed Caution Tape around the portable air conditioning unit on the corridor-side to prevent residents from entering the dining room. In a subsequent interview with the Maintenance Director on 07/12/2021 at 1:04PM, he/she stated that Corporate Maintenance Workers installed the portable A/C unit in the Third-Floor dining room. He/she also noted that the facility's Maintenance Staff were not provided with safety instructions for the A/C unit. The facility's Maintenance Director stated that the Corporate Maintenance Workers were responsible for educating nursing staff on any safety precautions regarding the portable A/C unit. During an interview on 07/12/2021 at approximately 01:18PM, the Corporate Director of Maintenance stated that the industrial portable A/C unit was installed in the Third-Floor dining room on 06/09/2021. The Corporate Director of Maintenance further stated that one of two compressors to the facility's chiller system was not functioning properly, and that the portable air conditioning unit was to be used during repair to maintain comfortable temperatures on the Third Floor. Additionally, the Corporate Maintenance Director stated that the portable A/C unit was only meant to be utilized for one to two days and that he/she was unaware that the facility had been utilizing the unit since its installation on 06/09/2021. The Corporate Maintenance Director further stated that the facility wanted to maintain comfortable temperatures on the Third Floor because residents on that floor become agitated. Subsequently, the Corporate Director of Maintenance stated that he/she did not think the exhaust tube could be pulled out, nor did he/she think a person would be able to fit through the 20-inch hole in the wooden encasements. The Corporate Maintenance Director stated that the facility's Maintenance Director was responsible for educating nursing staff on any safety precautions regarding the portable A/C unit. During a follow-up interview with the Administrator on 7/12/2021 at 01:24PM, room 317 was identified as the room where residents who have refused to apply the Wander-guard were located. The Administrator explained that these residents require precautions in place to address their safety and elopement risk. During an interview on 07/13/2021 at approximately 01:10PM, LPN #1 stated that the facility recently started to float nursing staff, and that he/she is new to the Third Floor. Additionally, LPN #1 stated that he/she was not educated on safety measures related to the portable A/C unit, nor were any of the nursing staff instructed to check the portable A/C unit during their shift. During an interview on 07/13/2021 at approximately 01:15PM, LPN #2 stated that she usually works on the Third Floor. He/she further stated that he/she was not educated on the safety measures related to the portable A/C unit. During a follow-up interview on 07/16/2021 at approximately 12:13PM, the DON stated that nursing staff were not officially trained regarding the safety of the portable A/C unit. The DON further stated that no one was thinking about the danger of the portable A/C unit, just the comfortability of the residents. Additionally, the DON stated that nursing staff may have received a verbal safety warning from Maintenance Staff, but nothing was written. Furthermore, the DON stated that the portable A/C unit was a temporary solution to maintain the comfort of residents. 483.25(d)(1)(2)

Based on observation, record review and interview during a recertification survey, the facility failed to provide timely and necessary care and treatment to prevent development and promote healing of pressure ulcers for one of six residents reviewed for pressure ulcers (Resident #253). Specifically, a knee brace (Jordan splint) worn at all times was not properly applied or addressed in the care plan, and skin integrity was not adequately monitored, for a resident identified to have risk for developing pressure ulcers. This resulted in the development of avoidable Stage 3 and unstageable pressure ulcers and actual harm that is not immediate jeopardy for Resident # 253. This is a repeat deficiency. The findings are: Resident #253 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan for "At-Risk for Disruption in Skin Integrity" was initiated on 12/23/14 and identified that the resident had the potential for disruption in skin integrity. The resident's risk factors were not specified in the care plan. Planned interventions included the use of heel pads, special cushion and air mattress, to maintain clean and dry skin, and to perform frequent routine check of skin for pressure, mobility and circulation. A Rehabilitation Interim Note dated 12/24/14 stated that a Physical Therapist (PT) had a meeting with a family member and discussed concern about the resident's position. According to this interim note, the resident's left leg was fully flexed on the hip and knee and application of a Jordan splint immobilizer brace to the left knee, a splint that extended from the thigh to the ankle, was recommended. According to Interim physician's orders [REDACTED].#1) on 12/29/14. No specific instructions as to when the splint should be removed, either for skin care or checking for skin breakdown, were included in the order. There was no documented evidence that the care plan for "At-Risk for Disruption in Skin Integrity" was revised, or that another care plan was used, to address the use of the Jordan Splint, including measures to prevent development of pressure ulcers and other skin breakdown secondary to the use of this splint. The admission Minimum Data Set (MDS, a resident assessment tool) completed on 12/30/14 indicated that the resident had a score of 15 out of 15 on a BIMS (Brief Interview for Mental Status) test used to determine orientation and ability to recall information. The MDS identified that the resident was totally dependent on staff for completion of most of her activities of daily living (ADL) that included bed mobility, transfer, toileting and personal hygiene and had functional limitation of range of motion on one side of the body. This MDS assessment further indicated that the resident had no pressure ulcers at the time of the assessment and was at risk for developing pressure ulcers. The December CNA (Certified Nurse Aide) Resident Profile record did not provide any instructions for the CNAs regarding skin check of the areas covered by the Jordan splint. A Weekly Skin Integrity Review form was completed by an LPN on 1/6/15 and noted that the resident had no areas of skin impairment. There was no documented evidence in the Weekly Skin Integrity Review forms, Nurse's Notes, the CNA Accountability and Resident Profile records, or elsewhere in the clinical record, that the resident was monitored for potential skin impairment of the left leg where the splint was applied from 1/6/15 until 1/14/15. The Nurse's Notes of 1/14/15 stated that an open area was noted on the lateral aspect of the left ankle. The open area was not described. The Nurse's Notes of 1/15/15 indicated that the wound care team was requested to evaluate the resident due to inflamed areas on the left posterior thigh. A Wound Care Consult form dated 1/15/15 was completed by the Wound Care physician and identified that the resident developed two pressure ulcers on the left lower extremity: 1) Left Posterior Thigh - measured 1 cm x 1.5 cm x 0.1 cm with slough and eschar formation, light serous drainage, surrounding tissue inflamed, no pain; and 2) Left Lateral (outer) Ankle - measured 2 cm x 1.5 cm x less than 0.1 cm, slough and scab formation, no drainage, surrounding tissue intact, no pain. No pressure ulcer stage was identified. The pressure ulcers were characterized on the form as Slough/Eschar, indicative that they were unstageable and had non-viable tissue. Treatments were ordered by the Wound Care physician on 1/15/15 to cleanse these areas daily with normal saline solution, apply [MEDICATION NAME] ointment ([MEDICATION NAME] is an enzyme used in helping to break up and remove necrotic or dead tissues) and to cover with dry protective dressing. A 1/15/15 entry in the care plan for "At-Risk for Disruption of Skin Integrity" noted the presence of the new pressure ulcers on the thigh and ankle. The care plan was not revised to address specific measures to reduce pressure on the areas of the leg at risk from current pressure ulcers or contact with the splint. A Weekly Skin Integrity Review form was completed by an LPN on 1/21/15 and noted that the resident had a skin opening on the left ankle and a skin opening on the left thigh. No further description was noted. RN #1 was interviewed on 1/22/15 at 9:45 AM and stated that the resident had two pressure ulcers, one on the left posterior thigh and one on the left lateral ankle. RN #1 stated that there was slough and eschar formation on the pressure ulcers that were characteristics of unstageable pressure ulcers. The unit RN charge nurse (RN #2) and the surveyor observed the resident on 1/23/14 at 8:45 AM and noted the following: Upon removal of the Jordan splint by RN #2, brown material, that appeared to be dried blood, was noted on the interior of the splint in the area that the splint covered the left posterior thigh. A pressure ulcer was noted on the left posterior thigh measuring approximately 2 cm x 1 cm, with yellowish eschar formation and slight redness of the surrounding tissue. No dressing or padding was in place to protect the skin on the resident's thigh, including the area of the pressure ulcer, from direct exposure to the splint. RN #2 stated that a dressing should have been in place to cover the pressure ulcer on the thigh to avoid direct contact and rubbing of the pressure ulcer directly against the surface of the Jordan splint. Additionally, two linear areas of deep tissue injury were also noted on the left posterior thigh, each measuring approximately less than 1 cm x 1 cm. No dressing or padding covered these areas. RN #2 stated that she was not aware of these two "skin tears." During the same observation, prior to removal of the Jordan splint, the splint was positioned in direct contact with the lateral aspect of the left ankle. A dressing was in place on the ankle and was removed. A pressure ulcer was noted on the left lateral ankle measuring approximately 2 cm x 2 cm with slough formation noted. The surrounding tissue was reddened and had dried yellowish secretions. At this time, RN #2 and the surveyor observed three areas of deep tissue injury on the posterior left lower leg. One area measured approximately 4 cm long by 1 cm with redness extending downwards for 2 cm with brown discoloration in the center. The other two areas each measured 2 cm x 2 cm and had scab formation. RN #2 stated that she did not know about these new areas of impaired integrity on the lower leg. The PT was interviewed on 1/23/15 at 9:00 AM and stated that, following a discussion with a family member, the PT recommended the Jordan splint to assist the resident maintain proper alignment of the left lower extremity and to prevent flexing of the left knee towards the resident's chest resulting from the acute brain stroke. The Jordan splint was applied to the left lower extremity from the mid-thigh down to the lower leg with the use of Velcro straps and covered most of the affected extremity including the ankle. The PT stated that the splint provided limited view of the skin for inspection. The PT stated that, on 1/14/15 while the resident was in the PT department, he observed a small skin opening on the left lateral ankle upon removing the splint. The PT stated that he called nursing and also reported his observation to the Wound Care Coordinator (WCC) on the same day. The PT stated that the WCC wanted to include the resident for wound rounds as the wound on the lateral aspect of the left ankle was a pressure point area. The PT stated that the nurses' aides apply the splint and should watch for any skin breakdown, especially on the edges of the splint. The PT stated that nursing should have applied padding on the pressure points and under the thigh because the resident had fragile skin. The PT stated that the splint required constant monitoring as it has the tendency to slide down if not properly applied. The PT stated that the splint may have slid down the resident's leg and that the lower portion of the splint rested directly on the bony prominence of the ankle causing the pressure ulcer. The PT stated that the pressure ulcer on the left posterior thigh was also caused by the splint. The PT stated that the splint should be snug to fit the entire length of the extremity. When asked if he provided any in-service education to the direct caregivers regarding the proper application of the Jordan splint, including the possible risks from its use, the PT stated that he does not do in-service for any device or equipment because some nursing staff members may have already seen or used that same type of splint before. The assigned 7:30 - 3:30 day shift Certified Nurse Aide (CNA #1) was interviewed on 1/23/15 at 10:20 AM and stated that she did not receive any instructions as to the proper application of the Jordan splint for this resident, including the possible risks of skin breakdown. CNA #1 stated that she did not need any in-service because she had seen this type of splint before for other residents, but not for this resident. CNA #1 stated that a nurse, whom she was unable to identify at this time, instructed her to keep the splint on at all times. CNA #1 stated that she just looks how the splint had been applied, before she removes it so she would know how to put the splint back on. CNA #1 stated that she checks the resident's skin but that she was not required to document that she performed skin inspection. CNA #1 stated that she removed the Jordan splint during morning care prior to sending the resident to Rehab on the morning of 1/14/15. CNA #1 stated that she did not observe any skin problems until the nurse told her the resident had a wound on the ankle and behind the thigh. RN #1 was further interviewed on 1/23/15 at 10:25 AM. RN #1 stated that she was not aware of the presence of the additional skin breakdown on the left leg and posterior thigh that were observed by RN #2 and the surveyor earlier that day. RN #1 stated that there was no care plan to address the use of the Jordan splint or to prevent pressure ulcers or skin breakdown associated with the use of the Jordan splint. RN #1 was asked to define the intervention for "frequent routine skin checks "as identified in the initial care plan of 12/23/14. RN #1 stated that routine skin checks are done by the evening and night shift nurses on a weekly basis and documented in Weekly Skin Integrity Review forms. RN #1 also stated that the CNAs do not need to document in the resident's accountability record that skin checks were performed, but they were expected to report to the nurse if there was any skin change. The attending physician observed the skin condition of the resident's left leg and was interviewed on 1/23/15 at 11:00 AM. The physician stated that he was aware of the pressure ulcers on the resident's left posterior thigh and left lateral ankle. The physician stated that they were caused by the splint and that they could have been avoided. The physician stated that additional padding should have been applied to prevent skin breakdown as the resident had fragile skin. Additionally, the physician stated that protective dressings should be applied and maintained over the impaired skin to avoid direct contact with the surface of the splint to facilitate healing. RN #2, who was also present at this interview, stated that the new "skin tears" on the left lower leg were "not there before" and that they may have been caused by the splint rubbing against the resident's fragile skin. The physician described these areas of impaired skin on the resident's left lower leg as deep tissue injuries. The Wound Care Consult form 1/23 also identified that the resident had deep tissue injury of the left lower leg. The Wound Care Consultant (WCC) was interviewed on 1/26/15 at 8:05 AM and stated that he did not like the Jordan splint because it was not adequately padded, especially on the pressure points that included the ankle. The WCC stated that he recommended to nursing that the edges of the splint be padded and to apply protective dressings on the left lateral ankle and behind the left thigh to prevent possible skin breakdown. In addition, the WCC stated that the Jordan splint was long as it covered the ankle and that the splint should have provided a better way to observe the skin under the splint. The WCC stated that a new knee brace that was applied on 1/25/15 was adequately padded, it was shorter and did not rest on the ankle. The 7-3 shift float CNA (CNA #2), who takes care of the resident in the absence of the regularly assigned 7-3 CNA, was interviewed on 1/26/14 at 8:30 AM and stated that she had not received any in-service regarding the use of any knee brace. The 11-7 shift Licensed Practical Nurse (LPN) was interviewed on 1/26/15 at 7:30 AM and stated that the assigned 11-7 CNA did not report any change in the resident's skin on her shift. This LPN stated that the Jordan splint always remained in place the whole night during her shift. The surveyor observed on 1/26/15 at 10:00 AM that the pressure ulcer on the left ankle measured approximately 2 cm x 2 cm x 0.1 cm and the center of the wound had yellowish slough formation. The surrounding tissue was slightly swollen and reddened and covered the entire bony prominence of the ankle. The WCC, who was also present at this time, described it to be a Stage III pressure ulcer. 415.12(c)(1)(2)

Based on observation, interview and record review, the facility did not provide treatment and services necessary to promote healing of identified pressure ulcers for two of seven residents reviewed for pressure ulcers (Residents #80 and #192). Specifically: 1. For resident #80, the facility did not conduct ongoing monitoring of an identified sacral pressure ulcer, did not position the resident off of her back as ordered by a physician and did not effectively utilize appropriate treatment of [REDACTED]. 2. For Resident #192, who had a history of [REDACTED]. This resulted in actual harm that is not immediate jeopardy for Resident #80 and the potential for more than minimal harm for Resident #192. The findings are: 1. Resident #80 is [AGE] years old and was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. No pressure ulcers were identified in the resident's Admission Nursing Evaluation record of 2/14/14. A care plan for Potential for Impaired Skin Condition was initiated on 2/14/14 and noted that the resident was at risk for developing pressure ulcers secondary to multiple factors including cognitive impairment, problems with bed mobility and transferring, bowel and urinary incontinence. Numerous care plan interventions were identified to prevent the development of pressure ulcers and included frequent, routine skin checks, keeping skin clean and dry, using pressure-reducing devices and turning and repositioning every two-four hours. The Admission Minimum Data Set (MDS; a resident assessment tool) was completed one week after admission on 2/21/14 and also noted that the resident had no pressure ulcers but had risk factors for the development of pressure ulcers as identified in the care plan, cited above, including cognitive impairment, incontinence and total dependence on others to meet needs for mobility and hygiene. An Interim Physician Order, dated 3/13/14, revealed that the resident developed a "suspected deep tissue injury" in the sacral area. (Deep tissue injury is defined as pressure-related injury to subcutaneous tissues underneath intact skin with the potential for rapid deterioration to Stage 3 and Stage 4 pressure ulcers). The Wound Care Consultant ordered on the same day, 3/13/14, to cleanse the area with normal saline solution and to apply [MEDICATION NAME] (a type of wound dressing) daily. Interdisciplinary Progress Notes indicated that the resident was sent to the hospital due to fever on 3/21/14. The resident was readmitted to the facility on [DATE]. According to the 3/26/14 Admission Nursing Evaluation, no pressure ulcers were present and the resident's sacral area skin condition was described as "red." A 3/26/14 Ulcer and Pressure Sore Risk Assessment again identified risk for development of pressure ulcers. A notation that the resident's sacral area was "red" was entered in the initial 2/14/14 care plan for Potential for Impaired Skin Condition. Interventions for pressure ulcer prevention were renewed. No new interventions were recommended or added. The Wound Care Consultant documented in the Wound Care Consult wound tracking record on 3/27/14 that the "suspected deep tissue injury" in the sacral area, that was identified on 3/13/14 prior to the above hospitalization , was healed. The unit Registered Nurse manager (RN #1) documented in the care plan for Impaired Skin Condition on 4/4/14 that the resident had increased redness in the sacral area. RN #1 also obtained telephone orders from the physician on 4/4/14 to keep the resident positioned off of her back and to perform treatments daily with Calcium Alginate (Calcium Alginate is a type of topical dressing typically recommended for wounds with heavy drainage). According to the Treatment Administration Records, pressure ulcer treatment and dressing changes were performed daily in the morning from that date through 4/9/14. There was no documented evidence that wound tracking reports of the resident's sacral skin condition or response to treatment were completed after 3/27/14. There was no documented evidence, from 3/27/14 to 4/9/14, that the resident's skin condition in the sacral area was assessed or monitored in Weekly Skin Integrity Review records, Treatment Administration Records, Physician's Progress Notes or Orders, Nurse's Progress Notes or elsewhere in the clinical record. The resident was observed lying on her back in bed at various times between 8:00 AM and 1:00 PM on 4/9/14, 4/10/14 and 4/11/14. The unit Registered Nurse manager (RN #1) was interviewed on 4/9/14 at 8:44 AM and stated that the resident had a suspected deep tissue injury in the sacral area that was resolved on 3/27/14. RN #1 stated that the resident currently had one pressure ulcer, a "small opening" at the same sacral site of the healed deep tissue injury. RN #1 stated that the Certified Nurse Aide assigned to the resident's care on the 7-3 day shift (CNA #4) had reported the small opening to RN #1 on 4/4/14 and that CNA #4 reported that the area "was starting to break up." RN #1 stated that the area was being treated. The Licensed Practical Nurse assigned to the resident's care on the 11-7 night shift (LPN #3) was interviewed on 4/11/14 at 7:15 AM. LPN #3 stated that she was not aware of the skin condition of the resident's sacral area because it was dressed and no dressing changes were performed on her shift. LPN #3 stated that she expected the CNA (Certified Nurse Aide) to report to her if the resident had any skin breakdown. RN #1 was further interviewed on 4/10/14 at 11:15 AM and revealed that she had not assessed the resident's skin since CNA #4 had reported the small opening in the sacral area on 4/4/14. The resident's sacral skin condition was then observed with RN #1 and CNA #4 during the interview above. RN #1 and CNA #4 turned the resident, cleaned away feces from the area and removed a dressing from the resident's sacral area. Reddened skin was present in the sacral area that measured approximately 4.0 cm by 5.0 cm. Two areas with Stage 2 characteristics and an area with Stage 3 characteristics were noted in the middle of the reddened area. The surrounding skin had more pronounced redness and was macerated (softened and deteriorating tissue from exposure to moisture) with slight slough formation (yellow, fibrous, non-viable tissue) noted on the edge of the Stage 3 area. CNA #4 was interviewed immediately after the above observation. CNA #4 stated that the resident had no skin breakdown or dressing in place until a week ago. CNA #4 stated that she observed a small skin opening in the resident's sacral area and reported it to RN #1 a week ago on 4/4/14. CNA #4 stated that the area had been covered with a dressing and she had not seen the area since she noted and reported the skin opening. CNA #4 stated that the resident's current skin condition did "not look good" as compared to the small opening that she observed and reported a week ago. RN #1 stated, during subsequent interview on 4/10/14 at 1:00 PM, that she did not classify the pressure ulcer and did not document her initial observations to describe the condition of the pressure ulcer or surrounding skin on 4/4/14. RN #1 stated that the pressure ulcer had no drainage or odor at that time. RN #1 further stated that she phoned the attending physician on 4/4/14. RN #1 stated that she (RN #1) recommended the use of Calcium Alginate wound dressings because she had observed the Wound Care Consultant order Calcium Alginate "for this kind of pressure ulcer." RN #1 stated that the physician then gave orders not to position the resident on her back, to cleanse the sacral wound with normal saline and then apply Calcium Alginate with a dry protective dressing. RN #1 stated that the physician relied on the Wound Care Consultant to manage the resident's pressure ulcer. RN #1 stated that the Wound Care Consultant was responsible for initiating a wound tracking record for the resident to document classification of the pressure ulcer, description of the wound condition and treatment plans to be implemented. RN #1 further stated that the Wound Care Consultant or the attending physician had not seen the resident on or since 4/4/14. RN #1 also stated that the assigned nurses were supposed to document any change in the resident's skin condition in the Progress Notes and that RN #1 expected the nurses to report changes or worsening in skin condition to her promptly. RN #1 stated that she had not received any reports from the nurses about the resident's skin condition. There was no documented evidence in wound tracking reports, Weekly Skin Integrity Review records, Treatment Administration records, physician progress notes [REDACTED]. Three unit Licensed Practical Nurses (LPN #4, #5, #6) were interviewed on 4/10/14 between 1:15 PM to 1:30 PM and they stated that many nurses performed wound dressings for the resident. The LPN assigned to care for the resident on 4/10/14 (LPN #4) was interviewed on that date at 12:05 PM. LPN #4 stated that today was her first time performing the resident's wound dressing. LPN #4 stated that she could not find any information in the clinical record as to the condition or progression of the pressure ulcer prior to that date. During further observation of the resident's sacral area with the RN #1 on 4/11/14 at 1:15 PM, RN #1 stated that, until the previous day with the surveyor, she had not inspected the resident's skin since 4/4/14. RN #1 stated that the sacral pressure ulcer appeared to be worsening as compared to the small opening that she observed on 4/04/14. RN #1 stated that the treatment nurses had not reported to her that the pressure ulcer was not improving despite daily wound treatments being done. RN #1 further stated that the care plan had not been reviewed since 4/4/14. RN #1 also revealed that the Wound Care Consultant assessed other residents with Stage 3 and Stage 4 pressure ulcers on 4/10/14 but RN #1 did not request assessment of the resident and the wound Care Consultant did not assess the resident's skin condition. The attending physician was interviewed on 4/11/14 at 2:00 PM and stated that he would not have ordered Calcium Alginate dressing unless the pressure ulcer was "weeping" or had a discharge. The physician stated that he had trusted RN #1's assessment and that the resident should have been seen by the Wound Care Consultant. According to the RN #1, The Wound Care Consultant was not available for interview. The corporate Physical Therapist (PT), who was trained in wound care, evaluated the resident's sacral pressure ulcer on 4/13/14. The PT documented his findings in the Wound Care Consult record, stating that, the resident had a Stage 3 pressure ulcer measuring 4.0 cm by 5.5 cm by 0.1 cm, 25% granulation with slough tissue formation noted and light, thin serous drainage present. The attending physician was interviewed on 4/14/14 at 12:55 PM and stated that he examined the resident on 4/12/14. The physician stated that he found that the sacral wound had two Stage 2 areas and that the surrounding skin was at Stage 1 level, with non-blanchable areas. The physician stated that he also observed a Stage 3 area located centrally in the reddened area with slight slough formation and maceration. The physician stated that he discontinued the use of the Calcium Alginate and replaced it with a [MEDICATION NAME] ointment (an enzymatic [MEDICATION NAME] agent used in healing skin ulcers by breaking up and removing dead skin and tissue). 2. Resident #192 is [AGE] years old with [DIAGNOSES REDACTED]. The MDS assessment of 2/17/14 indicated that the resident had severely impaired cognitive skills in daily decision making and was totally dependent on others to perform most aspects of activities of daily living including bed mobility, transfer, personal hygiene and toileting. This MDS also indicated that the resident had no pressure ulcers and that he was at risk for developing pressure ulcers. The care plan for Impaired Skin Condition of 3/24/14 indicated that the resident was readmitted to the facility on that date with a sacral pressure ulcer. Numerous care plan interventions were identified and included frequent or routine check of the skin for pressure ulcers. During an initial interview with RN #1 on 4/9/14 at 8:41 AM, RN #1 stated that the resident had no pressure ulcers. RN #1 stated that the resident was readmitted to the facility on [DATE] with an open area to the left gluteal fold which was resolved on 4/3/14. The Treatment Administration Record (TAR) for April 2014 indicated that treatments were completed on 4/3/14 on the left gluteal fold on 4/3/14. No current pressure ulcer treatments were noted. The resident was observed in bed during care on 4/10/14 at 11:50 AM. An open area on the right buttock measuring 1.0 cm x 1.0 cm was noted and the surrounding skin was reddened. The LPN assigned to the resident's care (LPN #2) was present at the above observation and stated that this skin opening was new and that she needed to inform the attending physician or the Wound Care Consultant. During further interview with LPN #2 on 4/10/14 at 12:00 PM, she stated that the resident had a Stage 2 pressure ulcer on the sacral area which was healed about a week ago. LPN #2 stated that the assigned CNA, CNA #1, did not report any skin breakdown on the buttock to LPN #2. There was no documented evidence that this pressure ulcer was addressed in Physician's or Nurse's Progress Notes, wound tracking record or care plan. The Wound Care Consultant evaluated the resident on 4/10/14 at 12:15 PM and documented in the wound tracking record that the resident had a Stage 2 pressure ulcer on the right buttock measuring 1.0 cm by 0.5 cm by less than 0.1 cm with excoriation of the surrounding tissue. The Wound Care Consultant recommended a topical treatment for [REDACTED]. CNA #1 was interviewed on 4/10/14 at 12:45 PM and stated that she found a small skin opening on the resident's right buttock which did not look bad when she cleaned and inspected the resident's skin early that morning. CNA #1 stated that she did not report it to the nurse because she thought that this skin opening was always there. The 11-7 shift RN #2 assigned to the resident on 4/10/14 was interviewed on 4/11/14 at 7:00 AM. RN #2 stated that the resident had a pressure ulcer on the sacral area when he was re-admitted to the facility on [DATE] that was healed on 4/3/14. RN #2 stated that the assigned 11-7 CNA shift on 4/10/14 (CNA #2) did not report to her that the resident had any new skin breakdown. CNA #2 was interviewed on 4/11/14 at 7:05 AM and stated that she was aware of the pressure ulcer. CNA #2 stated that she did not inform nurse in charge of the skin opening on the resident's right buttock because she thought it was always there. 415.12 (c) (2)

Based on observation, interview and record review, the facility did not provide treatment and services necessary to promote healing of identified pressure ulcers for two of seven residents reviewed for pressure ulcers (Residents #80 and #192). Specifically: 1. For resident #80, the facility did not conduct ongoing monitoring of an identified sacral pressure ulcer, did not position the resident off of her back as ordered by a physician and did not effectively utilize appropriate treatment of [REDACTED]. 2. For Resident #192, who had a history of [REDACTED]. This resulted in actual harm that is not immediate jeopardy for Resident #80 and the potential for more than minimal harm for Resident #192. The findings are: 1. Resident #80 is [AGE] years old and was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. No pressure ulcers were identified in the resident's Admission Nursing Evaluation record of 2/14/14. A care plan for Potential for Impaired Skin Condition was initiated on 2/14/14 and noted that the resident was at risk for developing pressure ulcers secondary to multiple factors including cognitive impairment, problems with bed mobility and transferring, bowel and urinary incontinence. Numerous care plan interventions were identified to prevent the development of pressure ulcers and included frequent, routine skin checks, keeping skin clean and dry, using pressure-reducing devices and turning and repositioning every two-four hours. The Admission Minimum Data Set (MDS; a resident assessment tool) was completed one week after admission on 2/21/14 and also noted that the resident had no pressure ulcers but had risk factors for the development of pressure ulcers as identified in the care plan, cited above, including cognitive impairment, incontinence and total dependence on others to meet needs for mobility and hygiene. An Interim Physician Order, dated 3/13/14, revealed that the resident developed a "suspected deep tissue injury" in the sacral area. (Deep tissue injury is defined as pressure-related injury to subcutaneous tissues underneath intact skin with the potential for rapid deterioration to Stage 3 and Stage 4 pressure ulcers). The Wound Care Consultant ordered on the same day, 3/13/14, to cleanse the area with normal saline solution and to apply [MEDICATION NAME] (a type of wound dressing) daily. Interdisciplinary Progress Notes indicated that the resident was sent to the hospital due to fever on 3/21/14. The resident was readmitted to the facility on [DATE]. According to the 3/26/14 Admission Nursing Evaluation, no pressure ulcers were present and the resident's sacral area skin condition was described as "red." A 3/26/14 Ulcer and Pressure Sore Risk Assessment again identified risk for development of pressure ulcers. A notation that the resident's sacral area was "red" was entered in the initial 2/14/14 care plan for Potential for Impaired Skin Condition. Interventions for pressure ulcer prevention were renewed. No new interventions were recommended or added. The Wound Care Consultant documented in the Wound Care Consult wound tracking record on 3/27/14 that the "suspected deep tissue injury" in the sacral area, that was identified on 3/13/14 prior to the above hospitalization , was healed. The unit Registered Nurse manager (RN #1) documented in the care plan for Impaired Skin Condition on 4/4/14 that the resident had increased redness in the sacral area. RN #1 also obtained telephone orders from the physician on 4/4/14 to keep the resident positioned off of her back and to perform treatments daily with Calcium Alginate (Calcium Alginate is a type of topical dressing typically recommended for wounds with heavy drainage). According to the Treatment Administration Records, pressure ulcer treatment and dressing changes were performed daily in the morning from that date through 4/9/14. There was no documented evidence that wound tracking reports of the resident's sacral skin condition or response to treatment were completed after 3/27/14. There was no documented evidence, from 3/27/14 to 4/9/14, that the resident's skin condition in the sacral area was assessed or monitored in Weekly Skin Integrity Review records, Treatment Administration Records, Physician's Progress Notes or Orders, Nurse's Progress Notes or elsewhere in the clinical record. The resident was observed lying on her back in bed at various times between 8:00 AM and 1:00 PM on 4/9/14, 4/10/14 and 4/11/14. The unit Registered Nurse manager (RN #1) was interviewed on 4/9/14 at 8:44 AM and stated that the resident had a suspected deep tissue injury in the sacral area that was resolved on 3/27/14. RN #1 stated that the resident currently had one pressure ulcer, a "small opening" at the same sacral site of the healed deep tissue injury. RN #1 stated that the Certified Nurse Aide assigned to the resident's care on the 7-3 day shift (CNA #4) had reported the small opening to RN #1 on 4/4/14 and that CNA #4 reported that the area "was starting to break up." RN #1 stated that the area was being treated. The Licensed Practical Nurse assigned to the resident's care on the 11-7 night shift (LPN #3) was interviewed on 4/11/14 at 7:15 AM. LPN #3 stated that she was not aware of the skin condition of the resident's sacral area because it was dressed and no dressing changes were performed on her shift. LPN #3 stated that she expected the CNA (Certified Nurse Aide) to report to her if the resident had any skin breakdown. RN #1 was further interviewed on 4/10/14 at 11:15 AM and revealed that she had not assessed the resident's skin since CNA #4 had reported the small opening in the sacral area on 4/4/14. The resident's sacral skin condition was then observed with RN #1 and CNA #4 during the interview above. RN #1 and CNA #4 turned the resident, cleaned away feces from the area and removed a dressing from the resident's sacral area. Reddened skin was present in the sacral area that measured approximately 4.0 cm by 5.0 cm. Two areas with Stage 2 characteristics and an area with Stage 3 characteristics were noted in the middle of the reddened area. The surrounding skin had more pronounced redness and was macerated (softened and deteriorating tissue from exposure to moisture) with slight slough formation (yellow, fibrous, non-viable tissue) noted on the edge of the Stage 3 area. CNA #4 was interviewed immediately after the above observation. CNA #4 stated that the resident had no skin breakdown or dressing in place until a week ago. CNA #4 stated that she observed a small skin opening in the resident's sacral area and reported it to RN #1 a week ago on 4/4/14. CNA #4 stated that the area had been covered with a dressing and she had not seen the area since she noted and reported the skin opening. CNA #4 stated that the resident's current skin condition did "not look good" as compared to the small opening that she observed and reported a week ago. RN #1 stated, during subsequent interview on 4/10/14 at 1:00 PM, that she did not classify the pressure ulcer and did not document her initial observations to describe the condition of the pressure ulcer or surrounding skin on 4/4/14. RN #1 stated that the pressure ulcer had no drainage or odor at that time. RN #1 further stated that she phoned the attending physician on 4/4/14. RN #1 stated that she (RN #1) recommended the use of Calcium Alginate wound dressings because she had observed the Wound Care Consultant order Calcium Alginate "for this kind of pressure ulcer." RN #1 stated that the physician then gave orders not to position the resident on her back, to cleanse the sacral wound with normal saline and then apply Calcium Alginate with a dry protective dressing. RN #1 stated that the physician relied on the Wound Care Consultant to manage the resident's pressure ulcer. RN #1 stated that the Wound Care Consultant was responsible for initiating a wound tracking record for the resident to document classification of the pressure ulcer, description of the wound condition and treatment plans to be implemented. RN #1 further stated that the Wound Care Consultant or the attending physician had not seen the resident on or since 4/4/14. RN #1 also stated that the assigned nurses were supposed to document any change in the resident's skin condition in the Progress Notes and that RN #1 expected the nurses to report changes or worsening in skin condition to her promptly. RN #1 stated that she had not received any reports from the nurses about the resident's skin condition. There was no documented evidence in wound tracking reports, Weekly Skin Integrity Review records, Treatment Administration records, physician progress notes [REDACTED]. Three unit Licensed Practical Nurses (LPN #4, #5, #6) were interviewed on 4/10/14 between 1:15 PM to 1:30 PM and they stated that many nurses performed wound dressings for the resident. The LPN assigned to care for the resident on 4/10/14 (LPN #4) was interviewed on that date at 12:05 PM. LPN #4 stated that today was her first time performing the resident's wound dressing. LPN #4 stated that she could not find any information in the clinical record as to the condition or progression of the pressure ulcer prior to that date. During further observation of the resident's sacral area with the RN #1 on 4/11/14 at 1:15 PM, RN #1 stated that, until the previous day with the surveyor, she had not inspected the resident's skin since 4/4/14. RN #1 stated that the sacral pressure ulcer appeared to be worsening as compared to the small opening that she observed on 4/04/14. RN #1 stated that the treatment nurses had not reported to her that the pressure ulcer was not improving despite daily wound treatments being done. RN #1 further stated that the care plan had not been reviewed since 4/4/14. RN #1 also revealed that the Wound Care Consultant assessed other residents with Stage 3 and Stage 4 pressure ulcers on 4/10/14 but RN #1 did not request assessment of the resident and the wound Care Consultant did not assess the resident's skin condition. The attending physician was interviewed on 4/11/14 at 2:00 PM and stated that he would not have ordered Calcium Alginate dressing unless the pressure ulcer was "weeping" or had a discharge. The physician stated that he had trusted RN #1's assessment and that the resident should have been seen by the Wound Care Consultant. According to the RN #1, The Wound Care Consultant was not available for interview. The corporate Physical Therapist (PT), who was trained in wound care, evaluated the resident's sacral pressure ulcer on 4/13/14. The PT documented his findings in the Wound Care Consult record, stating that, the resident had a Stage 3 pressure ulcer measuring 4.0 cm by 5.5 cm by 0.1 cm, 25% granulation with slough tissue formation noted and light, thin serous drainage present. The attending physician was interviewed on 4/14/14 at 12:55 PM and stated that he examined the resident on 4/12/14. The physician stated that he found that the sacral wound had two Stage 2 areas and that the surrounding skin was at Stage 1 level, with non-blanchable areas. The physician stated that he also observed a Stage 3 area located centrally in the reddened area with slight slough formation and maceration. The physician stated that he discontinued the use of the Calcium Alginate and replaced it with a [MEDICATION NAME] ointment (an enzymatic [MEDICATION NAME] agent used in healing skin ulcers by breaking up and removing dead skin and tissue). 2. Resident #192 is [AGE] years old with [DIAGNOSES REDACTED]. The MDS assessment of 2/17/14 indicated that the resident had severely impaired cognitive skills in daily decision making and was totally dependent on others to perform most aspects of activities of daily living including bed mobility, transfer, personal hygiene and toileting. This MDS also indicated that the resident had no pressure ulcers and that he was at risk for developing pressure ulcers. The care plan for Impaired Skin Condition of 3/24/14 indicated that the resident was readmitted to the facility on that date with a sacral pressure ulcer. Numerous care plan interventions were identified and included frequent or routine check of the skin for pressure ulcers. During an initial interview with RN #1 on 4/9/14 at 8:41 AM, RN #1 stated that the resident had no pressure ulcers. RN #1 stated that the resident was readmitted to the facility on [DATE] with an open area to the left gluteal fold which was resolved on 4/3/14. The Treatment Administration Record (TAR) for April 2014 indicated that treatments were completed on 4/3/14 on the left gluteal fold on 4/3/14. No current pressure ulcer treatments were noted. The resident was observed in bed during care on 4/10/14 at 11:50 AM. An open area on the right buttock measuring 1.0 cm x 1.0 cm was noted and the surrounding skin was reddened. The LPN assigned to the resident's care (LPN #2) was present at the above observation and stated that this skin opening was new and that she needed to inform the attending physician or the Wound Care Consultant. During further interview with LPN #2 on 4/10/14 at 12:00 PM, she stated that the resident had a Stage 2 pressure ulcer on the sacral area which was healed about a week ago. LPN #2 stated that the assigned CNA, CNA #1, did not report any skin breakdown on the buttock to LPN #2. There was no documented evidence that this pressure ulcer was addressed in Physician's or Nurse's Progress Notes, wound tracking record or care plan. The Wound Care Consultant evaluated the resident on 4/10/14 at 12:15 PM and documented in the wound tracking record that the resident had a Stage 2 pressure ulcer on the right buttock measuring 1.0 cm by 0.5 cm by less than 0.1 cm with excoriation of the surrounding tissue. The Wound Care Consultant recommended a topical treatment for [REDACTED]. CNA #1 was interviewed on 4/10/14 at 12:45 PM and stated that she found a small skin opening on the resident's right buttock which did not look bad when she cleaned and inspected the resident's skin early that morning. CNA #1 stated that she did not report it to the nurse because she thought that this skin opening was always there. The 11-7 shift RN #2 assigned to the resident on 4/10/14 was interviewed on 4/11/14 at 7:00 AM. RN #2 stated that the resident had a pressure ulcer on the sacral area when he was re-admitted to the facility on [DATE] that was healed on 4/3/14. RN #2 stated that the assigned 11-7 CNA shift on 4/10/14 (CNA #2) did not report to her that the resident had any new skin breakdown. CNA #2 was interviewed on 4/11/14 at 7:05 AM and stated that she was aware of the pressure ulcer. CNA #2 stated that she did not inform nurse in charge of the skin opening on the resident's right buttock because she thought it was always there. 415.12 (c) (2) Based on observation, record review and interviews conducted during a Post Survey Revisit, the facility did not ensure that care and monitoring to prevent development, to promote healing and to prevent deterioration and potential infection of pressure ulcers was provided for one of three residents reviewed for pressure ulcers (Resident #179). Specifically: 1. A pillow under the resident's calf to offload pressure and a protective dressing were not in place for a Stage 2 pressure ulcer on the left heel that was draining fluid and was described as having slough and/or eschar (non-viable tissue). 2. Initial and ongoing monitoring of a reddened area on the resident's right heel was not performed by a qualified health professional and a protective dressing was not in place as ordered by the physician. This resulted in the potential for more than minimal harm that is not immediate jeopardy. The findings are: Resident #179 is a [AGE] year old who is legally blind and has a [DIAGNOSES REDACTED]. According to the 1/30/14 Minimum Data Set (MDS) assessment for a significant change in the resident's status and the most recent 5/1/14 quarterly MDS assessment, the resident had a score of 3 out of a possible 15 on a Brief Interview for Mental Status (BIMS) test used to measure orientation and ability to recall information. These MDS assessments also identified that the resident was non-ambulatory, required total to extensive assistance with bed mobility, was totally dependent on others for transferring, personal hygiene and toileting and was always incontinent. The MDS assessments further identified that the resident had no pressure ulcers but was at risk for developing pressure ulcers. Ulcer and Pressure Sore Risk Assessments, dated 11/22/13, 2/11/14 and most recently 5/1/14, also identified that the resident had risk factors for the development of pressure ulcers including a history of pressure ulcers, problems with bed mobility and transfer and cognitive impairment. According to these documents, assessment that any of these factors was present, "would identify the resident at risk and trigger the implementation of specific and individualized preventive measures and a comprehensive care plan." physician's orders [REDACTED]. No interventions for heel protection when out of bed were identified. There was no evidence that a care plan with measurable goals and interventions to address prevention of pressure ulcers was developed for the resident. A Licensed Practical Nurse (LPN #A) documented in a Nurse's Note, dated 6/15/14, that both of the resident's heels were slightly red. LPN #A obtained an order from the resident's physician on that date, 6/15/14, to apply dry protective dressings to both of the resident ' s heels daily for redness. There was no documented evidence in the Treatment Administration Records that dry protective dressings were applied to the resident's heels on 6/16/14. There was no evidence that a Registered Nurse, Nurse Practitioner, Physician or other qualified health professional assessed the skin condition of the resident's left heel from the time redness was reported by LPN #A on 6/15/14 until 6/17/14. According to a Wound Care Consult sheet that was signed by the Registered Nurse/Unit Manager (RN) and dated 6/17/14, the skin condition of the resident's left heel had deteriorated and the resident then had a Stage 2 pressure ulcer on the left heel that measured 2 cm by 2 cm. No depth, a characteristic of a Stage 2 pressure ulcer, was described. Interventions noted on the 6/17/14 Wound Care Consult sheet included the use of a pillow under the resident's calf and heel protectors. Telephone orders for treatment of [REDACTED]. The orders instructed to cleanse the Stage 2 pressure ulcer on the left heel with normal saline solution, pat dry, apply Hydrogel and cover the heel with a dry dressing twice a day. Two days after the Stage 2 pressure ulcer of the left heel was noted, a Wound Care Consult form, signed by the Wound Care Physician and dated 6/19/14, described the left heel pressure ulcer as deteriorated and with slough and/or eschar (non-viable tissue), which measured at the upper aspect as 1.5 x 0.5 cm and at the lower as 1.5 x 1.5 cm. The physician ordered a change of treatment from hydrogel twice a day to [MEDICATION NAME] daily. Use of a protective dressing, pillow under the calf and heel protectors were continued. Wound Care Consult sheets, Nurse's Notes, other Progress Notes and physician's orders [REDACTED]. The skin condition of the resident's right heel, that was documented in a Nurse's Note by LPN #A to be slightly red on 6/15/14, was not described in a Wound Care Consult sheet, Nurse's Notes, other Progress Notes or in physician's orders [REDACTED]. No interventions for off-loading of pressure to the resident's right heel were identified. The Registered Nurse/Unit Manager (RN) was interviewed at 1:30 PM on 6/19/14. The RN was provided an opportunity to review the resident's clinical record and did not locate a care plan for prevention of pressure ulcers. The RN did provide a care plan dated 6/17/14, which addressed the actual impairment of skin integrity on the resident's left heel, subsequent to the deterioration to a Stage 2 pressure ulcer, with interventions that included use of heel pads. There were no interventions to address monitoring or care for the resident ' s right heel. The RN stated that she thought a care plan for pressure ulcer prevention was in place for the resident and that she was not aware of why there was a lack of monitoring and treatment of [REDACTED]. The Resident was observed on 6/19/14 at 2:20 PM in the day room. She was seated in a reclining chair with her legs elevated and with blue heel boots in place. There was no pillow in place below her calf and her heels were in resting on the footrest of the chair. The resident was again observed in bed on the morning of 6/20/14 at 8:50 AM being assisted with breakfast. The resident had blue boots on both feet. There was no pillow present below either calf. When the resident had completed her breakfast, the Registered Nurse Unit Manager, upon request, removed the blue boots in order for the surveyor to observe the prescribed protective dressings. No dressings were in place on either of the resident's heels at that time. The pressure ulcer on the resident ' s left heel had drainage which appeared on the blue boot and created the potential for development of infection. The skin on the resident's right heel, which was described as slightly red on 6/15/14, was now noted to have an open pressure ulcer that was not covered by a protective dressing and resulted in the potential for development of infection. The Registered Nurse Unit Manager then assessed the resident's right heel and described a Stage 2 pressure ulcer measuring 0.5 cm x 0.5 cm. The resident's physician was contacted and gave a telephone order for the right heel pressure ulcer to be cleansed with normal saline, to apply [MEDICATION NAME] treatment and cover with a dry protective dressing. The Certified Nurse Aide (CNA #A) who was caring for the resident on this day, 6/20/14, was interviewed at 10:15 AM. CNA #A stated that she had never cared for this resident before and that, when she, CNA #A arrived on the unit at 7:30 AM, the resident was resting on her right side. CNA #A stated that she removed a pillow from under the resident ' s sheets and positioned the resident on her back in preparation for breakfast. CNA #A verbalized no knowledge that protective dressings and a pillow for off-loading pressure were supposed to be in place for the resident. Attempts to reach the CNA who cared for the resident on 6/19/14 were unsuccessful. LPN #B, who worked during the day shift on 6/19/14, was interviewed by telephone at 11:15 AM on 6/20. LPN #B stated that he had completed the dressings for the resident on 6/19/14 according to instructions in the treatment book but, that he was unable to recall, during this phone interview, the specific treatment. LPN #C, who worked during the evening shift on 6/19/14, was interviewed by telephone on 6/20/14 at 10:45 AM. LPN #C stated that she had not carried out any treatments for pressure ulcers for this resident. LPN #C stated that treatments for the resident ' s pressure ulcers were completed during the day shift. LPN #D, who worked during the night shift on 6/19/14, was interviewed by telephone on 6/20/14 at 1:45 PM. LPN #D stated that she had administered medications to the resident and did not notice any dressings out of place. The Wound Care Physician was interviewed by telephone on 6/20/14 at 2:10 PM and stated that she observed the pressure ulcer on the resident's left heel on 6/19/14. The Wound Care Physician stated that she was not aware that there was a problem with the right heel and had not observed it. A Physical Therapist, who stated that he accompanied the Wound Care Physician on wound rounds on 6/19/14, was interviewed on 6/20/14 at 1:00 PM. The Physical Therapist stated that they removed the dressing to look at the wound on the resident's left heel. The Physical Therapist stated that they did not look at the right heel and that, on rounds, they only look at wounds the unit communicates to them. 415.12(c)(1)

Based on observation, interview and record review, the facility did not ensure adequate supervision for residents with histories of falls, both prior and subsequent to falls with injuries, and who continued to be at high risk for further falls. This was evident for two of five residents reviewed for accidents and resulted in actual harm, specifically, head injury requiring sutures for Resident #4 and hip fracture requiring surgery for [REDACTED].#4 and "safety devices" for Resident #22, resulting in the potential for more than minimal harm that is not immediate jeopardy. THIS IS A REPEAT DEFICIENCY The findings are: 1. Resident #4 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The resident was ventilator dependent, had feeding and breathing tubes, was non-ambulatory and required the extensive assistance of two people to transfer to a recliner chair, according to the 7/12/12 Admission MDS (Minimum Data Set) assessment. An entry in the Nurse's Notes on 7/5/12, the day of the resident's admission, stated that he pulled out his breathing tube twice and that wrist restraints were applied. The resident's 7/5/12 Admission physician's orders [REDACTED]. An Initial Restraint assessment was completed by the multidisciplinary team on 7/6/12 and stated that the resident was disoriented, confused and pulling out his breathing tube, did not respond to verbal redirection and required the use of bilateral wrist restraints. The resident also had an initial Fall Risk Assessment completed by an RN on 7/6/12 that indicated that he was at High Risk for Falls, with a score of 14 (10 or above represents High Risk). Risk factors identified included being intermittently confused and chair bound. Accident/Incident (A/I) Reports for the resident revealed that the resident fell from the chair in his room with wrist restraints "loose" but in place at 2:30PM on 7/8/12 and sustained a hematoma of the right forehead. Recommended steps to prevent recurrence included the use of bed and chair alarms. The facility in the 7/8/12 incident investigation, did not identify or address the potential risk of serious injury with continued use of wrist restraints for this active resident. The resident's Care Plan for Restraints/Restrictive Devices was initiated on 7/9/12 and stated that wrist restraints and side rails were in use because the resident was very restless in bed and unable to recognize the danger of climbing out of the bed or chair. Again, the facility did not address the potential risk of serious injury with continued use of wrist restraints and side rails for this active resident. The resident's Care Plan for Incident/Accidents related to Fall/Injury was initiated on 7/9/12. Interventions included the use of bed and chair mat-type alarms to implement the Falling Star Program, provide supervision as needed and monitor at frequent intervals. The interventions also included to "monitor, evaluate and implement care that addressed needs regarding frequent falls/accidents." The CNA Resident Profile had no instructions related to the frequency of supervising or monitoring the resident. A/I Reports for the resident were further reviewed and revealed that the resident fell from the chair in his room without injury with wrist restraints loose but "still tied" at 1:30PM on 7/14/12. According to the statements obtained as part of the investigation, the last known observation of the resident was 30 minutes prior to discovery. There was no evidence that the Director of Nursing (DON), who was responsible for the Accident/Incident investigation, or the multidisciplinary team considered whether or not the supervision provided to the resident was adequate. The DON and the team did not identify the potential risk of serious injury with continued use of wrist restraints for this active resident. No recommendations to prevent recurrence of accidents and injuries were identified in the investigative process and there was no revision to the resident's Care Plan at that time. The Physician examined the resident following the fall on 7/14/12 and documented in the Progress Notes to try not to restrain the resident. The multidisciplinary team performed a Follow-Up Restraint Assessment for the resident on 7/17/12 and determined that the continued use of bilateral wrist restraints was required because of attempts to remove the breathing tube. The resident fell from bed with both side rails up and wrist restraints in place at 1:45PM on 8/11/12, according to the A/I Report of that date. He sustained a small laceration above the right eyebrow. The last known observation of the resident identified in the investigation was 1 hour and 20 minutes prior to discovery. The facility did not investigate to determine whether supervision had been provided as per the Care Plan or consider whether the degree of supervision was adequate to protect the resident from accidents and injuries. An LPN documented in her investigative statement for the 8/11/12 incident that the resident was constantly climbing out of bed. The facility did not address the potential risk of serious injury with continued use of side rails and wrist restraints for this active, unattended resident. The recommendation to prevent recurrence was for the Physician to review the resident's medications. The resident was given a "STAT" dose of Ativan, an antianxiety medication, for agitation following the incident and the use of Seroquel, an antipsychotic medication, every evening was initiated the next day on 8/12/12. Nurses Notes revealed the resident was moved to a room across from the nurses' station on 8/16/12. Further review of A/I Reports revealed that the resident fell from his chair at the nurses' station with wrist restraints in place at 2:50PM on 8/29/12 and sustained a laceration above his right eyebrow that required 10 sutures. No recommended steps to prevent recurrence were identified through the investigation of the incident and the Care Plan was not revised. The facility did not address that three of three accidents with injuries for this resident involved the right side of his forehead and did not initiate use of an intervention to protect him from further injury to that area. The resident's Physician, who is also the Medical Director, documented in the Monthly Medical evaluation and Progress Note on 9/1/12 that the justification for the use of the resident's restraints was multiple falls with injury. physician's orders [REDACTED]. The resident was observed lying in bed unattended at 10:00AM on 9/6/12 with 3/4 length side rails raised on both sides of his bed and left and right wrist restraints in place securing his arms to the bed frame. The resident moved about continuously in the bed. He turned onto his left side with his right shoulder twisted and right arm extended behind him, bound by the then taut wrist restraint tied to the bed frame. The resident could be seen from the nurses ' station. Surveyor observied resident at his bedside wriggling about in a recliner chair, unattended, at 4:30PM on 9/6/12. Both arms were tied in place with wrist restraints attached to the chair. The resident moved all of his extremities, lurched forward repeatedly and attempted to rise by pushing both of his arms down on the armrests. He then slouched down, rested his arms on the armrests, raised his hips and legs and attempted to remove his stretch pants while his arms were restrained at the level of his waist. The chair pad device did not alarm. The resident could not be observed from the nurses ' station. Two evening shift CNAs (Certified Nurse Aides) #1 and #2, attended to the resident at 5:00PM on 9/6/12. He was responsive to their simple commands and redirection. The CNAs stated that the resident had to be restrained in the bed and the chair because he tried to pull his tubes out. They stated that they supervised the resident and removed the restraints during care and every hour for about ten minutes. The CNAs also stated that they checked on the resident often between caring for other residents, as much as possible, but at no specific interval. The CNAs stated that they talked to the resident which calmed him down. The CNAs further demonstrated that the resident had to lift his body completely off the chair pad for the device to alarm. They stated that the resident could move in the bed or chair but the alarm would not sound until the resident moved completely off of the pad. The resident was observed quiet in bed with the side rails elevated and his wrist restraints off at 11:15AM on 9/7/12. He was supervised at that time by an LPN (Licensed Practical Nurse) who stated that the side rails remained up but the wrist restraints were removed every hour from two minutes to up to fifteen minutes, depending on how much the resident was trying to pull out his tubes when his hands were free. The LPN stated that the resident was often quiet, sleeping one minute and climbing out of the bed a minute later. She stated that sometimes the resident responded to redirection and sometimes he did not. The LPN further stated that sometimes the resident was "wild" at about 2:00PM - 3:00PM, pulling on his tubes and attempting to climb out of bed. Two day shift CNAs, #3 and #4, were interviewed at 12:20PM on 9/7/12. They stated that the resident had to have wrist restraints because he pulled his tubes and moved around all of the time in the bed and the chair, except when he was asleep. The CNAs stated that the resident had to have the side rails up because he has fallen out of bed. The CNAs stated that they checked the resident every hour when he was sleeping and every half hour when he was awake because he put his legs over the rails and tried to get out of bed a lot. They stated that they also checked on him because the resident removed his pad alarm when he could reach it and some staff members did not position it out of the resident's reach. The RN Manager was interviewed at 1:45PM on 9/7/12. She stated that the Falling Star Program, identified above as a Care Plan intervention to prevent incidents/accidents, consisted of a small sticker at the resident's doorway to indicate to staff members that the resident was at high risk for falls. The RN stated that the frequency of supervision and monitoring expected for the resident, per the Care Plan, was not specified. She stated that all staff members were expected to peek at the resident and to check on him because of his high risk for falls. The RN further stated that she did not know how the resident fell , within seconds, even if he was just checked. She added that he fell two minutes after he was seen at the nurses' station on 8/29/12. The DON, who was responsible for A/I investigations, was interviewed at 3:00PM on 9/7/12. The DON stated that wrist restraints were necessary because the resident pulled out his breathing tube. The DON stated that the resident had side rails so that he would not roll out of bed because he moved all over the place. She stated that the side rails were also used to prevent the resident from trying to get out of bed because he threw his legs up over the rails. The DON additionally stated that the resident was last seen within minutes of when he fell from the chair at the nurses' station and sustained the head injury that required suturing on 8/29/12. She stated that, when he was discovered, the resident had freed himself of one wrist restraint and that the other was entangled around his leg in such a manner that several staff members had difficulty releasing him from the restraint. In a further interview with the DON on 9/7/12, she stated the facility did not address the potential danger of serious injury for the resident when unsupervised which was compounded by the use of physical restraints. The facility did not identify that three of four accidents occurred on the weekend. The facility did not identify that four of four accidents occurred at the same time of day, between 1:30PM and 2:50PM, despite the observation made by the LPN above. The facility did not evaluate whether or not the level of supervision provided for the resident, at least at that time of day, was adequate. The DON stated that she reported any A/Is that were of concern to the Administrator on a daily basis. The Administrator was interviewed at 3:45PM on 9/7/12 and stated that he was aware of the resident's two most recent falls. He stated that he was recently employed at the facility and was not aware that the resident had a prior history of falls. The Administrator stated that he had considered each of the two falls known to him as isolated events. The resident's Physician, who was also the Medical Director, was interviewed by phone at 2:00PM on 9/11/12 and was familiar with the resident. The Physician was aware that the resident had multiple falls and injuries. The Physician stated that he was not involved in the review of the resident's A/Is other than from the perspective of medical management. 2. Resident #22 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. According to the initial MDS (an assessment instrument) the resident scored 15 out of 15 (alert and oriented) during the Brief Interview for Mental Status (BIMS) portion of the assessment; required extensive assistance with transfer, limited assistance with ambulation in her room, occasionally incontinent of bladder and used a wheelchair for locomotion. The resident's initial Comprehensive Care Plan (CCP) dated 11/30/11 noted that the resident was at risk for incident or accident related to inability to comprehend need for dependence on others. The goals to address the resident's safety were to "Be free from fall/injury" and to "Maintain maximum independence without inhibiting safety." The interventions to achieve these goals included: reduce personal environment risk factors; teach/supervise/assist safe ambulation and transfer techniques; assess ambulation status; communicate need for assistance to staff caring for resident; and monitor at frequent intervals. Fall Resulting in Injury The resident's CCP was reviewed and revised related to falls without injury correlated to use of the toilet on: 1/7/12 at 6:40AM, 1/15/12 at 7:30PM, and 1/29/12 at 3:15AM. The revisions included the use of bed and chair alarms and a Velcro belt. According to the 4/12 CCP, the resident had no further falls until 4/16/12. The Accident/Incident (A/I) report of this fall revealed that the resident was found on the floor near her bathroom at 6:30PM. The recommendation made to address this incident was to toilet the resident every 2 hours and a non skid pad was placed on her wheelchair. Three days later, on 4/19/12 the resident was found on the floor at 4:15PM according to another A/I. The Unit Manager/RN's statement attached to the A/I stated that the CNAs and nurses were instructed to keep the resident in eye contact while out of bed and to make sure that the belt and chair alarm are on at all times. The resident's CCP was revised to reflect this instruction. There was no written instruction on how the staff would keep the resident in direct eye contact at all times when she was not engaged in an activity and was not in her bed. Observations from 9/5/12-9/11/12 revealed that the unit on which the resident currently resides has 2 day/dining rooms. Staff are not assigned to supervise the day rooms when they are not in use for dining. Also, frequently throughout the shifts, no one is in the hallway to provide direct supervision. The resident's quarterly MDS dated [DATE] reflected that the resident achieved a BIMS score of 12 at that time and that the resident's ability to balance her self independently had declined and her lower extremity presents problems with daily function. The CCP dated 5/12/12 showed that the resident experienced another fall on that date at 3:15PM outside her bathroom in her room. The CCP dated 5/13/12 and an x-ray on 5/13/12 showed that the resident had experienced a left hip fracture related to the fall and was hosptalized on [DATE]. An A/I of the fall was completed on 5/12/12, which showed that the fall was unobserved. No investigation of the incident and statements from the CNAs and unit nurses were attached to the A/I. An interview with the Director of Nursing (DON) on 9/10/12 in the afternoon revealed that the incident was investigated but the report of the investigation, including statements from the CNA's, could not be found. The DON stated that her investigation had shown that the resident was last seen on 5/12/12 at 2:00PM by the CNA assigned to her care. The DON at that time was not able to address the supervision of the resident from the time she was toileted until the time of the fall on 5/12/12. The Unit Manger/RN was interviewed on 9/10/12 at 6:20PM. She stated the instruction to be "kept in eye contact when out of bed" means is that staff is to view the resident all times when she is out of bed. The Unit Manager also stated that the nurses (LPNs) on the unit are responsible to ensure that the resident is provided the supervision needed. The CNA #5 (a float) assigned to the resident on 5/12/12 at the time of the fall was interviewed via telephone on 9/11/12 at 2:25PM. She stated that after she toileted the resident at 2:00PM on 5/12/12 the resident went to the Rotunda (a large multipurpose room on the second floor). The resident returned to the unit unknown to her. The CNA further stated that she was busy with the care of other residents at the time of the incident. A follow-up interview with the DON on 9/11/12 in the morning revealed that on 5/12/12 (the day of the fall resulting in injury) after 2:00PM the resident attended a program in the Rotunda. Again, the DON provided no information of the supervision of the resident after she left the activity and went back to her room. The DON stated the the activity staff routinely assigned to the Rotunda do not informs the residential units whenever residents leave an activity. Interviews with the CNAs #6, #7, on the unit (see below) revealed that the resident frequently left activities while they are in progress. However, as the DON stated there is no system in place for the staff on the unit to be informed of the resident's departure from an activity. Current Supervision and Accident Hazard According to the current MDS dated [DATE], the resident obtained a BIMS score of 3, indicating that the resident had significantly declined in her cognitive status since her prior MDS of 4/30/12 and her admission to the facility. None of the above mentioned A/Is addressed the effectiveness of the supervision of the resident when she is out of bed and the ineffectiveness of the Velcro/quick release belt since her plan of care was revised on 4/19/12 to include being kept in direct eye contact when out of bed. Interview with CNAs #6, #7, and LPNs #1, #2, on the unit revealed lack of consistency regarding supervision of the resident while out of bed and no system in place to keep the resident in direct eye contact when she is out of bed and in her room. On 9/10/12 at 2:30PM the day shift, CNA #6assigned to the resident stated that the resident is placed in her room when she is not in activities. The resident watches television while in her room. This CNA did not explain how the resident would be in direct eye contact of staff when the resident is in her room. On 9/10/12 during the evening shift, the resident was observed in her room after attending an activity program in the Rotunda. At that time, the CNA #7 assigned to care for the resident stated that the resident spends most of the time on the unit in her room. This CNA did not explain how the resident would be in direct eye contact while she is in her room. Immediately following this interview, the evening shift LPN #1 was interviewed. She stated that the resident is supposed to be placed in the hallway at the nurse's station when she in on the unit. After this interview, the resident was observed seated in her wheelchair unattended in her room. The wheelchair had bilateral leg/foot rests extended out in front of the resident. These posed a tripping hazard to the resident in the event she stood and attempted to transfer or ambulate with no supervision/assistance. No staff members were at the nurse's station (not for from the resident's room). The staff members who were in the hallway at that time were congregated at the far end of the hallway not in view of the resident's room. The day shift LPN #2 was interviewed on 9/11/12 in the afternoon. She stated that when the resident is out of bed and not in the Rotunda, she is to be in the hallway near the nurse's station. However, the resident chooses to spend time in her room and is to be checked on by the staff intermittently. The resident's plan of care was not revised to address her preference to stay in her room when not in activities. On 9/11/12 in the afternoon, the DON stated that the resident was initially on the Dementia Unit (which has scheduled activities from 10:00AM to 3:00PM daily on the unit and provides direct supervision of residents in the day) but the resident's family objected to have the resident remain on the Dementia Unit. This interview with the DON revealed that the need for closer supervision of the resident such as provided on the Dementia Unit was not addressed with the resident's family after the resident returned from the hospital. Observation on the unit revealed that no activities are planned for the unit and staff is not assigned to the two day/dining rooms on the unit. Since the resident's return form the hospital on [DATE], she experienced one more unobserved fall from her wheelchair. According to an A/I, this fall occurred on 8/14/12 at 2:00PM as a result of the resident attempting to go to the bathroom. The resident was found by a housekeeper sitting by the toilet in her bathroom. According to a written statement obtained from the CNA assigned to the resident at that time the resident was last seen at 1:15PM. The investigation of this incident did not address the supervision of the resident and the toileting schedule of the resident. During an interview with the Physical Therapist (PT) on 9/11/12 in the afternoon, he stated that the leg/foot rest posed an accident hazard for the resident. The "rests" were requested by the resident's family. He (PT) had had the "rests" removed and he has no knowledge who reattached them. 415.12 (h)(1)(2)