Every finding on record at Norwich Rehabilitation & Nursing Center

Based on observations, record review, and interviews during the recertification and abbreviated (NY00353879) surveys conducted 7/29/2025-8/1/2025, the facility did not ensure a safe, comfortable, and homelike environment for two (2) of two (2) residents (Residents #39 and #80) reviewed and seven (7) anonymous residents present at the group meeting. Specifically, Resident #39's room and bathroom had a strong odor of urine; Resident #80 had missing clothing items and a wheelchair with a wheel in disrepair; and seven (7) anonymous residents reported they had items missing from laundry.Findings include:The facility policy Assistive Devices and Equipment, dated 2/2022 documented certain devices and equipment that assisted with resident mobility were provided for residents. In the event equipment was not functioning or was in poor repair, it was immediately removed from use and a replacement device implemented in a timely manner. The facility policy Quality of Life-Homelike Environment, dated 3/2022, documented the facility would reflect a personalized, homelike setting to include such characteristics as an orderly environment and pleasant, neutral scents; and management would minimize, to the extent possible, institutional odors.The facility policy Personal Belongings, revised 3/2023, documented a resident's personal belongings and clothing would be inventoried and documented upon admission and when such items were replenished.The facility policy Resident Clothing/Laundry and Labeling Procedure, revised 9/2024, documented resident clothing would be labeled and logged to prevent loss while in the facility and clothing should be labeled and returned to the unit within 72 hours of admission, re-admission, receipt. During an anonymous group meeting on 7/29/2025 at 2:10 PM, seven residents reported they had lost clothing. Clothing and washable items went missing even if labeled, and staff said they would look for it but did not follow through. 1) Resident #39 had diagnoses including diabetes. The 7/11/2025 Minimum Data Set assessment documented cognition was not assessed, the resident was frequently incontinence of urine and required moderate assistance with most activities of daily living. The 8/5/2024 Comprehensive Care Plan, revised 2/4/2025, documented the resident had frequent incontinence related to decreased mobility. Interventions included the resident would request assistance to the bathroom; change brief when incontinent and when needed; and change clothing as needed after incontinence episodes. The July 2025's Daily Housekeeping Completion Checklists documented the following:-Resident #39's bathroom received all disinfecting/cleaning tasks daily.-Resident #39's bedroom received all disinfecting/cleaning tasks daily except 7/14/2025, 7/20/2025 and 7/24/2025. -Resident #39's bathroom received a deep cleaning or multiple cleanings on 7/1/2025, 7/2/2025, 7/3/2025, 7/7/2025, 7/9/2025, 7/10/2025, 7/11/2025, 7/12/2025, 7/15/2025, 7/23/2025, 7/26/2025, 7/27/2025, and 7/30/2025.During an observation on 7/29/2025 at 11:31 AM Resident #39's room had a strong smell of urine and was strongest on Resident #39's side of the room.During an interview and observation on 7/30/2025 at 11:38 AM Resident #39's two family members stated they picked up dirty laundry three times a week. The dirty clothes were kept in a laundry basket located next to the resident's bed. The laundry was not in bags, so they brought their own bags to put the soiled clothing in to take home to wash. They noticed a smell as if the clothing was sitting a while. The resident stated when their dirty clothes were in the laundry basket and were not in a bag, the smell was not contained and was not pleasant. During an observation on 7/31/2025 at 9:41 AM, the resident's hamper was next to the head of the bed. The hamper was more than half-full of clothing and smelled of urine and was not in a plastic bag. During an observation on 8/1/2025 at 9:15 the resident's room smelled of urine and was stronger in the bathroom near the toilet. During an interview on 8/1/2025 at 9:18 AM, Certified Nurse Aide #17 stated if family did the laundry, dirty clothing was placed in a plastic bag in a laundry basket kept in their room. Resident #39's family did their laundry, and the hamper was kept in their room right next to their bed. The resident resisted toileting help, and would only asked for help if their clothing was wet and needed changing. They cleaned the floor as best they could and reported any concerns to housekeeping. During an interview on 8/1/2025 at 9:26 AM Housekeeper #16 stated they cleaned Resident #39's room first each day and often cleaned it multiple times a day due to the odor. Yesterday they used shaving cream on the bathroom floor, which helped. They had talked to their supervisor about it in the past.During an interview on 8/1/2025 at 9:30 AM, the Director of Environmental Services #3 stated they were made aware about 3 months ago that Resident #39's bathroom smelled of urine. They stated all they could do was keep cleaning it. They had not tried any other cleaning products as it would be too risky not knowing how the resident might react. 2) Resident #80 had diagnoses including congestive heart failure. The 7/11/2025 Minimum Data Set assessment documented the resident's cognition was intact, utilized a manual wheelchair, and required substantial assistance with wheelchair mobility. The 7/7/2025 Comprehensive Care Plan documented an activities of daily living self-care performance deficit and physical mobility limitation. Interventions included the resident required limited assistance for locomotion using a bariatric wheelchair.During an observation and interview on 7/29/2025 at 2:48 PM Resident #80 stated they could not steer their wheelchair as it was so stiff. They stated they were missing shorts. The shorts had labels, but they were in the laundry now. They stated their family did their laundry, but some items were sent to facility laundry and did not come back. There was a sign on the closet documenting the family would do laundry.During an observation and interview on 7/30/2025 at 9:59 AM, the resident was sitting in their wheelchair. The left wheel on their wheelchair was frayed and they could not steer. They stated they told several staff for a week or two and was told by two higher ups that it would be fixed, but it was not.During an interview on 7/30/2025 at 2:28 PM Certified Nurse Aide #12 stated if a resident's walker or wheelchair was broken, they told therapy. They had a hard time pushing Resident #80's wheelchair for over a week. They told therapy and nothing was done.During an interview on 7/31/2025 at 8:50 AM Certified Nurse Aide #7 stated Resident #80 was missing laundry. Sometimes evening staff sent their items to facility laundry even though there was a sign on the door stating family did their laundry. During an interview on 7/31/2025 at 1:22 PM Receptionist #10 stated one of their job duties was to label property. When there was a new admission, they documented all items on an inventory list and labeled clothing with a permanent marker on the tag of the clothing. The inventory list went into the medical records mailbox to be scanned into the system. Once inventoried, all items went to the resident's room. If family brought in a bag of items, they asked if they were bringing back laundry or if there were new items to be inventoried. They had been told by residents they were missing clothing and reported that to social worker and the unit manager. They worked until 3:00PM and someone else covered the desk from 3:00 PM - 7:00 PM. The facility did not get admissions after 7:00 PM. During an interview on 7/31/2025 at 4:08 PM Housekeeper Supervisor #11 stated all clothing items were labeled by the receptionist. They were unsure if that was documented anywhere. Items were washed, hung and delivered within 24 hours. They did get clothes without labels and if they did not know whose clothing they were, the clothing was hung on a rack. They had many blankets not labeled. Resident #80's family did their laundry, but they still saw the resident's items in laundry and had just labeled their shorts as they had to return them. During an interview on 7/31/2025 at 12:20 PM Physical Therapist #13 stated if someone had a broken wheelchair or walker one of the therapists should be told. They were not notified Resident #80's wheelchair was broken. During an interview on 8/1/2025 at 7:18 AM the Maintenance/Environmental Service Director #3 stated they had heard about residents and their missing clothing. If they could not find the missing items, they called family members to see if they were taken home and searched every closet until they found it. If they could not find the items, they notified the Administrator. Sometimes things did get put in the wrong closet. They never threw clothing away. If a walker or wheelchair was not working, maintenance or therapy were notified. They looked at Resident #80's wheelchair stated the rubber on the wheel needed to be replaced. During an interview on 8/1/2025 at 7:33 AM Occupational Therapist #14 stated their department made sure wheelchairs were in proper working order. If a wheel was broken, they would fix it. If a wheel was broken it could make it harder to self-propel. They were not aware Resident #80's wheelchair was not working. They looked at the wheelchair and stated the wheel was broken. They could not replace the rim but could replace the wheel if they had the part. During an interview on 8/1/2025 at 8:59 AM Registered Nurse Unit Manager #6 stated if a wheelchair was broken therapy should be notified. They did not know the wheel was broken.During an interview on 8/1/2025 at 12:23 PM the Director of Rehabilitation #4 stated they fixed broken wheelchairs and if they could not be fixed, they threw them away. It was important wheelchairs were functioning properly for safety, comfort, and mobility. If something could not be fixed or had to order parts they would get a temporary replacement. During a follow-up interview on 8/1/2025 at 1:59 PM the Director of Rehabilitation Services stated equipment was checked every 3 months to include brakes and cushions. Equipment should be checked by all staff. If a problem was noticed, they would fix it. No one noticed Resident #80's wheelchair it and it was not brought to their attention. 10 NYCRR 415.29(j)(1)

Based on interview and record review during the recertification survey conducted 7/29/2025-8/1/2025 the facility did not develop and implement an effective discharge planning process that focused on the resident's discharge goals for two (2) of three (3) residents (Resident #1 and Resident #90). Specifically, there was no documented evidence of an ongoing discharge plan for Resident #1 and Resident #90.Findings include:The facility policy “Discharge Summary and Plan,” initiated 6/28/2025, documented when a resident's discharge is anticipated, a discharge plan will be developed. Every resident was evaluated for their discharge needs and would have an individualized post-discharge plan. The post-discharge plan was developed by the Care Planning/Interdisciplinary Team and included where the resident would reside, arrangements for follow-up care, resident's stated discharge goals, degree of caregiver/support person availability, capacity and capability to perform required care, factors that would make the resident vulnerable to preventable readmission and how those factors were addressed. The discharge plan was re-evaluated based on changed in the resident's condition or needs prior to discharge. The resident would be referred to local agencies and support services to assist in accommodating the resident's post-discharge preferences. 1) Resident #1 had diagnoses including cardiac arrest, coagulation defect, and atrial fibrillation (irregular heartbeat). The 7/1/2025 Minimum Data Set assessment documented the resident had intact cognition, required partial/moderate assistance with hygiene and oral care, and the discharge goal was a discharge back to the community. The 6/27/2025 Social Services Evaluation by Director of Social Services #9, documented Resident #1 was admitted for short term rehabilitation and active discharge planning was occurring for the resident to return to the community. The resident wished to be discharged back to their apartment where they lived alone. The 6/27/2025 physical therapy evaluation completed by Physical Therapy Assistant #20 documented Resident #1 required skilled physical therapy for gait training, facilitate functional mobility, promote safety awareness, improve dynamic balance, increase functional activity tolerance and increase lower extremity range of motion. The Comprehensive Care Plan initiated 7/2/2025, documented the resident wished to be discharged back to their apartment. Interventions included encouraging the resident to discuss feelings and concerns with impending discharge. The 7/27/2025 physical therapy evaluation completed by Physical Therapy Assistant #20 documented Resident #1 was ambulating 100 feet with a rolling walker and maintained standing balance without support against minimal resistance. There was no documented evidence of an ongoing assessment or re-evaluation of Resident #1's discharge goals. During an interview on 7/30/2025 at 10:26 AM, Resident #1 stated they were upset that they were functioning at their baseline and wanted to go back to their apartment. They were told by staff they could not be discharged because they required wound care for a facility acquired heel wound. They should be able to go home with homecare. During an observation and interview on 8/01/2025 at 1:04 PM, Resident #1 was using a rolling walker independently to ambulate. The resident stated they were very upset and felt depressed as physical therapy said they were ready to go home. During an interview on 8/1/2025 at 7:33 AM, Occupational Therapist #14 stated they were working with Resident #1, the resident's therapy had progressed and met all their goals. They were ready for discharge. During an interview on 8/1/2025 at 8:59 AM, Registered Nurse Unit Manager #6 stated Resident #1 had a right heel wound that was improving and required daily dressing changes. The Unit Manager spoke to the Director of Social Services yesterday and when the frequency of the dressing changes goes down to every three days the resident would be able to go home. During an interview on 8/1/2025 at 1:08 PM, Director of Social Services #9 stated they were responsible for coordinating and documenting the discharge progress. They met with the resident approximately 10 days ago and discussed their physical therapy goals. The resident had aide services prior to admission through the county. The interdisciplinary team met about the resident's discharge on [DATE] and it was determined the resident could not be discharged until the dressing changes were every three days as Home Care was not able to accommodate daily dressing changes. They did not document any discharge plan for Resident #1 and should have. 2) Resident #90 had diagnoses including fracture of left femur and orthopedic aftercare. The 7/18/2025 Minimum Data Set documented the resident had moderately impaired cognition, required moderate to substantial assistance for activities of daily living and dependent for transfers and mobility, and no active discharge planning for the resident. The Comprehensive Care Plan, initiated on 7/18/2025, documented the resident wished to be discharged back to their apartment, where they lived alone. The discharge goal stated the resident will communicate an understanding of the discharge plan and describe the desired outcome. Interventions included to encourage the resident to discuss feelings and concerns with impending discharge and to monitor for and address episodes of anxiety, fear, and distress. The 7/18/2025 Social Services Evaluation by Director of Social Services #9, documented Resident #90 had been admitted for short term rehab. They wished to be discharged back to their apartment. The 7/22/2025 admission Provider note documented the resident was admitted for rehabilitation and strengthening. The resident was refusing rehabilitation and they had a lot of challenging issues trying to get them home safely. The 7/22/2025 Social Services note, Director of Social Services #9 documented the resident wanted to be discharged against medical advice. They explained the risks of discharge to the resident and informed them that they were free to make the decision to leave the facility. The resident called their daughter and was told that their daughter would not be picking them up and to stay to receive care and physical therapy. The resident stated they were adamant about leaving and informed staff that they would hurt themselves if they could not leave. Social Work contact the residents Health Care Proxy and informed them of the resident's statement. The Health Care Proxy stated they would not support the resident leaving. The resident independently contacted the authorities reporting chest pain and was transported to the hospital by ambulance. The 7/22/2025 Emergency Department Nurses Note documented nursing called family to pick resident up from the hospital. Resident's daughter refused to pick them up and bring them home stating the resident did not have anyone in the home to care for her. The resident denied and stated their neighbors would help them. The hospital contacted the rehab facility and was told the resident was dependent and unable to walk because of a femur fracture. The hospital made the decision to send the resident back to the rehab facility. There was no documented evidence of an ongoing assessment or re-evaluation of Resident #90's discharge goals. On 7/31/2025 at 9:42 AM, Resident stated they still wanted to leave against medical advice. No one brought discharge paperwork or helped with discharge; they felt like they were being held hostage. They wanted a referral placed for full time skilled nursing to assist at home and to have physical and occupational therapy referral placed to get services at home. They wanted to go home so badly that regardless of needs they would what they had to do to leave. During an interview on 7/31/2025 at 9:21 AM, Social Services Director #9 stated that discharge planning was to begin on admission. They recorded resident's goals and what they thought they needed to achieve that goal to go home; they then discussed this with the interdisciplinary team and physical therapy. They usually met with the care team weekly to discuss residents. Resident #90 was able to make their own decisions, and their goal was to go home and live independently. The resident's family had concerns about their ability to maintain a quality level of living; the resident disagreed. The Resident was unsafe to go home and perform day-to-day tasks and would require full time skilled nursing care in order to be discharged safely. They had not placed any referrals for at home physical or occupational therapy for the resident. They had also not placed any referrals for full time skilled nursing care. They had multiple conversations with the resident regarding safety in the home and what type of care would be required. Social Services Director #9 stated there was no documentation of conversations with the resident regarding discharge planning and safety. They did not have any discharge plan after the discussion of the resident wanting to leave the facility against medical advice. 10NYCRR 415.11(d)(3)

Based on observations, interviews, and record review during the recertification survey conducted 7/29/2025-8/1/2025, the facility did not develop and implement a comprehensive person-centered care plan for each resident to include services provided to maintain the resident's highest practicable physical well-being for one (1) of one (1) resident (Resident #1) reviewed. Specifically, Resident #1 did not have a care plan for managing anticoagulant therapy (blood thinner).Findings include:The undated facility policy Care Plan-Timing and Revision, documented a comprehensive care plan was developed for each resident within seven days and included measurable objectives and timeframes to meet the resident's physical, mental, and psychosocial well-being. Assessments of the resident were ongoing, and care plans were revised when information about the resident and their condition changed. The comprehensive care plan was reviewed and updated by the interdisciplinary team when there was a significant change in the resident's condition, at least quarterly, and when the resident had been readmitted to the facility from a hospital stay. Resident #1 had diagnoses including cardiac arrest, coagulation defect, and atrial fibrillation (irregular heartbeat). The 7/1/2025 Minimum Data Set assessment documented the resident had intact cognition and received an anticoagulant. The 6/27/2025 physician order documented Eliquis (blood thinner) 5 milligrams twice a day for atrial fibrillation. The Comprehensive Care Plan initiated 6/27/2025 documented the resident had a pacemaker (electronic device implanted in the chest to regulate heartbeat) related to atrial fibrillation. Interventions included monitoring for malfunction and pulse lower than programmed rate. The Comprehensive Care Plan did not include use of an anticoagulant (blood thinner) or monitoring for bleeding precautions. During an interview on 7/31/2025 at 8:50 AM, Certified Nurse Aide #7 stated they were not sure if anticoagulant therapy should be in the resident's care plan but would like to know to monitor for bleeding when they shaved the resident. During an interview on 8/1/2025 at 8:37 AM, Licensed Practical Nurse #8 stated care plans were completed by the Registered Nurse Unit Managers along with department heads from social work, physical therapy, and activities. Anticoagulant therapy should be documented on the care plan so staff could monitor for bleeding precautions. Resident #1 was on an anticoagulant and should be monitored for bleeding. During an interview on 8/01/2025 at 8:59 AM, Registered Nurse Unit Manager #6 stated Resident #1 was on an anticoagulant administered and monitored by nursing staff. They were unaware it was not in the resident's care plan but thought it should be, so staff knew to monitor for bleeding. Care plans were completed by physical therapy, the infection control nurse, social work, activities, and Registered Nurse Unit Managers. Everything was manually added into the care plan. They referred to the resident's care plan and stated there was no documentation regarding anticoagulant therapy. 10NYCRR 415.11(c)(1)

Based on observations, record review, and interview during the recertification survey conducted 7/29/20225-8/1/2025, the facility did not ensure residents maintained acceptable parameters of nutritional status for one (1) of four (4) residents (Resident #3) reviewed. Specifically, Resident #3 had a significant weight loss, weekly weights were not completed as ordered, the medical providers were not notified of the weight loss and the resident had a functional decline in their eating ability and a referral for an occupational therapy evaluation was not submitted timely. Findings include:The facility policy, Weights, effective 3/2024, documented monthly weights were completed by the 7th of each month and weekly weights were distributed on Tuesdays and completed by end of day on Wednesday. The dietician was responsible to ensure weights were evaluated and notify the nurse manager to verify any weight variance of 5 pounds or more by immediate reweight. The dietician notified the nurse manager, medical doctor, and care plan team with any significant weight variance. Any variance of 5 percent in 30 days triggered the attending physician and responsible party was informed of the weight variance by the nurse manager or dietician and the same was documented in the resident's medical chart in the appropriate disciplines section. The facility policy, Nutrition (Impaired)/ Unplanned Weight Loss, effective 5/2025 documented nursing staff monitored and documented weight and dietary intake of residents. Five percent weight loss in a month was significant and greater than five percent was severe. The physician with the help of the multidisciplinary team identified conditions that may be causing weight loss such as a functional decline. Resident #3 had diagnoses including dementia, chronic kidney disease and heart failure. The 6/9/2025 Minimum Data Set assessment documented the resident had severe cognitive impairment, required supervision for eating, did not have weight loss and was on a mechanically altered diet.The Comprehensive Care Plan initiated 5/31/2024, and revised 5/22/2025 documented the resident had a nutritional problem and activity of daily living self-care performance deficit. Interventions included set up with meals, intake was monitored and recorded, supplements were provided as ordered, and weights were obtained per policy. The 4/28/2025 physician order documented weekly weights on Mondays. There was no documented evidence the resident's weights were obtained weekly from 4/28/2025-8/1/2025. The resident's documented monthly weights were, 224 pounds on 5/8/2025, 222.4 pounds on 6/3/2025 and 202 pounds (9.2 percent loss) on 7/1/2025. There was no documented evidence the 7/1/2025 weight was verified for Resident #3. The 7/14/2025 Registered Dietician progress note documented a weight decline of 20.4 pounds, a 9.2 percent weight loss in the past month was determined accurate. Meal intake ranged from 25 percent to 100 percent. Recommended changes included increasing the 2 calorie/milliliter supplement to four times a day and continued weekly weights as ordered. There was in no documented evidence the medical providers were notified of the resident's weight loss. On 7/27/2025, the Medical Director documented the resident was seen for a 60-day follow up visit. The Physical Exam noted a weight of 202 pounds and the Assessment and Plan did not include documentation related to Resident #3's weight loss. The July 2025 Activity of Daily Living Certified Nurse Aide Documentation included the resident required limited or extensive (more than set up) assistance with eating for:Breakfast meals on 7/9/2025, 7/12/2025, 7/14/2025, 7/19/2025, 7/25/2025, and 7/31/2025.Lunch meals on 7/4/2025, 7/9/2025, 7/11/2025, and 7/18/2025.Dinner meals on 7/9/2025, 7/10/2025, 7/12/2025, 7/15/2025, 7/18/2025, 7/20/2025-7/24/2025, 7/26/2025, 7/28/2025 (dependent), and 7/30/2025.During an observation on 7/30/2025 at 12:56 PM, Resident #3 was seated in their wheelchair at a table in the dining room. The resident had not eaten anything on their lunch tray but was drinking from their coffee mug. At 1:07 PM, the resident picked up their bread and ate it. At 1:23 PM the resident attempted to get their ziti and their green beans onto their fork but unable to do so. At 1:38 PM, they used their hands to attempt to get the ziti onto their fork. At 1:48 PM, Resident #3 was the only resident remaining in the dining room and observed picking up the ziti pasta with their hands and put it in a bowl. They were eating the ziti out of the bowl with a plastic spoon. Licensed Practical Nurse #23 was still present in the dining room. Staff did not provide any assistance to Resident #3 during the lunch meal. During an observation on 7/31/2025 at 8:45 AM, the resident was seated in their wheelchair at a table in the dining room for the breakfast meal. Occupational Therapist #25 sat with them while they ate. At 9:09 AM, the resident's food was moved to a scoop plate, the resident was given a weighted spoon, and a straw was placed in their prune juice. At 9:20 AM, Occupational Therapist #25 stated that the resident definitely needed more help with feeding and stated the scoop plate and the straws made a big difference in the resident's ability. The weighted spoon did not seem to make any difference. At 12:52 PM, Certified Nurse Aide #17 was sitting with the resident in the dining room for the lunch meal. They asked Licensed Practical Nurse #24 if they could assist a different resident because Resident #3 was eating independently with the scoop plate and a spoon. The 7/31/2025 Occupational Therapy evaluation by Occupational Therapist #25 documented a clinical impression that the resident required assistance with self-feeding at this time. Further skilled services were required to assess adaptations, improve thoroughness and attention, and the goal was increased intake. There was no documented evidence of an evaluation by Occupational Therapy prior to 7/31/2025. During an interview on 7/31/2025 at 1:19 PM, Certified Nurse Aide #17 stated Resident #3 used to eat independently but required cueing. Recently, often the resident's food just fell off the plate. The resident had needed more help over the past couple of months and they had to change their table location so they would be close enough to provide cueing. There was not enough staff to assist the resident's normally, and they often fed three residents at the same time. They reported the resident's increased difficulty in the past couple of months but there was a lot of turn over and they were not sure who they reported it to. The resident had lost weight because their clothes used to fit and now, they were big. They had not reported the noticeable weight loss. Weekly weights were printed and posted on Mondays, they did not know if the resident was a weekly weight. They were happy the resident was finally evaluated by occupational therapy and could eat independently again. During an interview on 8/1/2025 at 9:13 AM, Licensed Practical Nurse Unit Manager #15 stated the certified nurse aides reported weight loss and then a resident was reweighed. It was then reported to the dietician and the doctor. If the dietician put the resident on weekly weights, they were on a list that was emailed every Monday. Resident #3 lost weight because they had a decrease in appetite. There was a noticeable decline in the past couple of weeks and at times the staff had to feed the resident. They referenced the electronic medical record and did not know why the resident's weekly weights were not being completed as ordered. They looked at their emails and confirmed Resident #3 had been listed on the weekly email from the Registered Dietician as a weekly weight. They were also listed as a reweight. They were responsible to ensure weights were completed as ordered. They were also responsible to update medical of the significant weight loss and it was documented in a note. They did not notify medical of the weight loss, but they should have. During a telephone interview on 8/1/2025 at 10:53 AM, the Registered Dietician stated they reviewed weights three times a week. They expected weekly weights were completed as ordered and sent out an email every Monday with the weights that needed to be completed. The weights were part of the equation to determine nutritional needs. They requested a reweight on Resident #3 because of a 20-pound weight loss. They were still waiting on a reweight since 7/1/2025. Reweights were due by the 10th of the month. They did not notice that weekly weights had not been completed as ordered but did have the resident listed as a weekly weight on the weekly emails. They did not have verbal conversations with the unit managers, they just included them in the weekly email communication and expected that was followed. Nursing was responsible to notify them and the medical provider of weight loss per the facility policy. If the resident had a functional decline, nursing was responsible therapy was made aware for a proper assessment. During a telephone interview on 8/1/2025 at 11:57 AM, Licensed Practical Nurse #23 stated they work the evening shift. They came in early on 7/30/2025 at the facility's request. Certified nurse aides were expected to report a resident's functional decline. They were not made aware of any decline in Resident #3 but did put a referral in for therapy on 7/30/2025 because the resident seemed to only be able to feed themselves with the use of a bowl.During a telephone interview on 8/1/2025 at 12:40 PM, the Medical Director stated weights were expected to be obtained correctly and timely. If there was a weight loss, they looked for a dietary note, looked at historical weights, and evaluated if it was an expected loss or not. They had not been notified of Resident #3's 20 pound/ 9 percent weight loss in the past month. If the resident had a decline in the ability to feed themselves, they expected the nursing team put in a therapy evaluation. The weight loss needed an explanation and therefore the medical team needed to be involved.10NYCRR 415.12(i)(1)

Based on observation, record review, and interview during the recertification survey conducted 7/29/2025-8/1/2025, the facility did not ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (1) of three (3) residents (Resident #1) reviewed. Specifically, Resident #1 was observed with a continuous positive airway pressure machine, and the medical record did not include a physician order or a care plan related to the use of the continuous positive airway pressure machine. Findings include:The facility policy CPAP/BIPAP (continuous positive airway pressure/bilevel positive airway pressure) effective 5/2022 documented CPAP/BIPAP (continuous positive airway pressure/bilevel positive airway pressure) was used in residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/obstructive lung disease to promote comfort and safety. The machine was cleaned weekly with soap and water and the mask and tubing were cleaned daily with warm, soapy water and documented in the resident's medical record. The facility policy Oxygen Therapy-Medical Gases and their Cylinders, effective 2/2022 documented oxygen therapy was delivered by way of an oxygen mask or nasal canula using a portable oxygen cylinder or oxygen concentrator and must be verified by a physician order. 1)Resident #1 was admitted to the facility with diagnoses including obstructive sleep apnea, acute respiratory failure with hypoxia (low level of oxygen in the blood), and heart failure. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had intact cognition, required assistance of one for most activities of daily living, had a diagnosis including respiratory failure, and did not use continuous positive airway pressure/bilevel positive airway pressure therapy. The 6/27/2025 hospital transfer note documented Resident #1 used a continuous positive airway pressure machine. Resident #1 did not have a physician order for a continuous positive airway pressure machine and the comprehensive care plan initiated 6/27/25 and revised on 7/15/2025 did not include the use of a continuous positive airway pressure machine. The undated resident care instructions did not include use of a continuous positive airway pressure machine. During an observation and interview on 7/30/2025 at 10:26 AM, Resident #1 was observed to have a continuous positive airway pressure machine at their bedside. The resident stated they used the machine every night prior to admission and continued using it every night at the facility because they stopped breathing at night. Staff had not assisted them with cleaning the machine and they had to ask staff for the distilled water the machine required.During an observation and interview on 7/30/2025 at 10:23 AM, Certified Nurse Aide #12 was observed bringing a graduated cylinder of water to Resident #1. Resident #1 had a continuous positive airway pressure machine that they used every night and the resident asked them for distilled water for the machine. During an interview on 8/1/2025 at 8:37 AM, Licensed Practical Nurse #8 stated the use of a continuous positive airway pressure machine required a physician order and was documented on the care plan and treatment administration record. The treatment administration record would include the day of the week to clean the machine. The Registered Nurse Unit Managers were responsible for documenting the nursing section of the individual care plans and for updating them. During an interview on 8/01/2025 at 8:59 AM, Registered Nurse Unit Manager #6 stated a physician's order was required for a continuous positive airway pressure machine. They stated an order for a continuous positive airway pressure machine created a template that automatically populated on the treatment administration record so the nurse would know when to clean the machine. Registered nurses were responsible for completing the nursing section of the care plan initiating and updating them quarterly, annually, and as needed. Resident #1 was admitted to the facility with a continuous positive airway pressure machine. The admission nurse was responsible for notifying the physician to obtain an order for both treatments. There were a lot of admissions and discharges so it was possible for things to get missed.10 NYCRR 415.12(k)(6)

Based on observation, record review and interview during the recertification survey, the facility did not ensure the provision of food and drink was palatable, attractive, and at a safe and appetizing temperature for 1 of 2 meal trays tested. Specifically, food was not served at palatable and safe temperatures.Findings include:The facility policy Food and Nutrition Services, revised 3/2023, documented each resident would be provided with a nourishing, palatable, well-balanced diet and food and nutrition staff would inspect food trays to ensure the food appeared palatable, attractive and served at a safe and appetizing temperature.The 8/12/2020 facility policy Heating Foods and Beverages in the Microwave documented methods would be established for the safe heating of foods and beverages in the microwave to limit the risk of food borne illness and serving foods and beverages safe for residents to handle; foods would be heated to a temperature of at least 165 degrees Fahrenheit and allow to stand covered for 2 minutes after obtaining temperature equilibrium; and food would not be served unless the temperature was less than or equal to the recommended temperature. Resident #78's 7/31/2025 lunch meal ticket documented 8 ounces of water, 8 ounces of coffee, 4 ounces of milk, 3 ounces of baked chicken, oven browned potatoes 1/2 cup, seasoned beets 1/2 cup, canned fruit 1/2 cup, pears with graham cream 4 ounces. During an observation on 7/31/2025 at 12:48 PM with Licensed Practical Nurse #27, Resident #78's lunch meal was tested for temperature, and palatability. The resident was provided with a replacement tray. The chicken lacked flavor, was tough to cut and measured 114 degrees Fahrenheit; potatoes measured 112 degrees Fahrenheit; and the beets tasted cold and measured 106.5 degrees Fahrenheit.During an observation on 7/29/2025 at 12:43 PM Dietary Aide #28 put cream of chicken soup in the microwave for one minute, removed it and obtained a temperature 130 degrees Fahrenheit. They then served the soup. During an interview on 7/29/2025 at 2:10 PM Resident #8 stated the food was tasteless and soup was warm. During a telephone interview on 8/1/2025 at 10:31 AM, Dietary Aide #28 stated they warmed the cream of chicken soup in the microwave but was unsure for how long and could not remember what temperature they obtained. They thought 130 degrees Fahrenheit for the soup was not hot enough. They should have put the soup back in the microwave and then taken another temperature until it was 135 degrees Fahrenheit or higher.During an interview on 8/1/2025 at 1:40 PM, the Food Services Director stated hot food should be served at 165-180 degrees Fahrenheit and cold food under 38 degrees Fahrenheit. The temperatures obtained on the test tray were not hot enough. There was a microwave policy on the units that states to start at a minute, swirl, take a temperature, swirl, put back in the microwave, recheck the temperature until heated to 165 degrees Fahrenheit. If a temperature of 130 degrees Fahrenheit was obtained, it should have been put back in until a temperature of 165 degrees Fahrenheit was achieved. Dietary staff should know the correct temperatures. 10NYCRR 415.14(d)(1)(2)

Based on record review and interviews during the abbreviated survey (NY00361060), the facility failed to establish mechanisms for documenting and communicating the resident's choice regarding Advance Directives to the staff responsible for the resident's care for 1 of 3 residents (Resident #1) reviewed. Specifically, Resident #1 updated their Medical Orders for Life-Sustaining Treatment to reflect a change from wanting cardiopulmonary resuscitation (attempt to restart the heart) to do not resuscitate (allow natural death). The medical record and code status indicators were not revised to reflect the resident's Advance Directives wishes and the facility continued with cardiopulmonary resuscitation orders. Subsequently, when the resident was found without signs of life, the nurse verified the physician order for Full Code status (wishing cardiopulmonary resuscitation) and cardiopulmonary resuscitation was implemented when the resident wished not to be resuscitated. This resulted in no actual harm with likelihood of serious harm, serious injury, serious impairment, or death that is Immediate Jeopardy for all 79 residents in the facility who had advance directives in place. Finding include: The facility policy, Advance Directives, revised ,d+[DATE], documented if a resident did not have a do not resuscitate order upon admission but wanted one, the social worker coordinated completing necessary do not resuscitate paperwork. To ascertain the resident's wishes in an emergency, the resident's Medical Orders for Life Sustaining Treatment and physicians' orders were to be utilized as identifiers of the resident's status. If a resident indicated desire for do not resuscitate, nursing would notify the provider and obtain a written order. Resident #1 had diagnoses including myocardial infarction (heart attack), atherosclerotic heart disease (hardening of the arteries), and surgical aftercare following cardiac surgery. The [DATE] Brief Interview for Mental Status assessment documented the resident's cognition was intact. The [DATE] physician order documented Full Code. The Medical Orders for Life Sustaining Treatment form, signed by the resident on [DATE] at 5:00 PM, documented the resident wished for a do not resuscitate order. The form was witnessed by the Director of Social Services and Registered Nurse #3. The form was signed by Nurse Practitioner #8 on [DATE]. There was no documented evidence of a physician order in the resident's electronic medical record for do not resuscitate, and Full Code orders continued. The [DATE] Comprehensive Care Plan documented the resident's Advance Directive were do not resuscitate. Interventions included the Medical Orders for Life Sustaining Treatment were in place. The [DATE] Medical Director progress note documented the resident's long-term prognosis was poor considering underlying multiple medical problems which continually predisposed them to vascular consequence. The note documented to respect the Medical Orders for Life Sustaining Treatment form. The [DATE] at 12:26 PM Registered Nurse Manager #2 progress note documented they spoke with the resident's family member after the resident was found without pulse or respirations and was pronounced deceased by the provider. Written staff statements documented (there was no incident report): - from Assistant Director of Nursing #5, dated [DATE], just before 11:30 AM, an aide (unidentified) reported they needed a nurse immediately in the resident's room. Assistant Director of Nursing #5 and two other registered nurses (unidentified) immediately went to the room and found the resident cyanotic (bluish discoloration of skin from low oxygen), not breathing, and pulse not palpable (unable to be felt). Code status was verified in the electronic medical record and noted Full Code. Cardiopulmonary resuscitation was initiated, a Code Blue was called, as was 911. While gathering the Medical Orders for Life Sustaining Treatment for transport, it was noted the Medical Orders for Life Sustaining Treatment documented the resident wished a do not resuscitate order. Assistant Director of Nursing #5 immediately notified the Administrator. By this time the provider (Physician Assistant #4) had already called the resident's time of death (pronounced the time of death). Assistant Director of Nursing #5 spoke with Registered Nurse #3 via phone regarding witnessing the resident's Medical Orders for Life Sustaining Treatment. Registered Nurse #3 stated they did not verify if the resident's correct code status was reflected in the orders. The undated/unsigned Investigative Summary (later revealed in an interview that Corporate Director of Nursing #12 completed the summary on [DATE]) documented the Medical Orders for Life Sustaining Treatment was not present for the resident upon admission. On [DATE] at 1:32 PM, a telephone order was obtained from Physician Assistant #4 for Full Code. On [DATE] at 5:00 PM the Director of Social Services completed the Medical Orders for Life Sustaining Treatment with the resident reflecting the resident wished for a do not resuscitate order. The Medical Orders for Life Sustaining Treatment was witnessed by Registered Nurse #3. On [DATE], Nurse Practitioner #8 signed the Medical Orders for Life Sustaining Treatment. The resident suffered no adverse effects from administration of cardiopulmonary resuscitation. The resident remained unconscious, did not regain awareness, and was pronounced deceased without experiencing pain or suffering during the intervention. The [DATE] (untimed) Director of Nursing progress note (part of the investigative packet) documented they spoke with Registered Nurse #3 regarding the incident. Registered Nurse #3 acknowledged they co-signed the Medical Orders for Life Sustaining Treatment and failed to verify the physician order in the electronic medical record. During an interview on [DATE] at 10:20 AM, Registered Nurse #3 stated on the day the resident was admitted , they witnessed the resident's Medical Orders for Life Sustaining Treatment. They did not add the physician order for do not resuscitate because they assumed the resident's admission nurse would do that as part of the admission assessment. They stated they did not report to the resident's admission nurse they had co-signed the Medical Orders for Life Sustaining Treatment or that they did not complete the physician order. If the physician order did not match the Medical Orders for Life Sustaining Treatment, then staff could start cardiopulmonary resuscitation on a resident that wished do not resuscitate, or they might not start cardiopulmonary resuscitation on someone that wished Full Code causing harm. During an interview on [DATE] at 11:48 AM, the Director of Nursing stated after the nurse witnessed the Medical Orders for Life-Sustaining Treatment, the nurse was responsible to check that the physician order matched. During an interview on [DATE] at 1:31 PM, the Medical Director stated the physician order should be obtained and entered in the electronic medical record right away after the Medical Orders for Life-Sustaining Treatment was witnessed. During an interview on [DATE] at 4:50PM, the Administrator stated if the resident wished to change their code status, they expected the nurse who witnessed the Medical Orders for Life Sustaining Treatment to immediately update the code status in the electronic medical record. ______________________________________________________________________ The facility was notified of the Immediate Jeopardy on [DATE] at 5:38 PM. Immediate Jeopardy was removed on [DATE] at 1:47 PM prior to survey exit based on the following corrective actions taken: - 100% of staff on duty were educated according to the approved training plan. - All staff identified for education received education on [DATE] and [DATE]. The staff that did not receive education will complete education upon their return, prior to the start of their shift. - Interviews were completed on [DATE] to determine compliance with staff training and education including 3 licensed practical nurses, 3 registered nurses and 2 certified nurse aides. Staff confirmed participation and understanding of the education. 10NYCRR 400.21(c)

Based on record review, observation, and interview during the recertification survey conducted [DATE]-[DATE], the facility did not ensure storage and preparation of food in accordance with professional standards for food service safety for 3 of 3 kitchens (the main kitchen and Units 2 and 3 kitchenettes) reviewed. Specifically, the main kitchen had expired sanitizer strips for the three-bay sink; fruit flies were observed in the main kitchen and the Unit 2 and Unit 3 kitchenettes; the ice machines in the Unit 2 and 3 kitchenettes were damaged; the Unit 3 kitchenette had an undated open loaf of bread; and the Unit 2 kitchenette walls and ceiling were unclean. Findings include: The facility policy Cleaning of Kitchen and Kitchenettes revised ,d+[DATE] documented the dietary department should clean and sanitize the kitchenettes located in dining rooms and on units two and three after every meal service. The policy did not include any references to cleaning the walls and ceilings within Unit 2 and 3 kitchenettes. The facility policy Cleaning - Housekeeping effective [DATE] did not include instructions for cleaning the walls and ceilings in the Unit 2 and 3 kitchenettes. The facility policy Work Orders, Maintenance effective ,d+[DATE] documented work order requests should be written in the maintenance book at the nursing station. The undated facility policy Food and Supply Storage documented food items would be legibly labeled and dated. During observations in the main kitchen on [DATE] at 10:10 AM the three-bay sink station sanitizer strips had an expiration date of [DATE], and the directions poster on the wall behind the three-bay sink station was for a different type of sanitizer strip. The cart wash dirty room area had 30 fruit flies. During observations in the Unit 3 kitchenette on [DATE] at 10:10 AM the ice machine side cover was damaged with duct tape on it and there was an opened loaf of white bread with no expiration or opened date. During observations in the Unit 2 kitchenette on [DATE] at 11:35 AM a section of back wall behind a set of cabinets had a black powdery substance on it, the wooden back wall was bowed out and damaged, and the walls and ceiling were stained with food debris. There was one fruit fly on the wall. During observations in the Unit 3 kitchenette on [DATE] at 12:09 PM there was one fruit fly on the wall and the ice machine front cover was loose and not attached to the bottom of the machine. During observations in the Unit 2 kitchenette on [DATE] at 11:55 AM there was one fruit fly on the wall, the ice machine front cover was loose and not attached at the bottom, and the ceiling was stained with food debris. The pest control service report for ,d+[DATE], ,d+[DATE], and ,d+[DATE] documented service visits from a pest control vendor. The [DATE] service report documented fruit flies were observed in the main kitchen. During an interview on [DATE] at 1:51 PM, the Food Service Director stated they were not aware of expired test strips or that they were the wrong test strips. The three-bay sink was infrequently used as the dish machine had been functioning well. There had been fruit flies in the kitchen within the last month, and they were not aware of any fruit flies on the resident units as no staff had ever mentioned this to them. The Maintenance Director kept track of the pest control records and would call them if they had to come onsite. They stated food was expired three days after the open date and had verified on [DATE] that that there was no date written on the loaf of bread that had been opened on the third floor kitchenette. They were not aware of the unclean walls and ceiling located in the Unit 2 kitchenette or the black substance on the wall behind the cabinet. They stated that was not acceptable. They were not aware of the damaged ice machines in the Unit 2 and 3 kitchenettes. That was not acceptable due to potential infection control and safety issues. During an interview on [DATE] at 1:19 PM, the Housekeeping Supervisor stated when they started in their current position in [DATE], they were told to only clean the dining room walls outside of the kitchenette area. They were not cleaning the walls within the resident unit kitchenettes. The kitchen staff were responsible for cleaning the cabinets, walls, and ceilings within the kitchenette. They stated they were not aware of black powdery substance in the Unit 2 kitchenette. They had not seen any fruit flies within the resident units. They stated it was important to ensure that walls and ceilings were clean so the residents would have a home like and clean environment. During an interview on [DATE] at 1:41 PM, the Maintenance Director stated they were not aware of the damaged ice machine covers in the Unit 2 and 3 kitchenette ice machines as there were no work orders. They were not aware of any black, powdery substance inside the Unit 2 kitchenette cabinet walls or the damaged wood backing of the shelf. They expected a kitchen staff member who had been stocking the cabinet to see this and place a work order. A plant operations work order book was located at each nursing station, and this book was checked three times a day during each shift. They would then contact housekeeping staff or maintenance staff as needed depending on the concern. The housekeeping department was responsible for cleaning floors, walls, and ceilings, but they were not responsible for cleaning the walls and ceilings within the kitchenette area. It was important to ensure that walls and ceilings were clean so the residents would have a home-like and safe environment. During an interview on [DATE] at 4:08 PM the Maintenance Director stated they were told about the fruit flies within the main kitchen last week, and the pest control vendor had come onsite on [DATE] to investigate it. 10NYCRR 415.14(h) 48446

Based on observation, record review, and interview during the recertification and abbreviated (NY00325041) surveys conducted 1/3/2024-1/9/2024, the facility did not ensure allegations of abuse, neglect, or mistreatment were thoroughly investigated to prevent further potential abuse for 2 of 2 residents (Residents #62 and #235) reviewed. Specifically, Resident #235 reported they were slapped in the face by Resident #62, the incident was not thoroughly investigated and was not reported to the New York State Department of Health as required. Findings include: The facility Abuse Prevention Manual revised 8/2020, documented all reports of resident abuse, neglect, exploitation, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated. Findings of abuse investigations would also be reported. The individual conducting the investigation would, at a minimum: review completed forms; make a list of witnesses, review all pertinent and actual documents that are in the chart, analyze the documents obtained to determine if a root cause is clear, and take immediate corrective action as deemed necessary and in accordance with the issue involving the resident. The investigation was then submitted to the Quality Assurance and Prevention Improvement committee for opportunity for improvement and to prevent future occurrences. Upon conclusion of the investigation, the results of the investigation would be provided to the Administrator. Resident #62 had diagnoses including dementia with behavioral disturbances. The 10/13/2023 Minimum Data Set assessment documented the resident had severely impaired cognition, did not exhibit behavioral symptoms, and required supervision for walking. Resident #235 had diagnoses including peripheral vascular disease (poor circulation) and diabetes. The 9/25/2023 Minimum Data Set assessment documented the resident had intact cognition, required assistance of 1 for walking, used a wheelchair for locomotion on the unit, and exhibited no behavioral symptoms. Resident #62's comprehensive care plan dated 11/2/2023 documented the resident had the potential to be physically aggressive towards staff and residents. Interventions included to leave the resident alone when agitated and reapproach later, administer medications, monitor every shift, document observed behavior and attempted interventions in their chart, and when the resident became agitated, intervene before agitation escalated. The resident was at risk for wandering. Interventions included placement of a wander alert device, check placement and alarm daily, calmly redirect, encourage socialization with others, provide recreational programming, and encourage activities that kept them occupied. An Incident Report completed by Director of Nursing #3 documented: - on 12/8/2023 they received statements that were placed in the Human Resources mailbox by a resident's family member about an incident on 12/2/2023. The statements were dated 12/5/2023. - they began an investigation and documented licensed practical nurse #4 and certified nurse aide #5 observed Resident #62 approach Resident #235 who asked Resident #235 to get out of the wheelchair. Certified nurse aide #5 immediately intervened and both residents were separated. Resident #235 was assisted to the dining room per their request. There were no negative findings and both residents were assessed. - statements were obtained from staff working at the time of the incident. - the summary of the investigation documented Resident #62 was initially talking to Resident #235 and then placed their hands on the left shoulder of Resident #235 in a non-threatening or harmful way. Resident #62 asked Resident #235 to get out of the wheelchair at the same time staff intervened and immediately separated the residents. - Resident #62 had a history of wandering without purpose and at times was difficult to redirect. - there was no prior history of incidents between these residents. - immediate interventions included separation of the residents and Resident #62 was placed on close observation. - Licensed practical nurse #4 was counseled regarding reporting allegations of abuse with good understanding. - care plans were reviewed with no failure to follow care plan noted. Written statements included: - a 12/5/2023 grievance statement by Resident #235 documented Resident #62 entered their room uninvited two different times on 12/3/2023. This was the same resident who hit them in the face in the dining room on 12/2/2023. Resident #62 entered their room again on 12/4/2023. - a 12/2/2023 at 1:00 PM witness statement by licensed practical nurse #4 documented at first Residents #62 and #235 were talking, then Resident #62 pulled on the shirt of Resident #235 and told them Get out of the chair. Resident #62 did not hit Resident #235 in the face. Licensed practical nurse #4 was by the medication cart and the residents were near the clean utility room. Certified nurse aide #6 told licensed practical nurse #4 that Resident #235 had reported being hit in the face by Resident #62. Licensed practical nurse #4 checked on Resident #235 who stated that Resident #62 scared them. - a 12/8/2023 witness statement by registered nurse supervisor #7 documented they were the supervisor on duty the weekend of 12/2/2023 and 12/3/2023 and they were not notified of the incident between Residents #62 and #235. - a 12/8/2023 witness statement by certified nurse aide #6 documented Resident #235 reported to them that on 12/3/2023 Resident #62 came into their room and slapped them in the face. - a 12/8/2023 witness statement by certified nurse aide #5 documented they worked on 12/2/2023 when Resident #62 insisted Resident #235 get out of the wheelchair, grabbed them by the left of their shirt and tried to remove them from the chair. Certified nurse aide #5 separated the residents and asked Resident #235 if they were hurt. Resident #235 stated they were not hurt, just scared. The investigation did not include clarification of the location and date when Resident #235 alleged they were slapped in the face by Resident #62. The 12/5/2023 grievance statement by Resident #235 documented they were hit in the face by Resident #62 in the dining room on 12/2/2023. On 12/8/2023 Resident #235 reported to certified nurse aide #6 they were slapped in the face by Resident #62 on 12/3/2023 in their room. There was no documented evidence the alleged incidents were thoroughly investigated. There was no evidence of the close observation checks for Resident #62 as documented in licensed practical nurse #4's witness statement. Resident #62 was observed on 1/4/2024 at 11:50 AM walking from the dining room down the hall and into another resident's room. Certified nurse aide #5 escorted Resident #62 from the far side of the room to the door. Resident #62 attempted to sit on the bed by the door and the certified nurse aide stated, this isn't your bed, but I can take you to it. During an interview on 1/4/2024 at 4:21 PM, certified nurse aide #13 stated Resident #62 wandered up and down the hall frequently. The resident had gone in residents' rooms and some doors had stop signs to prevent the resident from entering. Resident #62 could get through the stop signs to enter a room. During an interview on 1/5/2024 at 10:01 AM, certified nurse aide #5 stated Resident #62 wandered the unit and hit a resident. They could not remember the name of the resident because that resident was discharged . They stated Resident #62 said to the other resident get out of the wheelchair and grabbed the resident's shoulder and shirt. They stated they and licensed practical nurse #4 separated the residents. During an interview on 1/8/2024 at 10:23 AM certified nurse aide #12 stated Resident #62 often went into other resident's rooms and laid in their beds as they liked to be warm. They did not witness Resident #62 hit anyone but heard they had hit a resident and was not allowed in the lounge unsupervised. During a telephone interview on 1/9/2024 at 9:30 AM licensed practical nurse #4 stated they witnessed an incident on 12/2/2023 when Resident #62 asked Resident #235 to get out of the wheelchair. They did not think it was abuse because they did not see Resident #62 touch Resident #235 because certified nurse aide #5 was blocking the view. They did not ask certified nurse aide #5 if Resident #62 grabbed or touched Resident #235 and should have. They followed up with Resident #235 who stated they were okay but Resident #62 scared them. During an interview on 1/9/2024 at 10:55 AM Director of Nursing #3 stated they initially heard about the incident between Resident #62 and Resident #235 reported on 12/8/2023 from Human Resources. They interviewed staff that witnessed the event, and it was reported that Resident #62 told Resident #235 to get out of the chair and grabbed the shirt and left shoulder. Certified nurse aide #5 and licensed practical nurse #4 both reported seeing Resident #62 grab the shirt of resident #235. This was considered resident to resident abuse and should have been reported to the administrator and the Department of Health. They reported the incident to the Administrator on 12/8/2023. During an interview on 1/09/24 at 11:36 AM the Administrator stated if staff witnessed abuse, they should report it immediately to their supervisor, the Director of Nursing, or the Administrator who would begin an investigation. They did not know about the incident between Resident #62 and Resident #235 because the Director of Nursing #3 completed the investigation. They stated licensed practical nurse #4 did not feel it was aggressive and has been re-trained that when in doubt to fill out an accident and incident report for investigation. Director of Nursing #3 did not feel it was reportable as grabbing a resident's shirt without trying to yank them out of the chair is different than trying to grab someone out of the chair. They stated if a resident said they were scared following an incident that would be abuse and should have been reported to the Department of Health. 10NYCRR 415.4(b)

48632 Based on observation, interview, and record review during the recertification and abbreviated (NY00327028) surveys conducted 1/3/2024-1/9/2023, the facility did not ensure each resident received adequate supervision and assistive devices for 1 of 4 residents (Resident #232) reviewed. Specifically, Resident #232 was care planned for a wander alert device to be worn at all times, the device was removed when the resident was sent to the hospital, the device was not reapplied when they returned to the facility, and the resident was not supervised until the device was replaced. Subsequently, Resident #232 was observed alone in a non-residential area. Findings include: The facility policy Elopement Prevention and Search for Missing Residents revised 2/28/2022, documented residents would be assessed on admission and readmission, adhering to the Minimum Data Set assessment process. Residents identified as a wanderer or exhibit potential for an elopement, would have a behavioral management plan developed including [wander alert device] bracelets and visual checks. Visual checks were determined by the interdisciplinary team and included 1:1 supervision as needed. If the wander alert device was noticed to be missing, a new one would be placed immediately. Resident #232 had diagnoses including cancer, anxiety, and coronary artery disease. The 10/31/2023 Minimum Data Set assessment documented the resident had moderate cognitive impairment, exhibited wandering behavior, was at risk of getting into potentially dangerous places, ambulated with supervision, and used a wander/elopement alarm daily. The elopement risk evaluation dated 10/26/2023 at 5:01 PM by registered nurse #9 documented that a wander alert device was placed on the resident for statements related to a desire to leave the facility. The resident was fully ambulatory, and they were exit seeking and stating that they were looking for their loved one. They were confused and determined to be unpredictable. The comprehensive care plan initiated 10/26/2023 and revised 10/29/2023, documented the resident had risk for elopement related to voiced intentions to leave. Interventions included placing a wander alert bracelet on resident, checking its placement and function every shift, and identifying patterns that triggered behavioral attempts to leave unsupervised. Nursing progress notes documented: - on 10/26/2023 at 6:22 PM by registered nurse #9 the resident was admitted to the facility, was exit seeking on admission and was a high elopement risk. A wander alert bracelet was applied to the resident's left ankle. - on 10/28/2023 at 12:40 PM by registered nurse #15 the resident was sent to the emergency room for evaluation after a fall. - on 10/28/2023 at 5:34 PM by registered nurse #15 the resident returned from the hospital. - on 10/29/2023 at 8:22 AM by licensed practical nurse #19 the resident had walked out of their room stating they were looking for their mother. - on 10/29/2023 at 2:38 PM by licensed practical nurse #19 the resident was noted to be in the basement and was brought back to the unit by laundry staff. A wander alert device was placed on the resident's left ankle. There was no documented evidence the resident had a wander alert device placed or was supervised upon return from the emergency roiagnom on [DATE] at 5:34 PM until they were discovered in the basement on 10/29/2023 at 2:38 PM. The unsigned facility Investigation dated 10/29/2023 documented at approximately 10:25 AM on 10/29/2023 the resident was observed in the south hallway on the first floor standing outside of the medical records storeroom by laundry personnel #23. The resident told laundry personnel #23 they were looking for their mother. Laundry personnel #23 returned the resident to Unit 3 at 10:27 AM and notified registered nurse supervisor #21. The resident was assessed and there were no negative findings. The summary of investigation documented it was determined the resident had a wander alert device placed on 10/26/2023. On 10/29/2023 while performing a daily function test activities aide #17 identified the wander alert device was missing and notified licensed practical nurse #19 who placed the resident in a high visibility area while they located a band for the wander alert. Upon further investigation it was determined when the resident left the facility for the emergency roiagnom on [DATE] staff removed the wander alert device and left it at the nursing station to be reapplied upon return from the hospital. The resident returned from the hospital on 10/28/2023 at approximately 9:00 PM. Staff were educated regarding the need to replace the wander alert device immediately or place the resident on 1:1 supervision when the wander alert device was off. Staff statements included with the investigation documented: - on 10/29/2023 activity aide #17 was checking residents for wander alert device placement and working status and discovered that Resident #232 did not have one on. They reported their finding to licensed practical nurse #19 at 9:30 AM. Licensed practical nurse #19 replied that they had it at the nursing station, it was removed when the resident went to the hospital on 10/28/2023. The statement did not document if the wander alert device was reapplied at that time. - on 10/29/2023 laundry personnel #23 documented they noticed Resident #232 on the first floor of the facility wandering alone at 10:25 AM. - on 10/29/2023 licensed practical nurse #19 documented they were notified by registered nurse supervisor #21 the resident was brought back to the unit from the basement by laundry staff. Activity aide #17 had spoken to them about the wander alert device not in place. They told the activity aide they were aware and needed to locate a new band. At that time the resident was wandering the unit and when not visible was checked on. There was no documented evidence the resident was placed on supervision due to not having a wander alert device upon return from the hospital on 10/28/2023 at 5:34 PM until 10/29/2023 at 10:25 AM when they were found in a non-resident area of the facility without a wander alert device. There was no documentation why the wander alert device was not reapplied upon return form the hospital. During an interview on 1/5/2024 at 10:01 AM, certified nurse aide #5 stated that residents could get on the elevators however if they were wearing a wander alert device, the elevator would not move, and an alarm would sound at the nursing stations. Activities staff kept a list of who wore wander alert bracelets, and they checked them every day to be sure they were on and working correctly. When a resident went to the hospital the wander alert strap was cut to remove it and the nurse would keep it in the medication cart to reapply if needed upon the resident's return. During an interview on 1/8/2024 at 13:00 PM, Activities Director #16 stated wander alert devices were checked daily by activities staff. When a resident went to the hospital, the wander alert bracelet strap was cut, and the device was kept by nursing to reapply when they returned. Activities staff was not available when the resident returned in the evening on 10/28/2023. The next morning when activity aide #17 noticed that the resident did not have their wander alert bracelet on, they notified them and the nurse on duty. The Administrator was notified as well. When activities aide #17 went back to the floor, they learned the resident had been located on the first floor alone by laundry worker #23. During an interview on 1/8/2024 at 1:14 PM, activities aide #17 stated they had checked for the resident's wander alert device during their daily rounds between 9:00 AM and 9:30 AM on 10/29/2023. After their rounds, at approximately 10:00 AM, they asked the nurses if they had put the wander alert device on the resident and they had not. During an interview on 1/8/2024 at 1:27 PM, licensed practical nurse #14 stated the nurse completing an admission or re-admission would determine if a resident needed a wander alert device. If a resident went to the hospital, the band was cut off and the device was kept in the medication cart and reapplied upon their return. Residents that needed a wander alert device and did not have one could elope from the building or wander to an unsafe area. During an interview on 1/8/2024 at 1:51 PM, the Director of Nursing stated wander alert devices were in the medication rooms and the medication carts, on both floors. The wander alert device was with the nurse but the nurse on duty did not have access to the needed strap necessary to apply the device. The device was not applied upon return from the hospital and the resident was able to get to the first floor in a non-resident care area. During an interview on 1/9/2024 at 10:55 AM, Director of Nursing #3 stated the resident was an elopement risk and had their wander alert device cut off prior to being sent to the hospital for evaluation. Upon return from the hospital the wander alert device should have been placed back on the resident. The wander alert device was not put on the resident when they returned from the hospital as the nurse on duty was unable to locate a strap to apply it. The nurse placed the resident on 15 minute checks until the day shift nurse came in to work and relayed the information about needing a wander alert strap. Director of Nursing #3 stated they could not locate documentation of 15-minute checks. They stated the wander alert device was not applied when the resident returned from the hospital and should have been. The resident was able to get off the unit to a non-resident care area which was a safety concern as the resident could have gotten out of the building or to an unsafe area. During an interview on 1/9/2024 at 11:36 AM, the Administrator stated residents were assessed for elopement status on admission by nursing. If they were determined to be at risk for elopement, a wander alert device was applied. The activities department conducted daily wander alert checks and documented them in a logbook. When a wander alert device was missing or not working properly, it should be replaced immediately. When a resident went to the hospital the wander alert device was usually cut off and it should be placed back on when the resident returned. If a wander alert device was not immediately available, the resident should be supervised every 15 minutes. At no time should a resident who was an elopement risk be unsupervised if they did not have a wander alert device available due to safety concerns. 10 NYCRR 415.12(h)(2)

Based on observation, record review, and interview during the recertification survey conducted 1/3/2024 -1/9/2024, the facility did not ensure that residents who required dialysis services received such services consistent with professional standards of practice for 1 of 1 resident (Resident #335) reviewed. Specifically, Resident #335 received hemodialysis (a process of purifying blood when the kidneys do not work properly) treatments at a community-based dialysis center and did not have on-going assessment and oversight before and after dialysis treatments including assessment of the dialysis access site; did not have a comprehensive care plan that addressed dialysis; and there was not consistent ongoing communication and collaboration between the facility and the dialysis center. Findings include: The facility policy Comprehensive Care Planning, revised 5/2023, documented an individualized or person-centered comprehensive care plan must be initiated by a registered nurse upon admission for all residents including medical issues based upon assessment results. The care plan included instructions to provide effective care that met professional standards of quality care. Hemodialysis was listed as a type of problem that should be included in the care plan. The facility policy Hemodialysis revised 6/2023, documented the facility provided pre- and post- hemodialysis care that was consistent with professional standards of practice. The purpose was to monitor symptoms pre- and post-dialysis to avoid complications during and after dialysis, and to ensure lines of communication between the dialysis center and the facility. Open communication was maintained with the dialysis center by use of a hemodialysis communication book that was provided to the resident on admission to take to and from the dialysis center every time they went. The licensed nurse completed pre- and post-dialysis vital signs and progress notes on dialysis days. Permacaths (central dialysis catheters inserted into a vein) were assessed for bleeding every shift and documented on the medication administration record. The comprehensive care plan related to dialysis was implemented. Resident #335 was admitted to the facility with diagnoses including infrarenal (area of the abdomen below the kidneys) abdominal aortic aneurysm (the main artery becomes weakened and bulges) and hypertension (high blood pressure). The Minimum Data Set assessment dated [DATE] documented the resident was cognitively intact, required substantial/ maximum assistance with bathing, partial/ moderate assistance with dressing, and required hemodialysis treatments. The hospital inpatient discharge summary dated 12/21/2023 documented the resident had acute renal (kidney) failure and was on hemodialysis. The resident had a permacath placed on that day and would receive dialysis the following day. The 12/21/2023 at 3:34 PM Clinical Admission Assessment documented the resident received hemodialysis. The assessment did not include the presence of any intravenous devices (permacath). The comprehensive care plan initiated on 12/21/2023 did not include dialysis and interventions for care. The 12/21/2023 physician order documented the resident was to receive dialysis on Tuesdays, Thursdays and Saturdays, and vital signs pre- and post-dialysis were to be obtained. The order did not include monitoring of the hemodialysis access site (permacath). A physician progress note dated 12/25/2023 did not include the presence of a permacath. The nursing progress notes dated from 12/21/2023 - 1/5/2024 did not document if the resident attended dialysis or that the dialysis access site was monitored. Medication and treatment administration records dated 12/21/2023 - 1/5/2024 documented the resident attended dialysis on 12/23/2023, 12/26/2023, 12/28/2023, 12/30/2023, 1/2/2024 and 1/4/2024. Vital signs were not obtained pre-dialysis on 12/23/2023 and 1/4/2024, or for post-dialysis on 12/26/2023 and 12/30/2023. There was no documentation the dialysis access site was monitored. The resident's dialysis communication book dated 12/21/2023-1/5/2024 did not include communication had occurred between the facility and dialysis center on 12/30/2023. During an observation and interview on 1/3/2024 at 11:23 AM, Resident #335 was in their room sitting on their bed with their spouse visiting. They stated ever since their abdominal surgery they had to go to dialysis on Tuesdays, Thursdays, and Saturdays. They stated the dialysis access site was a catheter on their right chest and facility staff did not look at the catheter and they were not monitored after dialysis. They stated the dialysis center checked the catheter during treatments and changed the dressing. During an interview on 1/8/2024 at 1:19 PM licensed practical nurse #4 stated they knew Resident #335 was a dialysis patient, but they did not know what type of dialysis access site the resident had. They did not check the dialysis access site because the resident was always dressed. It was important to check the site for signs of infection. Vital signs were obtained pre- and post-dialysis and were documented in the electronic record. During an interview on 1/8/2024 at 1:42 PM registered nurse #9 stated the comprehensive care plan should include dialysis. They created Resident #335's comprehensive care plan on admission and were not aware it did not include dialysis. It should have addressed dialysis so that staff knew how to take care of Resident #335 appropriately. Licensed practical nurses were responsible for vital signs being obtained and documented. During an interview on 1/9/2024 at 10:03AM with Director of Nursing #8, they stated it was the facility policy that vital signs were obtained pre- and post-dialysis. The licensed practical nurse or registered nurse was responsible for obtaining pre- and post-dialysis vital signs and they expected them to be documented. The registered nurse created the comprehensive care plan on admission, which included the type of dialysis, scheduled treatment days, pre-and post-dialysis vital signs, and that the dialysis site was monitored. It was important for that information to be in the comprehensive care plan for appropriate care. The licensed practical nurse or the registered nurse was responsible for the dialysis site being monitored every shift and it was to be documented in the medication or treatment administration record. If the site was not monitored, it could become infected. Licensed nursing staff should always know where the hemodialysis access site was located on a dialysis resident. 10NYCRR 415.12(k)

Based on observation and interview during the recertification survey conducted 7/6/21-7/9/21, the facility did not ensure it established and maintained an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 6 residents (Residents # 4, 15, 45 and 78) observed during medication administration. Specifically, licensed practical nurse (LPN) #10 was observed not performing hand hygiene between consecutive medication administrations for Residents #4, 15, 78 and 79. Findings Include: The facility policy Administration of Medication updated 3/1/20 documented that medications are administered in a safe and timely manner, and as prescribed. Staff follows established facility infection control procedures such as handwashing, antiseptic technique, gloves, isolation precaution for the administration of medication. During a medication pass with licensed practical nurse (LPN) #10 on 7/8/21, the following was observed: -at 11:29 AM, no hand hygiene was performed prior to or after administration of Resident #78's oral medications. LPN #10 was observed touching the computer equipment, opening, and closing medication cart drawers, touching medication bottles and packages and touching the resident's bedside table. LPN #10 then administered medications to resident #78 without performing hand hygiene and did not perform hand hygiene after administering medications to Resident #78. -at 11:41 AM LPN #10 touched the computer, the medication cart and proceeded to prepare the medication for Resident #15 without performing hand hygiene. -at 11:59 AM, LPN #10 was observed preparing and administering medication to Resident #79 without performing hand hygiene. After administering the medication to Resident #79 LPN #10 exited the room and did not perform hand hygiene. LPN #10 then touched multiple items including computer equipment, the medication cart, medication bottles. LPN #10 did not perform hand hygiene then proceeded to prepare medications for Resident #4. During an interview on 7/8/21 at 12:24 PM, LPN #10 stated that they should have performed hand hygiene between residents during the medication administration. LPN #10 stated that it is important to perform hand hygiene between residents to stop the spread of germs. During an interview with Director of Nursing (DON)/Infection Control Nurse on 7/8/21 at 4:33 PM, they stated that all staff should be following infection control protocols including performing hand hygiene. During a medication pass the nurse should be hand sanitizing between residents. Hand hygiene stops the spread of germs especially since objects such as medication carts, computers, and resident items were frequently touched. 10NYCRR 415.19(a)(1)(b)(2,4)

Based on interview and record review during the COVID-19 Focused Infection Control Survey on 12/21/20, the facility did not conduct testing based on parameters set forth for testing frequency for 3 of 4 employees reviewed (Employees #3, 4, and 10) and 1 of 3 residents reviewed (Residents #1). Specifically, the facility did not ensure Employees #3, 4, and 10 were tested weekly as required and did not ensure testing results for Resident #1 were obtained within 48 hours as required. Findings include: New York State Executive Order (EO) 202.30 (dated May 10, 2020), as modified by EO 202.40 (dated June 9, 2020), provides: the operator and administrator of all nursing homes and all adult care facilities, which are located in regions that have reached Phase Two of reopening, must test or make arrangements for the testing of all personnel, including all employees, contract staff, medical staff, operators and administrators, for COVID-19, once per week. The Centers for Disease Control and Prevention (CDC), Center for Clinical Standards and Quality/Survey & Certification Group, in guidance with Reference Number QSO-20-38-NH dated 8/26/20, documented: To enhance efforts to keep COVID-19 from entering and spreading through nursing homes, facilities are required to test residents and staff based on parameters set forth by the HHS (Health and Human Services) Secretary. Facilities can meet the testing requirements using rapid point-of-care (POC) diagnostic testing devices or through an arrangement with an offsite laboratory. The guidance further states: Facilities without the ability to conduct COVID-19 POC testing should have arrangements with a laboratory to conduct tests to meet these requirements. Laboratories that can quickly process large numbers of tests with rapid reporting of results (e.g., within 48 hours) should be selected to rapidly inform infection prevention initiatives to prevent and limit transmission. The guidance further provides: If the 48-hour-turn-around time cannot be met due to community testing supply shortages, limited access or inability of laboratories to process tests within 48 hours, the facility should have documentation of its efforts to obtain quick turnaround test results with the identified laboratory or laboratories and contact with the local and state health departments. The facility policy COVID-19 Testing Requirements dated 8/26/20 documents that all residents and staff will be required to undergo diagnostic [DIAGNOSES REDACTED]-CoV-2 (COVID-19) testing. The method of tests must be either PCR (polymerase chain reaction, a molecular test that detects presence of COVID-19) or [MEDICATION NAME] (detects specific proteins from [MEDICAL CONDITION] particle, usually point of care , POC, rapid test) tests in order to comply with this regulation. There are three triggers for testing: symptomatic, outbreak and routine/surveillance. - Symptomatic Testing: Test any staff or residents who have signs or symptoms of COVID-19. Facility must continue screening all staff, residents and other visitors. - Outbreak Testing: Test all staff and residents in response to an outbreak (defined any single new infection in staff or resident). Continue to test all staff and residents that tested negative every three days to seven days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result. - Routine Testing: Test all staff based on the extent of [MEDICAL CONDITION] in the community, using CMS' published county positivity rate in the prior week as the trigger for staff testing frequency - This frequency presumes availability of Point of Care testing on-site at the nursing home or where off-site testing turnaround time is <48 hours. - If the 48-hour turn-around time to get tests done cannot be met due to community testing supply shortages, limited access or inability of laboratories to process tests within 48 hours, the facility should have documentation of its efforts to obtain quick turnaround test results with the identified laboratory or laboratories and contact with the local and state health departments. The facility policy Point of Care [MEDICATION NAME] Test Devices for COVID-19 dated 9/14/20 documents rapid [MEDICATION NAME] tests can be used for screening testing in high-risk congregate settings in which repeat testing could quickly identify persons with a [DIAGNOSES REDACTED]-CoV-2 infection to inform infection prevention and control measures, thus preventing transmission. The BD Veritor and/or [MEDICATION NAME] Sofia2 rapid [MEDICATION NAME] tests will be utilized for use in diagnostic testing for the following scenarios: - For a person with symptoms suggestive of COVID-19, particularly in early stages of COVID-19 when [MEDICAL CONDITION] load is the highest. - For a person with a known exposure to COVID-19 to diagnose if they contracted COVID19. - For screening of individuals in high-risk congregate settings who may be asymptomatic or in a pre-symptomatic phase, in which rapid results and repeat testing afforded by point of care [MEDICATION NAME] tests can identify an individual with COVID-19 to help limit spread. The facility's HERDS (Health Emergency Response Data System) data from 12/20/2020 documented the facility had one resident that was positive for COVID-19. Employee Testing: 1) Employee #4's laboratory reports documented the employee was tested for COVID-19 on 11/11/20, 11/19/20 (8 days from the prior test), 11/25/20, 12/8/20 (13 days from the prior test), and 12/18/20 (10 days from the prior test). Employee #4's timesheet documented she worked in the facility on 11/11, 11/12, 11/19-11/23, 11/25, 11/27, 11/30, 12/3-12/7, 12/9, 12/11, 12/14, 12/17, and 12/18/20. During an interview on 12/21/20 at 10:32 AM., Employee #4 stated she worked as both a housekeeper and certified nurse aide (CNA) when needed. She was tested weekly at the facility. She was last tested on [DATE]. Employee #3's laboratory reports documented the employee was tested for COVID-19 on 12/9/20 and 12/18/20 (9 days from the prior test). Employee #3's timesheet documented she worked in the facility on 12/10/20 and 12/14-12/18/20. During an interview on 12/21/20 at 10:33 AM, Employee #3 stated she was tested weekly for COVID-19. Employee #10's laboratory reports documented the employee was tested for COVID-19 on 11/4/20 and 11/13/20 (9 days from the prior test). Employee #10's timesheet documented she worked in the facility on 11/4/20, 11/5, 11/7-11/8, 11/10-11/12, 11/14-11/15, and 11/17-11/18. When interviewed on 12/21/20 at 4:07 PM, the Infection Preventionist registered nurse (IP RN) stated she was responsible for oversight of staff testing. Staff were to be tested on ce weekly. She counted staff testing as being completed within a selected time frame from one day of the week through the 7th day the week (for example an employee should be tested on ce from Monday through Sunday) to meet the requirement. She stated she was unaware that if a staff tested beyond 7 days within a particular week, they would be out of compliance. For example, Employee #10 was tested Wednesday 11/4/20, which met the requirement that week; and was tested the following week on Friday 11/13/20, which she thought met the next weekly testing requirement. She stated it was within the current week and she was not aware the timeframe was out of compliance. When reviewing Employee #10 and 4's weekly testing dates, she stated they went beyond 7 days and should have been tested sooner. Resident Testing: 1) The Clinical Laboratory Evaluation Program (CLEP) application was signed by the Administrator and the Medical Director on 11/20/20. The application noted a due date of 1/3/21. Section 3 Part A included BD Veritor Plus Analyzer, Part B was not completed (test volume). A copy of a check dated 12/7/20, made payable to NYS Department of Health (DOH), signed by the Administrator, in the amount of $200.00 was noted as lab services reapp. A 12/18/20 email addressed to the Administrator from DOH CLEP documented receipt of the Limited Service Laboratory Registration Reapplication. The facility was to provide additional information in Section 3A/B for the estimated annual test volume for all waviered tests. The email included the facility indicated they wanted to add COVID-19 testing to their registration approval and if they wished to add it before the renewal date of 2/17/21, to obtain the Add/Delete Test Procedure Form ( a link was provided). Resident #1 had [DIAGNOSES REDACTED]. Nursing progress notes documented: - On 12/11/20 at 10:10 PM, the resident was more confused, complained of stomach pain that resolved later, and had one loose stool. - On 12/13/20 at 9:49 PM, the resident vomited twice during the shift, vital signs (VS) were within normal limits (WNL). - On 12/16/20 at 11:49 AM, the registered nurse (RN) was asked to assess the resident for chest pain. The resident stated it felt like an elephant was on their chest and complained of pain on an 8 out of 10 scale on the right side and radiating to the elbow. The resident denied shortness of breath, medical was notified. - On 12/20/20 at 10:51 AM, the resident's COVID-19 swab returned positive, wheezes noted in the right lower lobe, no respiratory distress. The resident was moved to the COVID unit. The laboratory report dated 12/20/20 documented the resident's specimen was collected 12/14/20, with a positive result for COVID-19 (6 days after the specimen was obtained). During an interview with the Administrator on 12/21/20 at 11:00 AM, she stated Resident #1 was positive for COVID-19, tested on [DATE], and the facility received the results from the laboratory on 12/20/20. At that time, the resident was moved to the COVID-19 unit. Resident #1 had a roommate who was to be tested on [DATE]. During an follow-up interview on 12/21/20 at 2:37 PM, the Administrator stated the point of care ([MEDICATION NAME]) testing machine arrived at the facility on 9/8/20. She was aware of the CMS guidance to have a back-up system in place in order to receive test results more timely but she did not think it had to be implemented at that time. She was not aware of the option to add the point of care testing to her existing Limited Service Laboratory Registration and thought it was to be added to the renewal application. The current registration was to expire on 2/17/21 and she had prepared the renewal application on 11/20/20, and submitted it on 12/7/20 with the addition of the [MEDICATION NAME] testing machine. The Administrator received a notification on 12/18/20 stating the application was incomplete and the estimated annual test volume needed to be included. The Administrator stated until recently, the end of November 2020 to December 2020, the laboratory had been inconsistent with timeframe from results being returned. Some results were not returned for 3-5 days. She was not aware of the need to have the point of care testing set up in order to perform diagnostic COVID-19 testing when the lab results were not returned within 48 hours. When interviewed on 12/21/20 at 4:07 PM, the Infection Preventionist registered nurse (IP RN) stated the resident had a roommate at the time of their positive test. Whole house testing was occurring every Monday for residents since the onset of COVID-19 in the facility which was at the beginning of December 2020. Rapid testing was not performed on the residents' roommate due to not being able to use the rapid test due to permissions not yet granted. The resident was identified as COVID-19 positive through serial testing. Resident #1 had medical conditions which may have appeared as COVID-19 symptoms, however they were not outside the resident's baseline. Residents would be tested according to guidelines such as if symptomatic, exposure to a positive resident, outbreak testing, medical leave/return, and as ordered by the physician. 10NYCRR 415.19(a)(1)

Based on observation, interview, and record review during the recertification survey, the facility did not develop a system to ensure Advance Directives were documented in a manner that was consistent with resident wishes for 2 of 2 residents (Residents #21 and 36) reviewed for Advance Directives and 3 additional residents (Residents #5, 57 and 168). Specifically, Residents #5, 21, 36, 57 and 168's code status indicators did not match the resident's documented Advance Directive physician orders. Findings include: The facility's policy Documentation in the Medical Record, revised ,[DATE], documents in order to ascertain the resident's wishes quickly in an emergency situation, residents in the facility are asked to wear a bracelet indicating if the resident has a DNR (do not resuscitate, allow natural death) order or wishes to have CPR (cardio [MEDICAL CONDITION] resuscitation). Other identification systems are also used to tell the staff which residents have DNR orders and which residents want CPR. This information can be found on the resident's Medical Orders for Life-Sustaining Treatment (MOLST) and the physician order [REDACTED]. 1) Resident #21 was admitted to the facility [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had intact cognition. A physician order [REDACTED]. The comprehensive care plan (CCP) updated [DATE] documented the resident's Advance Directives were DNR/DNI. Interventions included directives would be reviewed minimally on a quarterly basis as to the continuation of directives, and if a DNR, the resident would have a red wrist band, non-hospital DNR, and a physician order. The MOLST form updated on [DATE] documented the resident's code status was DNR. The undated Kardex (care instructions) documented the resident's code status was CPR. During an observation on [DATE] at 11:45 AM, a notebook containing the Medication Administration Record [REDACTED]. Next to Resident #21's name was red. The list was marked updated [DATE]. The resident was observed lying in bed without an identifying (red) wrist band on [DATE] at 9:30 AM and 1:30 PM and on [DATE] at 3:30 PM and at 3:48 PM. 2) Resident #36 was readmitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The [DATE] Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment. The Medical Orders for Life Sustaining Treatment (MOLST) dated [DATE] documented the resident had a DNR order. The physician's orders [REDACTED]. During an observation on [DATE] at 9:18 AM, a list posted at the nursing station contained the names of all the residents on the unit and next to each name was their code status (DNR or CPR) and the word red or white. The list was dated [DATE] and next to the resident's name was CPR/White. The undated Kardex (care instructions) documented the resident's code status was CPR. The comprehensive care plan (CCP) updated [DATE] and reviewed [DATE] at 9:40 AM, documented the resident's Advance Directives were full code status (CPR). Interventions included if DNR, a red wrist band. On [DATE] at 1:05 PM, a notebook containing the Medication Administration Record [REDACTED]. The list was marked updated [DATE] and next to the resident's name was CPR/White. The resident was observed not wearing an identification/color coded bracelet on [DATE] at 5:34 PM, [DATE] at 07:42 AM, and [DATE] 11:49 AM. There was no identification/color coded bracelet observed on the resident's wheelchair. On [DATE] at 3:35 PM, CNA #24 stated CNAs were able to initiate CPR if a resident was found unresponsive. She would determine code status by the color of the bracelet a resident had. If there was no bracelet on the resident or the resident's walker, she would refer to the Kardex. The CNA stated if she were to find Resident #36 unresponsive, she would initiate CPR according to the Kardex because it was marked CPR. 3) Resident #168 was admitted on [DATE] with [DIAGNOSES REDACTED]. The [DATE] Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment. The resident's Medical Orders for Life-Sustaining Treatment (MOLST) dated [DATE] documented a DNR order. The physician's orders [REDACTED]. The comprehensive care plan (CCP) documented the resident's Advance Directives were changed to DNR status on [DATE]. The Kardex (care instructions), dated [DATE] documented the resident was to receive CPR. The resident was observed on [DATE] at 2:30 PM wearing a red identification bracelet. On [DATE] at 11:45 AM, Licensed Practical Nurse (LPN) #5 was interviewed and stated to determine a resident's code status, she would refer to the Advance Directives list located in the medication administration book. She stated she would also double check the resident's medical record. She stated when a resident was wearing a red bracelet it would represent a DNR/DNI status and a white bracelet represented CPR status. On [DATE] at 3:48 PM, the Assistant Director of Nursing (ADON) was interviewed and stated the residents wore red bracelets for DNR/DNI and white bracelets for CPR. She stated there was a list for advance directives in the binders on the medication carts that contained the MAR. She would refer to the list to determine a resident's code status and then would double check in the resident's medical record. During an interview on [DATE] at 3:48 PM LPN #10 stated to determine a resident's code status she would check the list of resident's code status [REDACTED]. She stated any time there was a change, the unit manager was responsible to update it. During an interview on [DATE] at 3:49 PM, LPN #21 stated to determine a resident's code status she would check the resident's bracelet and send someone to check the resident's chart. On [DATE] at 3:52 PM, LPN #8 stated she would review the resident's record for the MOLST to verify if the resident's status was DNR or CPR and would also review the list that was in the book containing the MAR indicated [REDACTED]. On [DATE] at 2:23 PM, CNA #23 stated during an interview a CNA could initiate CPR if the resident's status was full code. She would refer to the resident's bracelet to determine if the resident was full code, if no bracelet she stated she would be unsure and would get a nurse who had a list on her cart to check. During an interview on [DATE] at 10:09 AM, registered nurse (RN) Unit Manager #7 stated she was responsible for checking to make sure the color-coded identification bracelets matched the MOLST forms and the Kardex reflected the current orders. She stated if there was a change she would notify the medical provider and social worker and update the resident's bracelet and Kardex to match the MOLST form. 10NYCRR 415.3(e)(1)(ii)

Based on observation, record review, and interview during the recertification survey, the facility did not ensure residents were free from significant medication errors for 1 of 5 residents (Resident #50) plus an additional 3 residents (Residents #37, 47, and 51) reviewed for unnecessary medications. Specifically, Residents #37, 47, 50, and 51 were prescribed [MEDICATION NAME] (medication to treat depression, anxiety, and [MEDICAL CONDITION]); Residents #37, 47, and 51 had multiple missed doses without medical provider notification or documentation, and other doses were documented as administered when the medication had not yet been provided by the pharmacy; Resident #50's medication was not observed in the medication cart when it was documented as administered and the medication had been used for another resident without proper authorization. Findings include: The facility's policy Administration of Medications and Treatments, effective 9/2017 documented licensed nurse procedures include: - Review physician's orders [REDACTED]. - Immediately documents medications administered in the proper time and date square via initials and identifies initials by signature in designated space on the administration records (MAR/TAR). 1) Resident #37 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The 3/26/19 Minimum Data Set (MDS) assessment documented the resident had intact cognition, experienced delusions, and had no behavioral symptoms. The resident was on antipsychotic and antidepressant medication. The psychiatrist's 3/6/19 visit summary documented the resident reported continuous [MEDICAL CONDITION] and anxiety The psychiatrist's visit summary dated 5/1/19 documented the resident reported infrequent middle [MEDICAL CONDITION] (difficulty returning to sleep after waking during the night or early morning). Recommendations included to start [MEDICATION NAME] 50 milligrams (mg) at bedtime and to ensure the resident went to bed at 9:30-10:00 PM for nighttime sleep. The physician's orders [REDACTED]. The physician's orders [REDACTED]. Nursing progress notes from 5/1/19 through 5/21/19 did not contain any documentation regarding the order for [MEDICATION NAME], the missed doses, or the need for clarification of the 5/2/19 order. The 24-hour report from 5/2/19-5/20/19 did not contain any documentation regarding the resident's [MEDICATION NAME] order. The 5/2019 MAR documented [MEDICATION NAME], 50 mg every day at 9:00 PM. The order date documented 5/2/19. The 5/3/19 entry was initialed as administered by licensed practical nurse (LPN) #11. Entries from 5/4-5/13/19 were initialed and circled (not administered), by multiple LPNs, including LPNs #8 and #12. There was no documentation on the back of the MAR regarding the reason the doses were not administered. During an interview with the pharmacy on 5/22/19 at 11:16 AM, the pharmacy representative stated the medication [MEDICATION NAME] did not come in a 5 mg dose, the smallest dose was 10 mg. When the prescription was received by the pharmacy on 5/2/19, a call was placed to the facility to clarify the order, as it was not able to be dispensed as written. The pharmacy received clarification of the [MEDICATION NAME] order on 5/14/19 and the [MEDICATION NAME] was dispensed for 50 mg on that date. On 5/22/19 at 4:15 PM, LPN #8 was interviewed and stated circled initials on the MAR meant the medication was not administered and the reason should be documented on the back of the MAR. She confirmed her initials were on the 5/2019 MAR on 5/7, 5/8, and 5/10-5/12/19, all circled. She stated she could not recall why it was not administered and she did not document her attempts to obtain the medication. The LPN stated the physician should have been notified if the medication was not given and she did not document her attempts to notify the physician and she did notify her unit manager a couple of times. On 5/22/19 at 4:46 PM, NP #13 stated during an interview the order she signed on 5/2/19 for [MEDICATION NAME] 5 mg was incorrect, as [MEDICATION NAME] did not come in a 5 mg dose. Twelve days was not timely to clarify an order and she should have been notified sooner so that she could have ordered another medication, approved the medication to be held, or clarified the dosage. During a telephone interview on 5/23/19 at 12:26 PM, LPN #11 stated if a medication was not available to administer, nurses should circle their initials that day, and note the reason the medication was not administered on the back of the MAR. He stated he entered his initials at the time the medication was passed, and he could not recall any issues with the resident's [MEDICATION NAME] not being available due to an incorrect dosage on the order. If he signed for [MEDICATION NAME] on 5/3/19 when the medication could not have been there, it must have been an error on his part. The LPN stated he should not have signed the MAR if he did not administer it the medication. During an interview with LPN Unit Manager #14 on 5/23/19 at 1:10 PM, she stated if the original order for [MEDICATION NAME] was incorrect at 5 mg, it could not have been administered on 5/3/19, as noted on the MAR. When it was not available to administer, the physician and pharmacy should have been called immediately and the error would have been found timely. Twelve days was not timely, and there should have been documentation on the MAR as to the reason it was not administered 5/4-5/13/19. On 5/23/19 at 1:42 PM, the Director of Nursing (DON) was interviewed and stated it appeared the LPN who signed the 5/3/19 MAR administered the [MEDICATION NAME], and it should not have been signed if the medication was not available. The pharmacy and physician should have been notified immediately if the medication was not being given and 12 days was not timely. The days the medication was not administered should have been documented regarding the reason. 2) Resident #47 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The 5/3/19 Minimum Data Set (MDS) assessment documented the resident had intact cognition, no behavioral symptoms, and took an antidepressant 7 out of 7 days. The psychiatrist's 4/3/19 visit summary documented the resident reported [MEDICAL CONDITION] and increased sleep latency. Recommendations included to start [MEDICATION NAME] 50 milligrams (mg) at bedtime. The 4/4/19 physician order [REDACTED]. The 4/2019 medication administration record (MAR) documented [MEDICATION NAME] 50 mg was not administered 4/9-4/11, 4/17, 4/21, and 4/25/19. There was no documentation on the MAR or in nursing progress notes why the [MEDICATION NAME] was not administered. The physician's progress note dated 4/15/19 documented current medications were reviewed and there were no changes. There was no documentation regarding [MEDICATION NAME] not being administered or unavailability from the pharmacy. The 4/2019 MAR documented [MEDICATION NAME] was administered on 4/19/19 by licensed practical nurse (LPN) #12 and the word borrowed was written under her initials. There was no other documentation on the MAR or in nursing progress notes regarding the medication's availability. The nursing progress note entered by LPN #12 dated 4/22/19 at 3:00 PM documented the pharmacy was called regarding [MEDICATION NAME]. The medication was ordered several times and was currently unavailable. One dose was to be sent tonight and she was told the medication required authorization. The facility was notified on 4/11/19 and management was unaware of the status. NP #13 was notified and provided an order to hold this evening's dose if the medication was not available. The 4/22/19 physician order [REDACTED]. On 4/22/19, the MAR documented [MEDICATION NAME] was held and LPN #12 noted the pharmacy was called and denied the medication. The LPN #12 progress note dated 4/25/19 at 10:00 PM, documented [MEDICATION NAME] was not available, and she spoke to the pharmacy. A prior authorization was needed, and the medication could not be sent until authorization was obtained. The pharmacy would send a courtesy 3-day supply but nothing more. A note was left for the nurse manager. During an interview with LPN #8 on 5/22/19 at 4:15 PM, she stated circled initials on the MAR meant the medication was not administered and there should be documentation on the back of the MAR for the reason. She stated the resident's [MEDICATION NAME] came in 2-3 day doses, she was not sure of the reason. She stated she called the pharmacy when it was out and was able to get it and she did not document her contact with the pharmacy. The LPN confirmed her initials on the 4/2019 MAR and stated she did not administer the medication on 4/9, 4/10, and 4/21 and was unsure of the reason. She stated she did not administer the medication on 5/8 and was unaware of the reason. She confirmed she provided the medication to the resident the evening of 5/21/19. The LPN was not able to produce the medication from the medication cart and stated she did not know why it was not there. She stated the days she signed for the medication she administered it. Borrowing medications from other residents was not allowed. The 5/2019 MAR documented [MEDICATION NAME] 50 mg was not administered 5/8/19, with no documented reason. The medication was held on 5/22/19 and LPN #8 documented at 8:00 PM, the pharmacy was called, and authorization was needed. The pharmacy report received 5/23/19 at 12:38 PM documented the resident's [MEDICATION NAME] was dispensed: - on 4/4/19 for 30 capsules/30-day supply; - on 4/25/19 for 3 capsules/3-day supply; - on 5/4/19 for 3 capsules/3-day supply; - on 5/9/19 for 3 capsules/3-day supply; - on 5/13/19 for 3 capsules/3-day supply; and - on 5/14/19 for 3 capsules/3-day supply. Based on the pharmacy report, the resident had enough [MEDICATION NAME] from 4/4/19 through 5/18/19. During an interview with NP #13 on 5/22/19 at 4:46 PM, she stated she somewhat recalled an issue with pre-authorization for the resident's [MEDICATION NAME]. If a resident was not receiving a medication she would expect to be contacted to order an alternative medication or to order the medication be held. If there was an issue with an authorization she should have been notified. She was unaware of the multiple days the resident did not receive the [MEDICATION NAME]. LPN #11 stated during a telephone interview on 5/23/19 at 12:26 PM, he vaguely recalled the resident getting [MEDICATION NAME] in smaller amounts, such as a 2-3 day supply. He had to keep calling the pharmacy and thought there was an issue with pre-authorization. During an interview with LPN #12 on 5/23/19 at 2:40 PM, she stated when a medication was out, sometimes it was borrowed from another resident who had the same medication. She recalled borrowing [MEDICATION NAME] from another resident on the unit (Resident #50) on 4/19/19 and confirmed she wrote borrowed on the MAR. There was an issue with the resident's medication only coming in 2-3 doses at a time. When it was not available again on 4/22/19, she called the medical provider and the pharmacy because she did not want to keep borrowing it from Resident #50. She was unaware of the reason the medication would not have been available if a 30-day supply was delivered on 4/4/19. She stated the facility received a receipt of all pharmacy deliveries. During an interview with LPN Unit Manager #14 on 5/23/19 at 1:10 PM, she stated the resident needed prior authorization for her [MEDICATION NAME] and the pharmacy was sending only a 2-3 day supply at a time. She was unaware of the reasons it was not administered 6 days in 4/2019 as it should have been noted on the MAR. She said she was not informed the medication was not available or that it was borrowed from another resident's medication, which was never allowed. She was unaware of the reason the medication was held or borrowed. The resident was currently out of [MEDICATION NAME], and the LPN Manager stated according to the pharmacy report, the resident would have been out of [MEDICATION NAME] after 5/18/19. The MAR documented [MEDICATION NAME] was administered 5/19-5/21/19. She was unaware the [MEDICATION NAME] for Resident #50 was not found in the cart on 5/22/19 or was held the evening of 5/22/19. During an interview with the Director of Nursing on 5/23/19 at 1:42 PM, she stated it was unclear what happened with the resident's [MEDICATION NAME], as it appeared the medication (according to the pharmacy report) was available to administer 4/4/-5/18/19. She reviewed the 4/2019 MAR and confirmed there were several missed doses, a held dose, and a borrowed dose. If the medication were available, all doses should have been administered unless documented for other reasons and borrowing was never allowed. She was unaware how the medication could have been administered 5/19-5/21/19 if the [MEDICATION NAME] ran out by 5/18/19. The DON stated one missed dose should have been brought to the attention of the medical provider as alternate medication or other orders may be provided. On 5/23/19 at 3:22 PM, the DON stated she was unable to locate any pharmacy receipts for the resident's [MEDICATION NAME] delivery on 4/4/19 or 4/5/19. 3) Resident #51 was admitted to the facility on [DATE] had [DIAGNOSES REDACTED]. The 5/3/19 Minimum Data Set (MDS) assessment documented the resident had intact cognition, did not exhibit any behavioral symptoms, and was on an antidepressant 7 out of 7 days. The psychiatrist's visit summary dated 3/20/19 documented the resident reported recurring [MEDICAL CONDITION] and minimal clinical efficacy from the prescribed [MEDICATION NAME] (antidepressant). Recommendations included discontinue [MEDICATION NAME] and start [MEDICATION NAME] 50 mg at bedtime for [MEDICAL CONDITION]. The physician's orders [REDACTED]. The pharmacy report received 5/23/19 at 12:38 PM documented the resident's [MEDICATION NAME] was dispensed: - on 3/23/19 for 14 capsules/14-day supply; - on 4/13/19 for 14 capsules/14-day supply; Based on the pharmacy report, there was no [MEDICATION NAME] for the resident from 4/6-4/12/19 and from 4/27-4/30/19. The 4/2019 MAR documented [MEDICATION NAME] 50 mg was administered 4/6-4/9/19, and 4/27-4/29/19. The medication was not administered 4/10-4/12/19 and 4/30/19 with no documented reason noted on the MAR or in nursing progress notes. The pharmacy report received 5/23/19 at 12:38 PM documented the resident's [MEDICATION NAME] was dispensed: - on 5/1/19 for 14 capsules/14-day supply; and - on 5/19/19 for 14 capsules/14-day supply. Based on the pharmacy report, there was no [MEDICATION NAME] for the resident from 5/15-5/19/19. The 5/2019 MAR documented [MEDICATION NAME] 50 mg was administered 5/15, 5/16, and 5/18/19. The medication was not administered 5/1 and 5/17, and not initialed on the MAR on 5/5 and 5/7/19 with no documented reason on the MAR or in nursing progress notes. On 5/19 and 5/20/19, it was not administered and was noted on the MAR the pharmacy was called. During an interview with the Director of Nursing on 5/23/19 at 1:42 PM she stated when the MAR was initialed by a nurse, it meant the medication was administered, when initials were circled, it meant it was not administered and a reason should be documented on the back of the MAR or in nursing progress notes. After one missed dose, the medical provider and the pharmacy should be notified. Upon review of the pharmacy report, the DON stated it appeared as if the resident received medication on the days the facility did not have the medication on hand and was not aware of how that occurred. During an interview on 5/23/19 at 1:44 PM registered nurse (RN) #7 Unit Manager stated there was no specific rule for reordering medications based on how many doses were left. Medications should not be borrowed from other residents. The MAR should be signed immediately after the medication was given, not before or later in the shift. During an interview on 5/23/19 at 1:58 PM, licensed practical nurse (LPN) #22 stated if a medication was missing from the cart, the physician needed to be contacted for a hold order, or the pharmacy needed to be contacted for a stat order for delivery. Medications were not supposed to be borrowed, but it would occasionally happen, and she would expect a note documenting that. 10 NYCRR 415.12(m)(2)

Based on observation, interview, and record review during the recertification survey, the facility did not ensure food was held and served at a safe and appetizing temperature for 2 of 3 meals tested , and outdated beverages were observed in 2 of 2 unit kitchenettes. Specifically, tested food temperatures were below acceptable range on the Unit 2 dining room; and outdated pitchers of beverages in the Unit 2 and 3 kitchenette refrigerators were observed. Additionally, outdated beverages were served to residents in the Unit 3 dining room. Findings include: The facility's policy titled Temperature Maintaining Equipment Policy (revised on 5/20/19), stated all hot foods will be held in a properly working steam table. The facility's undated policy titled Food and Supply Storage documented any properly opened, handled leftover or unused food/beverages will be stored in the appropriate container, labeled with name of the product and date of production. These items need to be used within 72 hours or discarded. Food Temperatures The 5/20/19 Trayline/Temperature Control Record documented the following temperatures of the breakfast foods when measured at 8:10 AM; pureed French toast 158 degrees Fahrenheit (F), pureed sausage 180 degrees F, pureed power cereal 182 degrees F, whole sausage 169 degrees F, eggs 193 degrees F and ground sausage 175 degrees F. The following observations were made on 5/20/19 in the Unit 2 dining room: -at 8:38 AM, the breakfast meal service started; -at 8:41 AM two bowls of pureed power cereal were observed sitting on top of the steam table surface; -between 8:47 AM and 8:54 AM, Resident #36's pureed thick toast and pureed sausage was sitting on top of steam table surface; -at 8:54 AM, Resident #36's meal tray was requested for testing and the resident was given a replacement. The pureed French toast temperature was measured at 117 degrees F and the pureed sausage temperature was 120 degrees F. The steam table control knobs were set on a heat level of 3. The highest heat level of this steam table was a level 6; - at 9:45 AM temperatures of the food in the hot holding steam table were measured with the Food Service Director. The measurements were taken with both a facility and a surveyor thermometer. The pureed sausage was 100 degrees F, whole sausage was 115 degrees F, eggs were 124 degrees F, and the ground sausage was 109 F. On 5/20/19 at 1:18 PM, the following temperatures were observed during a lunch meal test tray in the Unit 2 dining room; the Salisbury steak was 135 degrees F, the chicken was 126 degrees F, the mashed potatoes were 136 degrees F and the carrots were 112 degrees F. On 5/20/19 at 1:21 PM, the following temperatures were taken directly from the steam table in the Unit 2 dining room; the Salisbury steak was 121 degrees F and the chicken was 115 degrees F. The food tasted lukewarm and was not flavorful. At 1:31 PM, another piece of Salisbury steak was requested approximately 3 minutes after being taken off the steam table. The temperature of the steak was 127 F using a surveyor thermometer and 129 F using a facility thermometer. All control knobs on steam table were set at 6 (maximum). During an interview on 5/22/19 at 10:03 AM, the Food Service Director stated that housekeeping may have adjusted the temperature settings of the steam table during cleaning and was unsure why the knobs on the second-floor dining room steam table were not set on 6 during the 5/20/19 breakfast meal. The Food Service Director stated he had not done any test trays himself. Outdated Beverages During an observation on 5/19/19 at 3:21 PM, the 3rd floor unit kitchenette refrigerator had out dated pitchers of beverages and included a pitcher of strawberry milk dated 5/12/19, a pitcher of punch dated 5/13/19, and a pitcher of tomato juice dated 5/15/19. During an observation of the 5/19/19 dinner meal at 5:33 PM in the 3rd floor dining room, CNA #15 was observed serving strawberry milk dated 5/12/19 and tomato juice dated 5/15/19. During an interview on 5/19/19 at 5:39 PM, CNA #15 stated she did not check the dates on the pitchers prior to serving the residents. She stated the kitchen staff brought up the pitchers of beverages daily and was unsure how long food and beverages could stay in the unit refrigerators. CNA #15 was not observed removing the outdated drinks from the residents. During an interview on 5/19/19 at 6:27 PM, kitchen aide #16 stated the employee who worked the C- Position, cold beverage and nourishment position, prepared the strawberry milk, poured the pitchers of beverages for the units, and was responsible for labeling all the beverage pitchers brought up to the unit refrigerators. She did not state how long beverages could be left in the unit refrigerators. During an observation made on 5/19/19 at 6:35 PM the 2nd floor unit kitchen refrigerator had outdated pitchers of beverages including a pitcher of strawberry milk dated 5/11/19, a pitcher of tomato juice dated 5/11/19, a pitcher of punch dated 5/11/19, a pitcher of orange juice dated 5/12/19, and a pitcher of iced tea dated 5/13/19. During an interview on 5/20/19 at 7:18 AM, kitchen aide #17 stated she worked on Sunday 5/19/19 in the C-Position and was responsible for labeling the beverage pitchers and bringing the beverages to the unit refrigerators. She stated she overlooked the dates on the beverage pitchers. Open beverages could only stay in the unit refrigerators for 3 days (72 hours). She stated if the beverage was outdated it should not be served to the residents and the kitchen should have been notified. During an interview on 5/22/19 at 1:45 PM, both the registered dietitian (RD) #18 and the diet technician (DT) #19 stated beverages in the unit refrigerators should be labeled and dated when made and discarded after 72 hours of being prepared. During an interview on 5/22/19 at 1:53 PM, the Food Service Director stated the C- Position was responsible for preparing, labeling, and delivering the pitchers of beverages to the unit refrigerators. He stated it was expected that the C-Position staff member would discard any beverages outdated past 72 hours and all pitchers should be labeled and dated with the date it was prepared or poured. He stated the reason for food and beverages being discarded after 72 hours was to prevent food borne illness. Additionally, he was unaware of the outdated beverages in the unit refrigerators. During an interview on 5/22/19 at 3:10 PM, the Infection Control Nurse stated serving outdated beverages could be a risk for bacteria or food borne illness. 10NYCRR 415.14(d)(1)(2)

Based on observation, interview and record review during the recertification survey, the facility did not ensure it established and maintained an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 8 of 12 residents ( Residents #1, 2, 5, 17, 47, 114, 214 and 215) observed during medication administration; 1 of 1 resident (Resident #36) reviewed for urinary catheters; and 1 of 1 resident (Resident #115) reviewed for respiratory care. Specifically, licensed practical nurse (LPN) #1 was observed not performing hand hygiene between Residents #1, 2, 5, 17, 47, 114, 214, and 215 medication administration. Also, a blood sugar finger stick lancet (used to prick finger for blood test) was dropped on the floor then used on Resident #214. Additionally, Resident #36 was observed with his catheter bag and tubing resting directly on the floor, and Resident #115 was observed with outdated oxygen tubing. Findings include: Medication Pass Observation: The facility policy Blood Glucose Management, effective date 10/2015, included nursing will wash hands then apply gloves prior to using the lancet to obtain blood for blood glucose monitoring. After obtaining the fingerstick, nursing will dispose of used equipment and remove gloves and wash hands. The facility policy Administration of Medications and Treatments, effective date 9/2017, included nursing will wash/disinfect hands prior to and after medication administration. During a medication pass with LPN #1 on 5/19/19, the following was observed: - At 3:45 PM, no hand hygiene was performed prior to or after administration of Resident #5's oral medication. - At 4:00 PM, no hand hygiene was performed prior to or after administration of Resident #215's nebulizer (breathing) treatment and neurological checks, which involved grasping the resident's hands. - At 4:09 PM, no hand hygiene was performed prior to or after Resident #17's medication (Resident #17 refused to take medication). - At 4:19 PM, no hand hygiene was performed prior to Resident #215's as needed (PRN) inhaler. LPN #1 then proceeded to turn on an oxygen tank for an unidentified resident, took a cup of water to Resident #215, made a phone call to pharmacy, sent a facsimile (FAX) to pharmacy and no hand hygiene was performed between the tasks. LPN #1 then donned gloves for the next resident's medication administration. - At 4:34 PM, wearing gloves, LPN #1 picked up the glucometer (blood glucose monitoring device) and performed a fingerstick on Resident #1. She removed her gloves, did not perform hand hygiene, then gave an insulin injection. She then performed hand hygiene using alcohol gel (the first time hand hygiene was performed, after 5 consecutive residents). - At 4:45 PM LPN #1 donned gloves, gave an oral medication and performed a fingerstick on Resident #2. She sanitized the top of the medication cart, then removed her gloves. Hand hygiene was not performed. - At 4:52 PM, no hand hygiene was performed prior to or after Resident #47's oral medication and beverage supplement. - At 4:58 PM, LPN #1 donned gloves (no hand hygiene performed prior) and started to perform a fingerstick on Resident #214. After wiping the resident's finger with an alcohol wipe she dropped the lancet on the floor, picked the lancet up and used it for the resident's fingerstick. She then administered the resident his oral medication. No hand hygiene was not performed. - At 5:02 PM, LPN #1 drew up insulin into a syringe for Resident #114. She then donned gloves, performed a fingerstick and removed her gloves. She administered the insulin with her bare hands into the resident's abdomen, then removed the resident's dirty lunch tray and set it on top of the medication cart next to the glucometer. She sanitized the glucometer and put it away. She carried the dirty lunch tray to the tray cart. No hand hygiene was performed. During an interview with LPN #1 on 5/22/19 at 4:15 PM, she stated she should be washing her hands between residents and between glove changes. She was changing gloves a lot. She should have gotten a new lancet to use on Resident #214 and washed her hands. She stated she thought she had dropped the lancet on the floor after she had used it to prick Resident #214's finger. During an interview with the Infection Control Nurse on 5/23/19 at 11:09 AM, she stated nurses were expected to perform hand hygiene between residents and glove changes during a medication pass. There was alcohol-based hand sanitizer on the medication carts and on the walls. If hands were visibly soiled they should be washed in the sink with soap and water. If a lancet fell on the floor she would expect the nurse to place it in the sharps container, perform hand hygiene and get a new one before performing a fingerstick. She stated the nurses received annual infection control training at the facility, which included hand hygiene. Urinary Catheter The facility's policy, Catheter Positioning and Emptying of Drainage Bag, effective 9/2017 documented: - Never allow the urinary drainage bag to touch the floor as this causes contamination. - Change the drainage bag and tubing whenever it becomes soiled, or whenever the catheter is scheduled to be changed. Resident #36 was readmitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The 5/2/19 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment and had an indwelling catheter. The resident's comprehensive care plan (CCP) updated 3/29/19, documented the resident had an indwelling urinary catheter. Goals included being free of infection. Interventions included to monitor for infection and replace catheter regularly according to policy and procedure. The physician progress notes [REDACTED]. Several weeks ago, the resident's general condition deteriorated, and he was most recently sent to the hospital and admitted with a UTI. A physician order [REDACTED]. The resident was observed in bed: - On 5/19/19 at 3:25 PM, the catheter drainage bag was hung from the bed frame and resting directly on the floor. - On 5/20/19 at 6:24 AM, the catheter bag and several inches of tubing were lying directly on the floor. - On 5/22/19 from 11:40 AM to 12:03 PM, the catheter bag and several inches of tubing were lying directly on the floor. During an interview with certified nurse aide (CNA) #23 on 5/22/19 at 2:23 PM, she stated catheter bags were to be hung from the bed frame and were not supposed to touch the floor for infection control. She stated sometimes bags or pillowcases were used for the resident's catheter drainage bag so that the bag did not come in contact with the floor, as the bed was low for safety. She stated she cared for the resident today, there was no cover over the catheter bag and she did not think the catheter bag was touching the floor. During an interview with the Infection Control Nurse on 5/22/19 at 3:10 PM, she stated catheter drainage bags and tubing should not be in direct contact with the floor because it placed the resident at risk for infection. Respiratory Care The 10/2017 facility policy, Oxygen Therapy, documented all oxygen tubing, humidifier's, mask, and cannulas used to deliver oxygen should be changed weekly, when visibly soiled or as needed with date of change noted. Resident #115 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 5/1/19 Minimum Data Set (MDS) assessment documented the resident had intact cognition and received oxygen therapy. The physician's orders [REDACTED]. The 5/2019 treatment administration record (TAR), documented the oxygen tubing was changed on 5/2, 5/9, and 5/16/19. The resident was observed using oxygen via nasal cannula with oxygen tubing dated 5/2/19 on 5/20/19 at 2:49 PM and on 5/21/19 at 2:55 PM, 3:51 PM, and 4:37 PM. During an interview on 5/22/19 at 10:07 AM, registered nurse (RN) Unit Manager #7 stated oxygen tubing was changed weekly by the nurse on the Wednesday night shift. She stated the tubing should be labeled with date and initials of the nurse who changed it, and the nurse should sign the TAR to document the task was completed. She stated oxygen tubing should be changed for infection control purposes. During an interview on 5/22/19 at 3:10 PM, the Infection Control Nurse and the Director of Nursing (DON) stated oxygen tubing was to be changed every Wednesday on the night shift and be dated and initialed. She stated the purpose was to prevent infection. During an interview on 5/22/19 at 3:37 PM, LPN #6 stated she worked the night shifts on 5/9/19 and 5/16/19 and was responsible for changing the oxygen tubing during her shift. She stated she labeled and dated the resident's oxygen tubing on 5/9 and 5/16/19 when she changed it. 10NYCRR 415.19

Based on record review and interviews conducted during the recertification survey, the facility did not ensure 1 of 3 residents (Resident #58) reviewed for advance directives had the right to formulate advance directives. Specifically, Resident #58's Medical Orders for Life Sustaining Treatment (MOLST) was completed by a health care proxy (HCP, a person designated to make health care decisions for someone determined to lack capacity for decision making) and there was no documentation a concurring physician determined the resident's lack of capacity. Findings include: Resident #58 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The 11/16/2017 admission Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition, and was limited to total assist with activities of daily living (ADLs). The 11/9/2017 social services progress note documented the resident was confused and a MOLST was completed with the HCP. The 11/9/2017 comprehensive care plan (CCP) documented the resident had advance directives and cognitive deficits. Interventions included to provide simple choices, encourage participation in plan of care, explain all procedures and review advance directives at a minimum of quarterly. The 11/13/2017 nurse practitioner (NP) orders documented the resident was a Do Not Resuscitate (DNR, no cardiopulmonary resuscitation). The 11/20/2017 MOLST documented the resident was to be a Do Not Resuscitate/Do Not Intubate (DNR/DNI, no cardiopulmonary resuscitation/no mechanical breathing), no artificial nourishment, and was to be on comfort measures. The MOLST was signed by the resident's HCP. There was no 2-physician documentation determining the resident's lack of capacity to sign his own MOLST. The 11/20/2017 admission history and physical documented the resident was admitted from the hospital, had progressive dementia, was unable to participate in his own healthcare decision making, his condition was severe and prognosis guarded, and the physician was to complete a MOLST form on his behalf using his healthcare proxy. The 11/20/2017 physician progress notes [REDACTED]. The note documented the physician was to write an order to have the form placed in the chart. The 11/20/2017 physician order [REDACTED]. When interviewed on 12/28/17 at 05:02 PM, registered nurse (RN) Unit Manager #2 stated Resident #58 did not have capacity to make decisions regarding his advanced directives, she did not see a lack of capacity form in his chart, and it should be there or in the physician communication book and the social worker was responsible for ensuring they were completed. When interviewed on 12/28/17 at 05:16 PM, the Director of Social Services stated the facility used the MOLST lack of capacity form (a 2-physician concurring form) if a resident did not have capacity. The chart should have a dual lack of capacity form if the physician documented the resident did not have capacity and the form needed to be completed. When interviewed on 12/29/17 at 11:01 AM, the primary physician stated if the resident lacked capacity to sign their MOLST and the HCP signed for them, a dual physician lack of capacity needed to be done and the form was overlooked for the resident. When interviewed on 12/29/17 at 02:42 PM, the Director of Nursing (DON) stated the physician determined a resident's capacity with the social worker or physician while assessing their level of capacity. If the resident did not have capacity, the surrogate or HCP signed the MOLST, and the facility needed a lack of capacity form signed by 2 physicians. The physician was to document in a progress note when the MOLST was completed with the HCP or surrogate. She expected the RN Unit Managers to review the physician progress notes [REDACTED]. The RN Unit Managers should remind the social worker if a lack of capacity form needed to be done. 10 NYCRR 415.3(e)(1)(ii)

Based on observation, record review and interview during the recertification survey, the facility did not maintain clinical records on each resident in accordance with accepted professional standards and practices, that were complete and accurately documented for 2 of 2 residents (Residents #332 and 333). Specifically, Residents #332 and 333 did not have turning and positioning documented every two hours as care planned. Findings include: 1) Resident #333 was admitted on [DATE] and had a [DIAGNOSES REDACTED]. The 12/21/17 Minimum Data Set (MDS) assessment documented the resident was severely cognitively impaired; did not reject care; required extensive assistance of 2 persons for bed mobility and was at risk for pressure ulcers. The undated certified nurse aide (CNA) care guide (care instructions) documented the resident was to be turned and positioned every 2 hours while in bed. The 12/2017 turning and positioning schedule documented the resident was to be turned and repositioned every 2 hours while in bed. There were 203 blank areas out of 209 opportunities where turning and repositioning had not been documented from 12/14/17-12/29/17. During an interview on 12/29/17 at 12:29 PM, certified nurse aide (CNA) #1 stated the resident needed assistance with rolling in bed. The resident used the handrails to pull herself over with the assistance of staff. The CNA stated the resident was on a turn and repositioning schedule and it was supposed to be documented in the CNA care guide every 2 hours. During an interview on 12/29/17 at 1:00 PM, registered nurse (RN) Unit Manager #2 stated the resident was on a turning and repositioning schedule. She stated turning and positioning should be documented when it was done. During an interview on 12/29/17 at 1:17 PM, licensed practical nurse (LPN) #3 stated the resident was on a turning and repositioning schedule and was to be repositioned from side to side to keep her off her bottom related to the open area she had. She stated CNAs documented positioning on the turning schedule. 2) Resident #332 was readmitted [DATE] and had a [DIAGNOSES REDACTED]. The 12/21/17 comprehensive care plan (CCP) documented that the resident was at risk for developing pressure ulcers. Interventions included the resident was an extensive assist of two with bed mobility, a Hoyer lift (mechanical lift) for all transfers and an extensive assist of two with toileting. The 12/22/17 physician's orders [REDACTED]. The 12/09/17 certified nurse aide (CNA) care guide (care instructions) documented the resident was an extensive assist of two for rolling and repositioning. The 12/2017 turning and positioning schedule documented the resident's position was to be changed every two hours. There were 43 blank areas out of 103 opportunities, where turning and repositioning had not been documented from 12/21-12/29/17. The 12/2017 treatment administration record (TAR) documented the resident was to be turned and positioned every two hours. There were 3 of 24 unsigned shifts that turning and repositioning for the shift had not been documented from 12/22-12/29/17. During an interview on 12/29/17 at 12:29 PM, CNA #1 stated that staff kept the resident clean and dry, and she was transferred with a mechanical lift. He was aware of the turning and positioning schedule and where it was documented. During an interview on 12/29/17 at 1:00 PM, registered nurse (RN) Unit Manager #2 stated the resident was on a turning and positioning schedule to prevent skin breakdown. She stated turning and positioning should be documented when it was done. During an interview on 12/29/17 at 1:17 PM, licensed practical nurse (LPN) #3 stated the resident had no skin breakdown and staff turned and repositioned her. She stated the CNAs documented turning and position on the log in the book with the CNA care guides and on the kiosk. 10 NYCRR 483.70(i)

Based on record review, observation, and interview conducted during the abbreviated Survey (NY 328), reviewed for advance directives, it was determined the facility did not ensure staff were trained for emergencies. Specifically, for licensed practical nurses (LPN)'s # 2 and 3, performing CPR on a resident in the facility, the facility did not ensure the cardio [MEDICAL CONDITION] resuscitation (CPR) certifications were current. Findings include: The facility cardio [MEDICAL CONDITION] resuscitation (CPR) policy dated ,[DATE], documented the facility nursing staff were to provide CPR to residents without a Do Not Resuscitate (DNR) order. The policy documented CPR certified nursing personal were available in the facility 24 hours a day. Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented the resident's cognition was intact. The resident's Physician orders [REDACTED]. The facility investigation dated [DATE] documented registered nurse (RN) #1, licensed practical nurse (LPN) #2 and LPN #3 responded to a code blue and initiated CPR to Resident #1 for a 20-minute period. LPN #2's CPR certification card documented the expiration date for certification was [DATE]. LPN #3's CPR certification card documented the expiration date for certification was [DATE]. When interviewed on [DATE] at 12:45 PM the Human Resource (HR) Director stated she did not monitor licensed staff for CPR certification renewals and did not coordinate that process. She stated the former DON e-mailed her a list of staff to be recertified for CPR and she did not know what to do with the information. She stated she did not follow up with the DON to ask what she should do with the names on the list. When interviewed on [DATE] at 1:49 PM the Director of Nursing (DON) stated, all licensed nursing staff in the facility were trained and CPR certified. She stated The Human Resource (HR) department in the facility were to ensure the staff were CPR certified upon hire and maintained a list of when the staff were to be recertified. She stated the Associate Director of Nursing (ADON) and the staffing Coordinator were responsible to maintain the staff's recertification. When interviewed on [DATE] at 2:00 PM, the Per Diem staff educator, RN #13 stated he had a verbal agreement to perform tasks within the facility and conducted orientation for new employees. He stated he did not monitor staff for CPR certification or recertification. When interviewed on [DATE] at 2:28 PM the Administrator stated, the DON was responsible to ensure license staff received training in CPR while at the facility and to ensure the certification was current. She stated HR was responsible to maintain a list of staff due to be recertified. 10NYCRR 415.3(e)(1)(ii)

Based on record review and interview conducted during the abbreviated survey (NY 378), it was determined the facility did not ensure care and services were provided to attain or maintain the highest practicable physical well-being for 2 of 4 residents (Residents #1 and 2) reviewed for anticoagulation medications (blood thinner/[MEDICATION NAME]). Specifically, the facility did not have an effective system in place to ensure follow up on [MEDICATION NAME] time/international normalized ratio (PT/INR, measures how thin the blood is) laboratory results for Resident #1 and #2. This resulted in actual harm for Resident #1 as she was hospitalized requiring [MEDICATION NAME] reversal agents and treatment to address blood loss. Findings include: 1) Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was intact and she required extensive assistance with most activities of daily living (ADLs) and received anticoagulation medication daily. The comprehensive care plan (CCP) dated 8/3/2017 did not identify the resident was on a anticoagulation medication and was at risk for complications related to the medication. The physician history and physical dated 7/21/2017 documented the resident had A-fib and the [MEDICATION NAME] would be increased to 5 milligrams daily with the PT/INR rechecked in 3-4 days. A physician order [REDACTED]. A laboratory form documented the resident's PT/INR was drawn on 7/25/2017 at 2:48 PM and the INR results were 1.90 (therapeutic range 2.00 - 3.00). There were initials documented at the bottom of the form with the date 7/26. A [MEDICATION NAME] flow sheet documented the resident had a PT/INR on 7/21/2017 and the next draw was due on 7/25/2017. There was no further documentation on the flow sheet after 7/25/2017. The 7/2017 medication administration record (MAR) documented [MEDICATION NAME] 5 mg starting on 7/22/2017 and there was a line under the date of 7/25/2017 with small print under the line documenting INR. The 5 mg of [MEDICATION NAME] continued to be administered after 7/25/2017 with no documented evidence the PT/INR results were reviewed or followed up on. physician progress notes [REDACTED]. The 8/2017 MAR documented [MEDICATION NAME] 5 mg was administered from 8/1/2017 - 8/23/2017. The MAR did not contain any documentation regarding PT/INR's. A nursing progress note dated 8/14/2017 on the 3:00 PM - 11:00 PM shift documented the physical therapist had reported the resident had a bruise on the resident right upper arm. The resident reported she did not know how she got the bruise and she had denied any abuse. A nursing progress note dated 8/23/2017 at 8:00 PM documented the resident and her family member were concerned regarding bruising on her arms and abdomen. A chart review was completed and it was identified the resident had not had any recent PT/INR testing done. Physician was called and a new order was placed to obtain a PT/INR. A nursing progress note dated 8/23/2017 at 11:10 PM documented the lab called with a critical INR level of 14.6 (therapeutic range 2.00 - 3.00), Hemoglobin (Hgb) level of 7.0 (normal range 12.2-15.5) and a Hematocrit (Hct) of 23.0 (normal range 37.0-47.0). The resident was transferred to the emergency department. A hospital discharge summary dated 8/24/2017 documented the resident was admitted for observation as she had a critical INR and Hgb & Hct level, she received vitamin K ([MEDICATION NAME] reversal agent) and a blood transfusion. During an interview with the Director of Nursing (DON) on 8/31/2017 at 9:55 AM, revealed there was no PT/INR/[MEDICATION NAME] policy prior to the incident and she had since developed one. She stated all other resident's in the facility on [MEDICATION NAME] were reviewed to ensure their PT/INR's were up to date. During an interview with the nurse practitioner (NP) on 8/31/2017 at 12:15 PM he stated he would either get called with the PT/INR results or would review them when in the facility. He stated he would ask what the PT/INR level was as well as the current dose of [MEDICATION NAME] and would change the order for [MEDICATION NAME] accordingly and order a repeat PT/INR. Sometimes he was given a laboratory report himself. Othertimes, the physician would be given the report and the physician would initial that he had gone over the results and provided orders over the phone. He stated the facility did not have a good process for monitoring to ensure all PT/INR results were addressed as information was scattered. Resident #1's INR got missed as there was no nurse manager on the unit who reviewed the [MEDICATION NAME] and PT/INR orders. He stated they depended on the nursing staff to ensure orders were in place and follow up was addressed and done. He stated the facility needed to develop a [MEDICATION NAME] book and not the [MEDICATION NAME] flow sheets placed with the MARs as there were new nurses on the carts all the time and the forms needed to be easily accessible for the NP and physicians. During an interview with licensed practical nurse (LPN) #2 on 8/31/2017 at 1:28 PM she stated she would know a resident had a PT/INR due by reviewing the [MEDICATION NAME] Flow Sheet and the MAR. She stated the resident's on [MEDICATION NAME] had a flow sheet placed in with their MARs, which would identify when the next INR was due. The medication nurse would review it daily when passing medications. She stated when an INR was due it was highlighted in the MAR with the [MEDICATION NAME] order and that way the medication nurse would know she needed to review the PT/INR results and question the dose. She stated if she received a lab she would either call the physician with the results or hand them to him if he was in the facility at the time. During an interview with LPN #3 on 8/31/2017 at 1:45 PM she stated she would know a PT/INR was due as there would be a date in the MAR and she would look to make sure it was drawn. If no block in MAR and no recent INR by Wednesday, as that was when they were done, she would notify the supervisor. She stated she did not review laboratory reports as that was the responsibility of the Nursing Supervisor. She stated if she was handed a laboratory report she would place it in the chart for the physician to review or she may call him if the results were out of range. During an interview with the registered nurse (RN) #4 Nursing Supervisor on 8/31/2017 at 2:10 PM she stated there would be a block on the MAR indicating when the INR was due and the [MEDICATION NAME] should not be given after that date in the MAR as a new order would be written. The [MEDICATION NAME] flow sheet should be reviewed daily by the medication nurse and if they noticed it was not filled in they should notify the Nursing Supervisor. She stated it was the responsibility of the nursing supervisor to call the physician with the laboratory results and document right on the report that the physician was notified and what changes were made if any. During an interview with LPN #6 on 8/31/2017 at 3:50 PM she stated in the MAR a date with the [MEDICATION NAME] order would state when the PT/INR was due. If no date she would not give the [MEDICATION NAME] and she would not administer the [MEDICATION NAME] after the INR due date was written on the MAR. She would also review the [MEDICATION NAME] flow sheet as that would contain all the needed information. During an interview with the physical therapist #9 on 9/1/2017 at 8:30 AM she stated she had noticed last month the resident had bruises on both arms and she had reported to the nursing staff on the unit. She stated the resident told her she was not sure how she got the bruise, whether she had bumped it against something or if it was from the blood pressure cuff. During an interview with LPN #10 on 9/1/2017 at 8:40 AM she stated the date of an INR would be highlighted in the MAR so the medication nurse would know the labs needed to be addressed as PT/INRs were done weekly. She stated the medication nurse should have noticed the resident's [MEDICATION NAME] orders in the MAR did not have a date and they should have questioned it and notified the MD that a recent PT/INR had not been done. She stated she had noticed a problem recently with residents not getting labs done. She thought it was due to a lack of training as they had several new nurses who were not aware of the process. During an interview with LPN #12 on 9/1/2017 at 9:20 AM she stated she did recall a physical therapist had reported to her about a bruise and she passed that to the oncoming shift and told them they would have to do some sort of incident about it. During an interview with LPN #13 on 9/1/2017 at 9:55 AM she stated she worked for an agency and had questioned before what their policy was regarding PT/INRs. She stated she was told that if a resident needed one it would be documented in the MAR. If she noticed a date in the MAR for a PT/INR she would notify the supervisor to follow up. She stated PT/INRs often were not her priority as she was responsible for two medication carts during her shift and there was not much time for anything else other than passing medications. During a subsequent interview with the DON on 9/1/2017 at 12:20 PM she stated an accident and incident report was initiated for all injuries of unknown origin including bruises. If a resident had an unexplained bruise she would review their medications and if on a anticoagulant she would review their laboratory values. She stated she was not aware the resident had a bruise on 8/14/2017 and had she known they may have identified the PT/INR error sooner. 2) Resident #2 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The 8/25/2017 Minimum Data Set (MDS) assessment documented the resident's cognition was moderately impaired, he required extensive assistance for most activities of daily living (ADLs) and received anticoagulation medication daily. The comprehensive care plan (CCP) dated 8/24/2017 did not identify the resident was on anticoagulation medication and was at risk for complications related to the medication. A physician order [REDACTED]. A physician history and physical dated 8/15/2017 documented the resident had A-fib and they would continue to monitor his INR. A laboratory report dated 8/15/2017 documented the resident's INR results were drawn on 8/15/2017 at 6:20 AM and the results were 1.32 (therapeutic range 2.00 - 3.00) The report documented the results were reported to the facility at 9:06 AM. There were initials documented on the bottom of the lab report with no date indicating when the lab had been reviewed. The medication administration record (MAR) documented the resident had an PT/INR due on 8/14/2017. The initials in the box were circled on 8/14/2017 and on 8/15/2017. On the back of the MAR it was documented by LPN #12 8/15/2017 no INR f/u at 1600. There was no documented evidence the resident's [MEDICATION NAME] dose was adjusted to meet the therapeutic range or a repeat PT/INR was ordered. A physician progress notes [REDACTED]. During an interview with LPN #12 on 9/1/2017 at 9:20 AM initially stated she was not sure regarding the process of ensuring PT/INRs were done and addressed as she did not work there very often. She stated if there was a date of an INR with a [MEDICATION NAME] order in the MAR she would go look to see what the results were before giving the [MEDICATION NAME]. If the INR was not within normal limits she would notify the physician. She stated she would not document on the lab sheet to indicate it was addressed. She would document a telephone order and a nursing progress note. She stated she could not recall seeing a date of the resident's PT/INR or if she had notified anyone and was sure she had. She stated if she put her initials on the MAR with a circle around them it indicated the medication was not given. During an interview with the physician on 9/8/2017 at 1:54 PM he stated he was either notified by phone or given the laboratory results when in the facility. He stated he would always ask a series of questions when notified of results including the results and current dose. He stated he would verbalize the new orders of [MEDICATION NAME] dose and when to repeat the PT/INR to the nurse. She would write out a telephone order and document the new orders on the lab sheet. He stated prior to the incident with Resident #1 there had not been a [MEDICATION NAME] flow sheet to refer to. He stated he did not know why the resident did not have his PT/INR addressed and that would indicate to him the nurse did not do what she was supposed to do. 10NYCRR 415.12