Every finding on record at Oneida Center for Rehabilitation and Nursing

Based on observation, record review, and interview, the facility failed to ensure the providers wrote, signed, and dated their progress notes at each visit for one (1) of three (3) residents (Resident #1) reviewed. Specifically, Nurse Practitioner #4 initiated and completed a federally mandated visit on Resident #1 including a physical assessment, after Resident #1 was discharged to the hospital and did not return to the facility. Findings include:The 10/2025 facility policy, Physician Documentation, revised 04/26/2023, documented at the time of each physician's visit; a progress notes shall be written, signed, and dated in the physical chart or electronic medical record. The physician shall document in accordance with accepted professional standards of practice, and current Federal and State Regulations. Physician documentation shall be complete and accurately reflect the resident's status throughout the length of their stay. The 03/25/2026 Provider Note by Nurse Practitioner #4 documented Resident #1's blood pressure was completed on 03/25/2026 at 5:48 AM, and their oxygen saturation was completed on 03/25/2026 at 8:11 AM. There was a completed physical assessment of Resident #1 documented. The document was signed by Nurse Practitioner #4 on 03/28/2026 at 5:50 PM. The 03/26/2026 at 1:43 AM, Nursing Note by Licensed Practical Nurse #5 documented Resident #1 had a change in condition with delirium behaviors and was sent to the hospital for evaluation. Vitals were started on Resident #1 at 1:38 AM on 03/26/2026. The 03/26/2026 Provider Note by Nurse Practitioner #4 documented Resident #1 was seen for a federally mandated visit on 03/26/2026. They documented Resident #1 had multiple comorbidities, behaviors were stable, and completed a physical assessment. The included assessment vitals were completed on 03/26/2026 at 1:38 AM and 1:39 AM (the same vitals from the change in condition nursing note on 03/26/2026 at 1:43 AM). The assessment documented Resident #1 was sitting up in their chair, awake, pleasant, and cooperative. They had a clear pharynx (throat), moist mucus membranes, bilateral peripheral pulses were palpable, bowel sounds were present, compression wraps were on the left lower leg, they were alert and in no acute distress, their lungs were clear, they were wearing oxygen, and the provider could heart their heart rhythm. The document was signed by Nurse Practitioner #4 on 03/31/2026 at 4:18 PM. During an interview on 04/29/2026 at 12:18 PM, Licensed Practical Nurse #6 stated the providers were only in the building from 8:00 AM to 6:00 PM, and were on call until 7:00 PM. Nurse Practitioner #4 only worked Tuesdays and Thursday. The provider notes auto-generate in the resident's charts for midnight, but there was a time change thing that happened, so it shows up in the chart as 1:00 AM no matter what time they are started the visit note. The provider has to manual change the time, and most of the providers did not change the time stamp. The visit note pulls the vitals, medications, and diagnoses into the note for the providers to review and edit if need be. The note will pull the most recent vitals taken. If the vitals from the change of condition were in the provider note, then the provider note was started afterwards. During an interview on 04/29/2026 at 1:41 PM, Nurse Practitioner #4 stated they worked varying hours in the facility, but on the day shift. They were currently covering for another provider that was out on leave, and this facility was not their primary facility. Routine visits were scheduled during the day. They stated Resident #1 had a federally mandated visit due on 03/25/2026, They stated they visited Resident #1 on 03/25/2026 which was supposed to be a discharge visit to go home. They wrote in their notebook that Resident #1 went to the hospital on [DATE] and accidentally put in the wrong date. When asked about the 03/25/2026 visit note for the follow up for pain, Nurse Practitioner #4 stated that the follow up for pain visit on 03/25/2026 and the visit note for 03/26/2026 should have been combined. They stated they were reviewing the records as the facility told them the state was reviewing cases. They noted the mistake and already corrected it. They were not familiar with the facility electronic medical record system, as it was not the same as their primary facility. They did not see the resident on 03/26/2026. They did not always sign off their visit notes on the same day as the visit. They had a lot going on between the two facilities, and things in their personal life, that they were not able to complete and sign off the visits on the same day. During an interview on 04/29/2026 at 2:10 PM, the Administrator stated they did not have audits for the timeliness of provider documentation and completions of notes. They tracked the 30-60-90 federally mandated visits and when they were needed but did not track when the visits were completed and signed off by the providers. The facility had just got a new medical director and had a covering nurse practitioner. They stated that a mandated visit should not be completed on a resident that was sent to the hospital, and not in the facility. During an interview on 04/29/2026 at 2:20 PM, the Director of Nursing stated that if the vitals were in the provider note, that meant the note was opened after the vitals were taken. The system pulls the last set of vitals when generating the document. If the provider created the visit note for that day, the vitals would automatically generate. So, if the vitals in the note were from the change in condition for Resident #1, the note would have been created after the resident went to the hospital. During a telephone interview on 05/06/2026 at 5:26 PM, the Medical Director stated providers had three days to complete their documentation. The complete review of their note and plan of care requirements should be done in that three day window, including locking and signing the note. It was not appropriate to take longer than three days to sign a provider note. The provider notes opened as a template and the information in the note was pulled from the resident's chart automatically. They reviewed the template and could make changes manually, if they wanted. If vitals were in the note that meant the note was started after the vitals were taken. It was not appropriate to have a provider note with a physical assessment included if the resident was no longer in the building. A mandatory visit note would not be required based on the federal requirements once the resident went to the hospital, the timeline would start again on their return. If the provider felt they needed to address the mandatory visit to stay current with the requirements the note should only include, the resident went to the hospital and when, no physical assessment. 10 New York Codes, Rules and Regulations 415(b)(2)(iii)

Based on observations, record review, and interviews during the recertification survey conducted 12/3/2024-12/10/2024, the facility did not ensure residents had the right to a dignified existence in a manner and an environment that promoted the maintenance or enhancement of quality of life for 4 of 5 residents (Residents #5, #58, #61, and #106) reviewed. Specifically, Resident #58 was not called by their preferred name and a certified nurse aide in the resident's room loudly communicated personal information to a nurse across the hall; Resident #61 was not provided with a toothbrush to complete oral care; and Residents #5 and #106 were transported backwards in their wheelchairs. Findings include: The facility policy, Resident Rights, revised 5/28/2024, documented all healthcare personnel were to treat the residents with kindness, respect, and dignity. All residents had the right to a dignified existence. Residents also had the right to participate in their care planning and treatment and self-determination. The facility policy, Quality of Life/Dignity, revised 5/28/2024, documented each resident was to be cared for in a manner that promoted and enhanced quality of life, dignity, respect, and individuality. Residents were to be treated with dignity and respect at all times. The residents were to be groomed as they wished to be groomed. The staff were to speak respectfully to residents, including addressing the resident by their name of choice and not labeling or referring to the resident by their room number, diagnosis, or care needs. Verbal staff-to-staff communication regarding residents were be conducted outside the hearing range of residents and the public. 1) Resident #58 had diagnoses including hypertension, chronic viral hepatitis C (a viral liver infection), and cerebral infarction (stroke). The 9/30/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition and required substantial to maximum assistance for most activities of daily living. The Comprehensive Care Plan dated 1/25/2024 documented the resident preferred to dress comfortably and preferred to be called by their first name. Interventions included to assist the resident with their daily activities as needed and to respect and encourage the resident's preferences and choices. During an observation on 12/5/2024 at 12:04 PM, Certified Nurse Aide #34 stood at the resident's door and loudly called come on [resident's last name] three times without entering the resident's room. Certified Nurse Aide #34 loudly asked from the doorway why the resident slept so much and if the resident liked to sleep all day. During an observation on 12/6/2024 at 12:08 PM, Certified Nurse Aide #34 called to the resident by their last name loudly from the doorway to get up for lunch. Certified Nurse Aide #34 walked into the room and loudly stated come on and called the resident by their last name again. The resident stated they could not get up because they were having contractions. Certified Nurse Aide #34 stuck their head out of the resident's room and loudly called to Licensed Practical Nurse #30 who was behind the desk outside of the room, come get your resident they said they were having contractions. During an interview on 12/09/2024 at 2:10 PM, Resident #58 stated they preferred to be called by their first name. They stated it was annoying when the staff referred to them or called them by their last name. During an interview on 12/09/2024 at 2:18 PM, Certified Nurse Aide #34 stated it was not okay to yell a resident's personal information from the resident's room to the nurses' station. The nurse should be pulled aside and given the information. It was not dignified to yell to the resident from the doorway to get up for lunch. They should have asked the resident from inside their room. They stated they called Resident #58 by their last name because the resident was older than them so it would be weird to use their first name. Elders were to be respected and they looked at the residents like they were their grandparents. During an interview on 12/09/2024 at 1:43 PM, Corporate Resource Licensed Practical Nurse (acting Unit Manager) #4 stated staff should not have yelled resident personal information from a resident room to the nurse at the nurse's station. During a follow up interview on 12/10/2024 at 10:19 AM, they stated a resident should be called by their preferred name, especially if it was identified on their plan of care. It was important for residents to be treated with dignity and respect as everyone should be treated with dignity and respect. This was the resident's home. 2) Resident #61 had diagnoses including glaucoma (a chronic eye disease), drug induced movement disorder, and epilepsy (a seizure disorder). The 11/29/2024 Minimum Data Set documented the resident had intact cognition and required supervision for oral hygiene. The Kardex (care instructions) active as of 11/1/2024 documented supervision with oral hygiene, oral care with AM and PM care. The Comprehensive Care Plan created 6/7/2020 documented the resident required assistance with activities of daily living. Interventions included encourage resident to participate to the fullest extent possible with each interaction, and the resident required supervision or verbal cues with oral hygiene. During an observation and interview on 12/3/2024 Resident #61 stated they could not brush their teeth because they did not have a toothbrush and never had one. There was no toothbrush in the resident's bathroom. During an observation on 12/4/2024 at 2:04 PM there was no toothbrush located in the resident's room or bathroom. During an observation and interview on 12/6/2024 at 10:20 AM Certified Nurse Aide #31 looked for a toothbrush in the resident's room and could not find one. They stated the resident brushed their teeth when they were showered. The resident had refused their shower on 12/5/2024. During an interview on 12/10/2024 at 10:01 AM Corporate Resource Licensed Practical Nurse (Acting Unit Manager) #4 stated the resident often threw things away and may have thrown away their toothbrush. They stated it was important for residents to have their teeth brushed so their mouth did not feel horrible. Lack of mouth care was not dignified. 3) During an observation on 12/3/2024 at 11:04 PM Resident #5 was sitting in a Geri Chair (a specialized reclining wheelchair). An unidentified staff told the resident it was time to go to the bathroom and pulled the resident backward in their wheelchair down the hallway. During an observation on 12/4/2024 at 2:01 PM Resident #5 was sitting awake in their Geri chair. An unidentified staff gave the resident a drink and asked them if they were ready and pulled the resident down the hall backwards in their Geri chair. During an interview on 12/5/2024 at 10:01 AM Corporate Resource Licensed Practical Nurse (Acting Unit Manager) #4 stated residents should not be pulled backwards in their wheelchair. It was not dignified, and the resident would not be able to tell where they were going. During an observation on 12/6/2024 at 1:02 PM Resident #106 was transported to their room in their Geri chair by an unidentified staff and was pulled backwards down the hallway. 10 NYCRR 415.5(b)(1-3) 51469

Based on observation, interview, and record review during the recertification survey conducted 12/3/2024-12/10/2024, the facility did not ensure each resident had the right to be fully informed in a language that they can understand for 1 of 1 resident (Resident #104) reviewed. Specifically, Resident #104's primary language was not English, and the resident was not fully informed of their health care status in a language they understood, and communication tools were not used by direct care staff to determine the resident's needs. Findings include: This facility policy, Translation services, revised 1/2020, documented that a language access program would ensure that individuals with limited English proficiency would have meaningful access to information and services provided by the facility. Resident #104 had diagnoses including perforation of intestine, anemia, and hearing loss. The 9/30/24 Minimum Data Set assessment documented the resident wanted or needed an interpreter to communicate with a doctor or health care staff, the resident had absence of spoken word, had adequate hearing, was rarely/never understood, sometimes understood others, and had severely impaired cognitive skills for daily decision making (the resident's cognition was unable to be assessed by an interview). The resident's 3/27/2024 Admission Record documented the resident's primary language was a language other than English. The Comprehensive Care Plan documented: - on 3/27/2024 the resident was at risk for actual impaired health literacy that was related to their nonverbal status. The resident would communicate barriers to health literacy with the interdisciplinary team through the next review period. Information would be adapted to accommodate the residents cognitive, perceptual, and behavioral disabilities. Assistance would be offered to the resident to identify any barriers to learning and the resident would be encouraged to ask questions. - on 3/29/2024 the resident was unable to make recreation and leisure preferences known. Their past hobbies and interests were unknown. The resident would be engaged in a variety of activities that were appropriate to the level of functioning and of benefit, such as audiobooks. The resident would partake in sensory cognitive stimulation such as music. Offer alternative setting and provide 1 to 1 bedside visits. Provide close supervision during activities. Provide assistance or special adaptive equipment as needed. Provide with diversional activity supplies during periods of increased confusion or agitation. Watch for signs of overstimulation or fatigue during periods of agitation or confusion. - on 7/16/24 the resident had a decline in psychosocial well-being related to adjustment to nursing home placement and language difference. An interpreter would be utilized when necessary. The resident would demonstrate effective coping behavior through the next review. Support resident's familiar routines and encourage contact with resident's support system. The September 2024 activity attendance record documented the resident participated in Daily Chronicles every day In September 2024. This was the only activity marked as attended except for one arts and crafts activity. A 9/27/2024 at 10:30 AM Director of Nursing Interdisciplinary Team Meeting progress note documented nursing, social services, therapy, administration were in attendance. The resident was not appropriate to attend due to severe cognitive impairment. The resident did not have capacity for medical decisions. They attempted to reach family on multiple occasions, messages were left for call back with no response. The 11/26/2024 progress note by Nurse Practitioner #15 documented the resident was unable to answer many questions due to cognitive impairment. There was no documented evidence how it was determined the resident had severe cognitive impairment when they were unable to answer questions. There was no documented evidence the resident was assessed for communication needs and if a translation service was provided. Resident #104 was observed: - on 12/3/2024 at 9:30 AM sitting at the dining room table with other residents and staff members during an activity. Unidentified staff attempted to communicate by using facial expression, hand gestures, and English language. The resident did not appear to understand. - on 12/4/24 at 11:00 AM lying awake in bed with the television turned on with a show broadcasted in English. The resident was not engaged in watching the television. - on 12/6/24 11:09 AM at a table with other residents while the activities staff were making bracelets. The resident was not engaged in the activity. There was no communication with the resident. The staff asked the resident in English if they wanted a horse to color. The resident did not answer the question. - on 12/09/2024 at 10:40 AM given a fishing activity to do independently by Activity Assistant #33. There was a television with the volume elevated and a Bluetooth speaker with loud music on the activity cart in the same area. The combination of the television and the Bluetooth speaker made a very loud and chaotic environment. There was no observed communication between the resident and staff. During an interview on 12/09/24 at 11:01 AM, Activities Assistant # 33 stated the description of the activity titled daily chronicles was a printed paper with the daily menu on the front and a special event in history on the opposite side and was in English. They stated Resident #104 did not participate in daily chronicles because they would not understand it as it was in English. Activity Assistant #33 stated they mainly use hand gestures to communicate, because the resident did not know English. They stated they were not aware of any audio books in the resident's language. During an interview on 12/10/24 at 10:30 AM Activities Director # 32 stated communication with the resident was more nonverbal. The resident did not have any audio books available to them in their primary language. The Activity Director referenced the availability of a communication board that was present in the resident's room. The Activity Director stated it could be utilized with the resident to allow them to make their needs known. The resident's interests were unknown, and the family availability was limited as they would only visit during off hours. The Activity Director had not spoken to the family to determine specific activities the resident would enjoy. The residents main recorded activity attendance was reading the daily Chronicles. The Activity Director stated this was an error as the Chronicle was written in English, and this would not be an appropriate activity due to both the residents language barrier and their intellectual delay. During an interview and observation on 12/10/24 09:42 AM Licensed Practical Nurse #30 stated they were unaware of the existence or location of a communication board for the resident. Licensed Practical Nurse #30 inquired with several unidentified certified nurse aides in the immediate area who all stated they were not aware of a communication board to use with the resident. Licensed Practical Nurse #30 looked in the resident's room and confirmed there was no communication board for resident use. During an Interview on12/10/24 at 12:04 PM Licensed Practical Nurse Unit Manager #4 stated Resident #104 was developmentally delayed but the resident did have some ability to receptively communicate in their native language. They stated the resident was not completely deaf and had no specific tools to assist with communication. 10NYCRC483.10(c)(1)(4)(5)

Based on observation, record review, and interview during the recertification survey conducted 12/3/2024 -12/10/2024, the facility did not ensure a safe, clean, comfortable, and homelike environment for 1 of 3 units (3rd Floor) reviewed. Specifically, the 3rd Floor had multiple unclean floors and walls, damaged walls, and unpleasant odors. Findings include: The undated facility procedure for Resident Room Cleaning documented the cleaning schedule should be reviewed before cleaning as well as the rotational cleaning schedule. Supplies should be gathered and the following cleaned: dust surfaces including bedside tables, dressers and overhead lights; empty trashcans from bathroom and living spaces and replace liners; clean bathrooms with disinfectant, cleaning from dirty to clean, flush toilet after cleaning; high and low dust surfaces in rooms including under the bed frames; sweep and mop living areas; clean and mop the hallway floors; and clean and dust the hall pictures and handrails outside of rooms. The facility policy, Maintenance Services, dated 8/2019 documented the maintenance department was responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Functions of the maintenance department were to maintain the building in good repair and free from hazards, establish priorities in providing repair service, and provide routine scheduled maintenance to all areas. The following observations were made on the 3rd Floor: - on 12/3/2024 at 10:09 AM, room [ROOM NUMBER] had a strong urine odor in the bathroom. - on 12/3/2024 at 11:38 AM, the dining room had a strong urine odor. - on 12/3/2024 at 11:45 AM, the railing in the dining room next to room [ROOM NUMBER] had scrapes, and room [ROOM NUMBER]'s door was scraped and faded in color. - on 12/3/2024 at 1:14 PM, the dining room alcove wall had several scrapes. - on 12/3/2024 at 3:42 PM, the floors in room [ROOM NUMBER] A were unclean, the bathroom tiles were lifting and there was a sticky trap behind the bathroom door with unidentified bugs on it. - on 12/5/2024 at 9:09 AM, the hallway near the dining room had a strong urine odor. - on 12/5/2024 at 9:36 AM, the dining room alcove floor had 3 ripped and torn areas. - on 12/5/2024 at 12:54 PM, the kitchenette was unclean. During an interview on 12/9/2024 at 1:55 PM, Housekeeper #27 stated they worked 3 days and were off 2 days. The 3rd Floor was their assigned unit, and they were responsible for cleaning resident rooms, bathrooms, mopping floors, and cleaning shower rooms. They stated the 3rd Floor always smelled like urine and they did their best to clean up as needed. During an interview on 12/9/2024 at 2:07 PM Director of Maintenance #28 stated there was a book on each unit for work orders and staff also had access to a phone application to place work orders. If staff did not tell them a repair was needed, maintenance would do rounds to see if items needed repair or respond to resident requests. They recalled fixing room [ROOM NUMBER]'s tiles two years ago and stated it might have been a quick fix. They were not aware they needed to be fixed again. During an interview on 12/9/2024 at 2:20 PM Director of Housekeeping #29 stated the housekeeping staff was responsible for cleaning common areas, resident rooms, the dining room, high and low touch areas, common bathrooms, the nursing station, and kitchenettes. Staff should report and address any odors the minute they arrive on the unit. If work could not be completed, the housekeeping staff should tell them. The housekeeping staff was required to hand in daily cleaning checklist sheets at the end of the day. It was important to keep resident rooms clean because it was their home and for infection control reasons. 10 NYCRR 415.29(b)(j)(1)

Based on observations, record review, and interviews during the recertification survey conducted 12/3/2024-12/10/2024, the facility did not develop and implement a comprehensive person-centered care plan that included measurable objectives to meet medical, nursing, and mental and psychosocial needs for 3 of 6 residents (Residents #58, #100, and #101) reviewed. Specifically, Resident #100 had a physician order to receive nothing by mouth and was care planned to be offered a bedtime snack; Resident #58 did not have a comprehensive care plan that addressed their diagnosis of liver disease, their care plan was not updated when their transfer status changed, and they did not have fall mats as planned; Resident #101 had physician orders for an antipsychotic medication and did not have a care plan to address the medication and non-pharmacological interventions. Findings include: The facility policy, Care Plans-Comprehensive, revised 8/2/2024 documented a comprehensive person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs was developed and implemented for each resident. The interdisciplinary team reviewed and updated the care plan when there was a significant change in the resident's condition, when the desired outcome was not met, when the resident was readmitted from a hospital stay, and at least quarterly. 1) Resident #58 had diagnoses including chronic viral hepatitis C (an infection that affects the liver) and cerebral infarction (stroke). The 9/30/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition, moderately severe depression, and required substantial to maximum assistance for most activities of daily living, including transfers. Fall Mats and Transfers: The Comprehensive Care Plan documented: - initiated 4/27/2021 the resident was at risk for falls/had an actual fall related to confusion, gait and balance problems, and a history of falls. Interventions included floor mats, ensure the resident had appropriate footwear, and be sure the call light was within reach. - initiated 10/27/2021 and revised 5/16/2024 the resident required assistance with activities of daily living related to confusion, impaired balance, limited mobility, and limited range of motion. Interventions included to encourage the resident to utilize the call bell for assistance, substantial assistance of 2 for transfers from bed to chair and from sitting to standing. The Kardex (care instructions) documented floor mats at the bedside as indicated, substantial assistance of 2 for transfers. The 8/7/2024 physical therapy discharge summary documented the resident required stand by assistance for transfers and bed mobility. There was no documented evidence the comprehensive care plan was updated to reflect the resident's change in transfer status. The following observations of the were made: - on 12/03/2024 at 12:08 PM, lying in bed with no fall mats. - on 12/05/2024 at 9:16 AM, in their room asleep with the bed slightly lowered with no fall mats. - on 12/06/2024 at 9:35 AM, in bed asleep with no fall mats. - on 12/09/2024 10:24 AM, asleep in bed with no fall mats. During an observation on 12/05/2024 at 12:04 PM Certified Nurse Aide #34 was at the resident's door and was loudly encouraging the resident to get up for lunch. Certified Nurse Aide #34 did not enter the resident's room. Certified Nurse Aide #34 encouraged the resident from the doorway, to transfer themself to their wheelchair from the edge of the bed. During an interview on 12/09/2024 at 10:39 AM, Certified Nurse Aide #35 stated they knew how to care for a resident by reading the Kardex at the kiosk. They checked the Kardex everyday because something could change every day. They stated Reside #58 required supervision for transfers but could transfer themself and often did without waiting for staff. They stated the resident was very adamant about not being touched. During an interview on 12/09/2024 at 1:43 PM, Corporate Resource Licensed Practical Nurse (acting Unit Manager) #4 stated the Director of Nursing, Assistant Director of Nursing, or the Minimum Data Set Coordinator were responsible for updating the care plans on the Third Floor as they were a licensed practical nurse and could not alter the care plans. They stated Resident #58 was supposed to have floor mats next to their bed. They stated they thought they saw them in the resident's room but the resident was up and down often so staff may not have put the mats down. They stated Resident #58 could transfer themself using the mobility bars on their bed. During an interview on 12/09/2024 at 2:18 PM, Certified Nurse Aide #34 stated they knew how to care for a resident by looking at their care plan. They stated Resident #58 required supervision for transfers and did not like to be touched. They stated if a resident was care planned to have two-person substantial assistance the staff should not be encouraging the resident to transfer themself. It was important to follow the care plan for the staff's and resident's safety. Liver disease: Physician orders documented: - 6/13/2024 30 milliliters of lactulose oral solution two times a day for elevated ammonia level (liver disease can cause elevated blood ammonia levels, elevated levels can cause multiple symptoms). - on 10/16/2024 xifaxan (used to treat liver problems) oral tablet 550 milligrams one tablet by mouth two times a day for liver disease. An 11/18/2024 Physician #40 progress note documented the resident had increased ammonia levels related to chronic hepatitis C and alcohol abuse. The resident would need their ammonia levels checked periodically. There was no documented evidence of a comprehensive care plan that addressed the resident's liver disease or ammonia levels. 2) Resident #101 had diagnoses including bipolar disorder, major depressive disorder, and unspecified dementia. The 10/20/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition, moderate depression, no behavioral symptoms, and was taking an antipsychotic. The 6/24/2024 physician order documented 2 milligrams of Rexulti (antipsychotic) once a day at bedtime for dementia with aggression. The 11/2024 Treatment Administration Record documented monitor resident behaviors (breaking furniture, hitting staff, throwing things) every shift. Record the number of episodes, record interventions by number (1 redirected, 2 one to one, 3 refer to nursing notes, 4 diversional activities, 5 assisted back to room, 6 toileted, 7 offered food/drink, 8 psychiatry/psychology consult, 9 changed position, 10 adjust room temperature, 11 backrub, 12 reapproached) with a start date of 3/6/2024. The resident did not have any documented behaviors in 11/2024. There was no documented evidence of a comprehensive care plan addressing aggressive behaviors, non-pharmacological interventions for aggression as documented on the Treatment Administration Record, or the use of an antipsychotic medication. The Kardex (care instructions) active as of 12/9/2024 documented distract resident from wandering by offering pleasant diversions and educate/encourage appropriate behavior. 3) Resident #100 had diagnoses including dysphagia (difficulty swallowing) and acute respiratory failure. The 10/4/2024 Minimum Data Set assessment documented the resident had severely impaired cognitive skills for daily decision making, was dependent for activities of daily living, did not have a swallowing disorder, had a feeding tube, and received 51% or more of calories through a tube feeding. The Comprehensive Care Plan initiated 5/1/2024 documented the resident had a nutritional problem related to dysphagia, and nothing by mouth with tube feeding. Interventions included nothing by mouth, review meal/fluid consumption records, offer snack every night at hour of sleep, and fluid intake every shift (do not include fluid with meals). The Kardex (care instructions) active as of 12/9/2024 documented to offer the resident an hour of sleep snack every evening. The November 2024 Documentation Survey Report (certified nurse aide documentation) documented hour of sleep snack every evening. The report was marked as NA (not applicable), was blank, or had incorrect documentation of resident accepting snack. The resident did not receive an hour of sleep snack. During an interview on 12/9/2024 at 2:18 PM Certified Nurse Aide #34 stated the snack should not be on Resident #100's documentation and they frequently accidently marked it in the computer as given and would have to go back in and correct it. They stated they never gave the resident a snack and it needed to be removed from the system. During an interview on 12/09/2024 at 2:45 PM Minimum Data Set Coordinator #39 stated they, the Director of Nursing, and the Assistant Director of Nursing were responsible for updating the care plans for the two floors that had licensed practical nurses as Unit Managers. The care plans were updated as needed. They were unsure who was overall responsible for ensuring the care plans were up to date and accurate. Medications that were included on the care plan should include psychotropics. They stated if a resident was on Rexulti, they should have a care plan for antipsychotic medications. If a resident had liver disease and was on medication for it, they should have a care plan. Residents should have care plans for their current diagnoses, the medications they are on, and for other areas such as social work and activities. The care plan should tell you the picture of the person. The activities of daily living information on the care plan came from therapy assessments. If a resident was able to transfer at a higher level than what they were care planned for, the staff should let someone know. If a resident was documented as needing two person assistance, they should use two until the resident was assessed and the care plan updated. The certified nurse aides should not encourage a resident who was care planned for two-person assistance to transfer themself. That would not be following the care plan. If a resident's care plan included fall mats, they should have fall mats in place. It was important for the care plan to be up to date for the care of the resident. If the care plan was not up to date, mistakes could be made which could cause harm. During an interview on 12/09/2024 at 3:01 PM, the Director of Nursing stated they were responsible for ensuring care plans were up to date and accurate. They stated a resident who was on Rexulti should have a care plan for the grouping of the medication. If a resident received treatments and medications for liver disease, they should have a care plan. If a resident required two-person substantial assistance the certified nurse aides should not have encouraged the resident to transfer themself. It was important to follow the care plan to prevent injury. There was no formal way for the certified nurse aides to communicate items that were not up to date or changes needed to the resident's care plan. They should let the Nurse Manager know and if they were a licensed practical nurse, they should communicate it to the correct parties. It was important the care plan was up to date and accurate to give the resident the best treatment. During an interview on 12/10/2024 at 1:43 PM Corporate Resource Licensed Practical Nurse (acting Unit Manager) stated the certified nurse aides should not document on Resident #100's meal intakes and hour of sleep snacks. The program should not have generated that since the resident did not receive anything by mouth. The staff all knew the resident did not receive anything by mouth and would not offer a snack. 10NYCRR 415.11(c)(1)

Based on observations, record review, and interviews during the recertification survey conducted 12/3/2024-12/10/2024, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 4 residents (Resident #86) reviewed. Specifically, Resident #86 had unclean and untrimmed fingernails. Findings include: The facility policy, Activities of Daily Living Care and Support, revised 3/13/2024, documented activities of daily living care and support would be provided for residents who were unable to carry out activities or daily living independently. That included but was not limited to supervision and assistance with hygiene, mobility, elimination, dining, and communication. Nail care would be provided as needed for the resident and residents with certain medical conditions might require a licensed nurse to perform. Resident #86 had diagnoses including absence of left above the knee amputation and chronic obstructive pulmonary disease (lung disease). The 10/13/2024 Minimum Data Set assessment documented the resident was cognitively intact, did not reject care, and required supervision with eating, oral hygiene, upper body dressing, and personal hygiene. The Comprehensive Care Plan initiated 11/30/2022 documented the resident required assistance with activities of daily living. Interventions included to encourage the resident to participate to the fullest extent possible with each interaction and the resident required supervision, verbal cues or touching assistance with personal hygiene. The undated resident care instructions documented prevent resident from scratching, keep hands and body parts from excessive moisture, and keep fingernails short. During observations and interviews at the following times, Resident #86 had long, jagged nails with black/brown debris under them: - on 12/3/2024 at 1:20 PM. The resident stated staff did not offer or assist them with cutting their nails. - on 12/4/2024 at 9:11 AM. - on 12/5/2024 at 10:04 AM. - on 12/6/2024 at 10:30 AM. - on 12/9/2024 at 2:28 PM. The resident stated they asked the staff for nail clippers because the debris under their nails smelled bad and they were unsure what it was. They never received the nail clippers. The December 2024 certified nurse aide documentation survey report documented the resident received care from 12/3/2024-12/9/2024 including personal hygiene. During an interview on 12/9/2024 at 2:32 PM, Certified Nurse Aide #17 stated they cared for Resident #86 last week and they were familiar with them. If they documented care was completed on a resident that meant all personal hygiene was done. Personal hygiene consisted of oral care, haircare, shaving, dressing, bathing, and nail care. Resident #86 required supervision and set up assistance with care and the only thing they refused was an occasional shower. They stated if the resident refused care they would reapproach them, document the refusal, and notify the nurse who would then write a progress note. They stated it was important to cut Resident #86's nails and make sure they were clean to prevent them from cutting themselves or getting an infection. During an interview on 12/10/2024 at 10:09 AM, Certified Nurse Aide #18 stated they cared for Resident #86 on 12/3/2024 and on 12/10/2024. When they documented care was completed it included dressing, nail care, haircare, mouth care, and a bed bath. If a resident refused care they would reapproach them, if they continued to refuse, they would document the refusal, and would notify the nurse. It was their responsibility to trim and clean nails unless the resident was a diabetic, then the nurse would complete it. They stated they should have been checking resident's nails and they did not notice if Resident #86's nails were unkept. It was important to keep Resident #86's nails clean and trimmed so they did not cut themself and develop an infection. During an interview on 12/10/2024 at 10:26 AM, Licensed Practical Nurse Unit Manager #19 stated when the certified nurse aides documented care was completed it meant they performed mouth care, bed bath, shaving, nail care, and dressed the resident. If a resident required supervision, it meant the staff member was present during care to ensure the resident was safe and assisted with setup and help as needed. If a resident refused care the certified nurse would reapproach the resident, if they continued to refuse, the certified nurse aide should document the refusal and notify them. They had not been notified of Resident #86 refusing care or they would have addressed it. They expected the certified nurse aides to offer nail care daily and it was important for nails to be short and clean to prevent cuts and infections. During an interview on 12/10/2024 at 10:51 AM, Licensed Practical Nurse #20 stated if the certified nurse aides documented the residents care was completed that meant they completed all their personal hygiene, and it was to be completed every shift. Personal hygiene consisted of toileting, shaving, nail care, and mouth care. The certified nurse aides were responsible for nail care unless the resident was a diabetic, then the nurse would complete it. They stated it was important to keep resident's nails short and clean for dignity reasons, to prevent them from cutting themselves, or getting an infection. During an interview on 12/10/2024 at 1:38 PM, the Director of Nursing stated certified nurse aides were expected to clean and trim resident's nails daily as needed. If they documented care was completed it meant all personal care. They stated it was important to keep Resident #86's nails clean and trimmed to prevent cuts and infections. 10NYCRR 415.12(a)(3)

Based on observations, record review, and interviews during the recertification survey conducted 12/3/2024-12/10/2024, the facility did not ensure ongoing provision of programs to support each resident in their choices of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 2 of 5 residents (Residents #100 and #101) reviewed. Specifically, Resident #101 was not invited to or assisted to attend activities that were meaningful to them and met their interests and preferences; and Resident #100 was not provided with in-room stimulation that met their interests and preferences. Findings include: The facility policy, Activity Programs, revised 5/2019, documented the facility must provide an ongoing program to support residents in their choices of activities based on the comprehensive assessment, care plan, and preferences of each resident. The activity program consisted of individual, small, and large group activities that were designed to meet the needs and interests of each resident. The facility policy, Dementia Program, reviewed 6/1/2024, documented the facility would provide care to residents with dementia that was specialized, individualized, and person-centered. The facility provided residents who had diagnoses of dementia with person-centered activities designed to provide familiar routines and create social outlets. 1) Resident #101 had diagnoses including bipolar disorder, major depressive disorder, and unspecified dementia. The 10/20/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition, had moderate depression, had no behaviors, and required set up assistance for all activities of daily living. The 1/18/2024 Admission Minimum Data Set assessment documented the resident it was very important to listen to music, to be around animals, to keep up with the news, to do things with groups of people, to do their favorite activities, and somewhat important to have books, magazines, and newspapers to read. The Comprehensive Care Plan dated 1/19/2024 documented the resident was able to make their recreation and leisure preferences known. The resident's interests included bingo, crafts, and word search puzzles. Interventions included to assist the resident to find programs of interest; introduce the resident to peers with similar interests; introduce distracting stimuli such as music, conversation, and touch; invite and escort the resident to activities of choice and interest; provide the resident with any assistance or special adaptive equipment as needed; provide the resident with independent leisure supplies; and provide a monthly calendar/daily schedule of events. The Comprehensive Care Plan dated 2/13/2024 documented the resident displayed or reported mood symptoms related to major depressive disorder, feeling down or depressed, having little energy, feeling bad about themselves, and had trouble concentrating. Interventions included to encourage participation in activities of interest, provide the opportunity for the resident to express themselves, provide support and reassurance, and psychiatric/psychology visits as needed. The 10/15/2024 Director of Activities #32 Activity Assessment documented the resident liked socializing with their peers in the common area and the activity room. The resident was always willing to lend a helping hand to other residents. They enjoyed crafts, music programs, social hours, bingo, table games, and special events. The activity staff would encourage the resident to participate in activities that met the resident's interest. The resident's Kardex (care instructions) documented to invite/escort the resident to activities of choice and interest and provide/offer technology device. Resident #101's December 2024 activities log documented: - on 12/1/2024 to 12/4/2024 the resident had no activities marked as attended or refused except for the daily chronicle - on 12/5/2024 the only activity marked as complete other than the daily chronical was the coffee/tea/snack cart - on 12/7/2024, the resident was marked as unavailable for bingo, coffee/tea/snack, and music listening. - on 12/8/2024, the resident was marked as unavailable for a movie and religious/spiritual activity. The following observations of activities on Unit 3 were made: - on 12/03/2024 at 11:38 AM, Activities Aide #42 was at a table with six residents, including resident #101. There was a box of beads directly in front of the activities aide. The activities aide was threading beads and not engaging with the residents or giving them items make. The residents at the table did not have items in front of them. - on 12/03/2024 at 12:23 PM, the large activity calendar on the wall in the dining room documented most of the scheduled activities were conducted in the activity room. - on 12/05/2024 at 9:33 AM Corporate Resource Licensed Practical Nurse (acting Unit Manager) #4 asked the Activities Aide #42 about doing nails for the residents at 10:00 AM and Activities Aide #42 agreed. At 9:53 AM Activities aide #42 was on the unit with varied items on their cart and was set up in the dining area. They did not invite residents to join in the music, coloring, or making bracelets. Resident #101 was not in the dining area. Nail painting did not occur at 10:00 AM. At 11:07 AM, a cookie activity was taking place in the atrium of the building. No residents from 3rd floor were invited due to current isolation of the unit. At 1:52 PM, Corporate Resource Licensed Practical Nurse (acting Unit Manager) #4 stated staff was supposed to bring up cookies from the cookie activity but that did not occur. - on 12/06/2024 at 9:50 AM, Activities Aide #33 was engaging residents as they came into the dining area and inviting them to join the activity. They did not go from room to room to invite residents to the activity. At 10:10 AM, Resident #101 came into the dining area and asked about the pictures that were scheduled. Activities Aide #33 stated they were not doing pictures at this time, but they were going to do Christmas pictures downstairs with a backdrop, trees, and headbands. Resident #101 was not taken downstairs for Christmas pictures. - on 12/10/24 at 9:40 AM no activities were happening on the floor. There were 4 residents at the tables in the dining area with nothing in front of them and 5 residents in the alcove off the dining room with the TV on. During an interview on 12/03/2024 at 1:13 PM Resident #101 stated they liked to do crafts and to attend activities. They stated staff did not always come get them for activities. 2) Resident #100 had diagnoses including altered mental status, severe protein-calorie malnutrition, and cerebral edema. The 11/4/2024 Minimum Data Set assessment documented the resident had severely impaired cognition for daily decisions and was dependent for activities of daily living. The 5/10/2024 Admission Minimum Data Set Assessment did have the section Preferences for Customary Routine and Activities completed. The Comprehensive Care Plan initiated 5/2/2024 documented the resident was unable to make recreation and leisure preferences known, social history was provided by the resident's representative. Past hobbies and interests included listening to county music, and watching police shows on TV. Interventions included escort the resident to activities of benefit, introduce distracting stimuli (music, conversation, touch), offer alternative setting, provide 1:1 bedside visits, provide close supervision during activity, and provide diversional activities/supplies during periods of increased confusion/agitation, and review prior interest/preferences with family/friends. The 10/30/2024 Director of Activities #32 Activity Assessment documented the resident was unable to respond. They preferred independent pursuits, one to one in both their room and on the unit, required invitations and transport to/from activities, and had personal music equipment. The resident participated independently in music appreciation, sensory stimulation, and social events. The resident's November 2024 Activity log documented the resident refused one to one visits 17 of 30 days; was unavailable for one to one visits 8 of 30 days; and had eye movement, eye fluttering, and facial movement during one to one visits 5 of 30 days. The resident's December 2024 Activity Log documented: - on 12/6/2024 the resident was unavailable for social hour and a special event. - on 12/7/2024 the resident refused bingo, a movie, and listening to music, and coffee/tea hour/snack cart. - on 12/8/2024 the resident was unavailable for a movie and religious/spiritual activity. There was no one to one documented from 12/1/2024-12/9/2024. During an interview on 12/4/2024 at 9:00 AM the resident's significant other stated the resident was always in bed. The resident was unable to move, talk, or eat. They rarely saw staff interact with the resident. The TV was on as background noise, but the resident did not really watch it. Resident #100 was observed: - on 12/5/2024 at 9:52 AM in their room reclined in their wheelchair, positioned in front of the TV, the TV was not on. At 12:10 PM in their room asleep with the TV on. At 2:12 PM in their room asleep. - on 12/6/2024 at 9:37 AM lying in bed with no music or TV. AT 10:39 AM sitting in their room in their wheelchair, positioned perpendicular to the TV. There was a Western playing on the TV. - on 12/9/2024 at 10:19 AM asleep in bed. There was no TV or radio playing. - on 12/10/2024 at 9:37 AM up in wheelchair with the TV playing a Western. During an interview on 12/09/24 at 1:15 PM, Activities Aide #42 stated they only substituted on the Third Floor for if the normal activities aide was not there. They stated when the unit was not isolated, they usually brought residents down to activities and the normal assigned activities aide stayed on the unit. They stated since the residents could not come down to the scheduled activities they did jewelry with them, brought music and snacks, and the residents also liked to color. Cookies, snacks, drinks, jewelry, and coloring were normally what they did when they were assigned to the unit. They stated they usually did the bracelets for the residents because the pieces were too small, so they had the residents tell them what they wanted, and they would make it for the resident. They believed there was a special calendar for the Third Floor, but they did not know where it was. They recorded attendance on paper in a binder in the activity room. They stated Resident #100 usually just watched TV. They did see the resident at many activities, but the resident listened to music and watched a lot of TV. During an interview on 12/09/2024 at 1:27 PM, the Activities Director stated they had one activities aide normally assigned to the Third Floor unit, but most of their staff was part time, so it was hard to find coverage. They tried to make sure there was someone on the unit in the morning and about two to three times a week they did not have anyone on the Third Floor in the afternoon. They stated they did not have structured activities on the Third Floor unit as the residents did not seem to like it. It was a lot easier to just fill up a cart with different things for the residents and let them choose. They invited residents who could attend structured activities down to the main floors for activities. With the third floor on isolation for the week, they sent some items, like the foam gingerbread houses, up to the Third Floor to be completed. They stated the activities staff was supposed to go around to the rooms on the floors and invite residents to attend activities. It was important to provide activities for all interests because residents had different interests. There was a big age, mental ability, and physical ability range in the facility, so they tried to have activities that were from different areas. During a follow up interview on 12/10/2024 at 9:15 AM, the Activities Director stated the activities log should have been marked if a resident was invited and refused. They stated many of residents were interested in beading/bracelet making, but the staff should not just be doing it for the residents. They should assist the residents if needed but just making a bracelet for the residents was not an activity for the residents. They stated Resident #101 was almost always down in activities if the unit was not on isolation. They stated Resident #101 had been a little lost the last week as they could not come down to activities and they want to be active. They stated they did not set any activities or any plans in place for Resident #101 to supplement not being able to go to activities while the unit was on isolation. They stated activity aides would offer Resident #100 soft music or aromatherapy. They can tell the resident got agitated by the look on their face. It was difficult to find activities Resident #100 would tolerate. Sometimes they leave the Chronicle with Resident #100 and have someone read it to them. 10NYCRR 415.5(f)(1) 51469

Based on observations, record review, and interviews during the recertification survey conducted 12/3/2024-12/10/2024, the facility did not ensure a resident who was fed by enteral means (tube feeding, delivery of nutrition directly to the stomach or small intestine) received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 2 residents (Resident #100) reviewed. Specifically, Resident #100's tube feeding water flushes were not administered as ordered and the tube feeding was observed unlabeled. Findings include: Resident #100 had diagnoses including unspecified protein-calorie malnutrition and dysphagia (difficulty swallowing). The 11/4/2024 Minimum Data Set Assessment documented the resident had severely impaired cognition, was totally dependent for eating, did not have signs and symptoms of a swallowing disorder, weighed 126 pounds, did not have weight loss, and received nutrition through a feeding tube. The 5/1/2024 comprehensive care plan documented the resident required tube feeding related to dysphagia. Interventions were discussed with family/caregivers/resident concerns regarding tube feeding, advantages, disadvantages and complications from tube feeding, administer tube feeding per Registered Dietitian recommendations and physician orders, Jevity 1.5 via PEG tube at 70 milliliters per hour starting at 8:00 PM for a total volume of 1400 milliliters. Auto flushes at 40 milliliters per hour starting at 8:00 PM with a total volume of 800 milliliters, check for tube placement prior to administration, keep head of bed elevated at 30 degrees during administration, listen to lung sounds as needed and monitor/document/report to physician signs of aspiration, tube dislodgement, fever, shortness of breath, abnormal lung sounds, tube dysfunction or malfunction, abnormal lab values, abdominal pain, distention, nausea/vomiting or dehydration. The 10/29/2024 PM physician order documented Jevity 1.5 via enteral tube at a rate of 70 milliliters per hour to begin at 8:00 PM for a total volume of 1400 milliliters to be delivered (20 hours total run time). The 12/2024 Medication Administration record documented: - Jevity 1.5 via enteral tube at a rate of 70 milliliters/hour to begin at 8:00 PM for a total volume of 1400 milliliters to be delivered. Stop tube feed when total volume of 1400 milliliters is infused. Verify with pump setting the total volume has been delivered. Document total volume infused (PM shift, total volume should be delivered by around 4:00 PM). The time for administration was documented as 2:30 PM. - Auto flush water via enteral tube at a rate of 50 milliliters per hour, verify infusion every shift. Keep head of bed elevated at least 30 degrees during administration. Stop auto flush when volume of 1000 milliliters is delivered. Verify pump setting that volume has been delivered. The order had a start date of 11/22/204. The auto flush water at a rate of 50 milliliters per hour was signed as administered at 8:00 PM from 12/1/024-12/9/2024. During an observation on 12/3/2024 at 12:00 PM, Resident #100's enteral tube feeding nutrition bottle and auto flush water bag was not labeled or dated. The Medication Administration record documented Licensed Practical Nurse #45 administered the tube feeding on 12/2/2024 at 8:00 PM. During an observation on 12/9/2024 at 10:19 AM, the Resident's enteral tube feeding auto flush was set to 40 milliliters per hour on the pump. The Medication Administration record documented 12/8/2024 at 8:00 PM medication administration record documented the enteral tube feed order was signed by Licensed Practical Nurse # 37 for auto flush of 50 milliliters per hour as administered. During an interview on 12/6/2024 at 2:39 PM Registered Dietitian #37 stated they determined the flow rate on Resident #100's enteral tube feeding based on their calorie and protein needs and the auto flush rates for hydration. They were not aware the resident's auto flush setting was changed to 40 milliliters per hour and expected to be notified if there was a change. It was important for Resident #100's auto flush rate to run at the required amount for hydration due to the resident's nothing by mouth status. During an interview on 12/9/2024 at 11:20 AM Licensed Practical Nurse #38 stated they knew what medications or treatments a resident had by checking their medication and treatment administration records. They were responsible for checking the resident's enteral feeding to ensure the rate was correct and the nutritional content was being administered. They administered the resident's medications and refilled their auto flush bag when they came on shift and did not notice the flow rate of the auto flush bag. It was important for Resident #100's enteral feedings were administered correctly so the resident received adequate hydration. Licensed Practical Nurse #38 stated they did not observe the auto flush water flow rate on the pump when they administered the resident's medications. During an interview on 12/9/2024 at 1:43 PM, Registered Nurse Unit Manager #4 stated the registered dietitian was responsible for enteral feeding orders and nursing checked the medication administration records and followed up to ensure the resident was receiving the correct amount and flow rate. Nursing should check to ensure the pump was functioning properly and if there was an issue they should report it. Resident #100's enteral tube feeding pump was not checked to ensure the proper amount had been administered. It was important for the resident to receive the correct flow rate to ensure they received proper hydration. During an interview on 12/9/2024 at 3:01 PM, the Director of Nursing stated nursing was responsible for checking a resident's enteral tube feeding to ensure that the proper rate and flow were set correctly, and the resident's tube was not leaking. If there were problems with a resident's enteral tube feeding, they expected nursing to notify the dietitian and medical as the incorrect flow rate could affect the resident's total 24-hour fluid intake. They stated if nursing did not know how to correct the problem, they should get a manager to assist them. During an interview on 12/10/2024 at 12:05 PM, Nurse Practitioner #15 stated Resident #100's enteral tube feeding flow rates were determined by Registered Dietitian #37 and they followed the recommendations. They would expect to be notified if the resident's flow rate was incorrect. They stated it was important for the resident's enteral tube feeding orders to be followed because they determined what the resident needed for nutrition and hydration. 10 NYCRR 415.12(g)(2)

Based on observations, record review, and interviews during the recertification survey conducted 12/3/2024 through 12/10/2024, the facility did not provide on-going assessment and did not obtain informed consent prior to the installation of bed rails (side rails) for 1 of 2 residents (Resident #68) reviewed. Specifically, Resident #68 had bed rails on both sides of the bed and did have informed consent for the placement of bed rails and was not regularly assessed to ensure the bed rails remained appropriate. Findings include: The 9/2019 facility policy, Side Rails, documented that each resident would be assessed for functional status on admission, readmission, quarterly, any significant change, and as needed. Side rails would only be used by a resident to assist with his or her bed mobility. The Rehabilitation Department might be asked to also evaluate the resident's need for side rails as determined by the Interdisciplinary Team. The staff should obtain consent for the use of side rails/enabler from the resident prior to their use. Resident's that require the use of side rails would obtain a physician order indicating that side rails were used to assist with bed mobility. Resident #68 had diagnoses including acute dyskinesia (movement disorder) and adult failure to thrive. The 11/6/2024 Minimum Data Set assessment documented the resident was cognitively intact, required supervision for bed mobility, partial assistance for transfers, and did not use bed rails. The 7/16/2024 Quarterly Restraint/Side Rail Assessment completed by Registered Nurse #26 documented the resident had a potential restraint of a side rail or enabler bar. The side rail was being used for safety, and resident weakness and leaning forward. The side rail would assist the resident turning side to side, holding self to one side of the bed, moving up and down in bed, supporting balance while transferring, and provide security to the resident. The side rail would help avoid rolling out of bed, would obstruct the resident's view, and would impede freedom of movement. The determination was full side rails were recommended at all times. The risks and benefits of side rails were discussed with the resident, the decision was made as a result of a discussion with therapy. A consent for side rail and a physician order for the side rails was obtained, the care plan was updated, and the certified nurse aide tasks documented. The 7/16/2024 Comprehensive Care Plan documented the resident used enablers (devices attached to the bed to provide a hand hold for getting in and out of bed) for increased independence and mobility related to impaired bed mobility. Interventions included offering resident assistance with position changing and bed mobility often during the shift and orient the resident to call light and safety measures. The care plan did not include the use of full side rails as documented in the 7/16/2024 Quarterly Restraint/Side Rail Assessment. There was no documented evidence of a physician order for the use of side rails. The 11/19/2024 Quarterly Restraint/[NAME] ail Assessment completed by Registered Nurse Unit Manager #23 documented the resident did have side rail or enabler bars as potential restraints. The section side rail assessment and determination was blank. During observations on 12/10/2024 at 9:47 AM and 1:54 PM, Resident #68 had brown half side rails (not enabler bars) on both sides of the bed. The rails started at the top of the mattress and extended down to where the movable portion of the bed met the stationary portion of the mattress, approximately half the length of the mattress. During an interview on 12/10/2024 at 9:50 AM, Licensed Practical Nurse #25 stated they were not sure how frequently bed rails were assessed, the Unit Manager was responsible for those assessments. They were not sure if the certified nurse aides were required to document on the use of the bed rails. Bed rails required a physician order for use, or they would be considered a restraint. Resident #68 did not have an order for bed rails. During an interview on 12/10/2024 at 10:02 AM, Certified Nurse Aide #22 stated that Resident #68 had bed rails in place. There was no required documentation for Certified Nurse Aides, and it was not included on the resident's care instructions. It was important for bed rails to be on the care instructions so they could ensure safety of the resident. If a resident stated they were interested in getting bed rails they would notify Physical Therapy and the Nurse Supervisor, who would work through the process with the resident. During an interview on 12/10/2024 at 10:18 AM, Registered Nurse Unit Manager #23 stated they were not sure how frequently bed rail assessments needed to be completed, they would have to check the policy. Nursing and Therapy were responsible for completing the bed rail assessment. If the bed rail impeded view or restricted movement of the resident it would not be put on the bed. The bed rails required a signed consent form, and they were responsible for completing that. Bed rails should be included on the care plan, and if they were on the care plan they should be included on the care instructions with a location for certified nurse aides to document on. They stated their electronic medical record had the ability to do that with a check box. They stated they were responsible for updating the care instructions and the required documentation for the certified nurse aides. They completed a quarterly assessment on 11/19/2024. The assessment documented no restraints, but should have documented the enabler bar, which would have opened the rest of the assessment for the resident. It was important to have on-going monitoring because they could have a change in condition, or not use the enabler bars correctly. During an interview on 12/10/2024 at 1:34 PM Director of Rehabilitation #24 stated that therapy made the initial recommendation for side rails, but nursing assessed the residents quarterly for side rails. The on-going assessments, care plan, orders, care instructions, were the responsibility of nursing. They ensured the resident could safety use enabler bars but would never make a recommendation for full or hospital style bed rails. The Director of Rehabilitation reviewed the residents therapy notes and recommendation. They stated therapy did not assess or recommend any type of enabler bars for Resident #68, but nursing could add them without a therapy recommendation. During an interview on 12/10/2024 at 1:53 PM, the Director of Nursing stated bed rail assessments were done quarterly, however, they were decreasing the number of bed rails in the facility. The Unit Manager was responsible for the assessments and therapy was also involved. If the bed rail was documented as restricting movement, it would be a restraint. A signed consent form should be completed for a resident with bed rails. The bed rails should be on the care instructions for the resident, and the Unit Manager was responsible for updating that. Resident #68 had enabler bars and did not have an order for them. They stated side rails and enablers bars were different. Side rails required a physician order, but enabler bars did not. Nursing should not be putting side rails or enablers bars in place without a recommendation from therapy. They were not sure if 11/19/2024 side rail assessment was completed or fully done, but they should be done quarterly. It was important to have the assessment completed for safety risks and appropriateness of the bed rail/enablers bar. The on-going monitoring was important because if the resident did not need them, they could be removed, and if they had a decline in condition the bed rails could assist with mobility and independence. During an interview on 12/10/2024 at 2:08 PM, Licensed Practical Nurse Assistant Unit Manager #21 stated Resident #68 had enabler bars on their bed. Nursing would not put bed rails/enabler bars in place without therapy recommendations. They stated some of the beds were old and they were just there, versus the newer beds where the bed rails could go on and off more easily. They were not sure what type of bed Resident #68 had. Electronic mail received 12/10/2024 at 2:46 PM from the facility Administrator documented they did not have documented informed consent for Resident #68's bed rails. 10NYCRR 415.12(h)(1)(2)

Based on observations, record review, and interviews during the recertification survey conducted [DATE] - [DATE], the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the facility's main kitchen. Specifically, the main kitchen had unclean surfaces and expired food items. Findings include: The facility policy, Food Storage, revised [DATE], documented sufficient storage facilities would be provided to keep foods safe, wholesome, and appetizing. Food would be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination: -All stock would be rotated with each new order received. Rotating stock was essential to assure the freshness and highest quality of all foods. -All freezer units would be kept clean and in good working condition. The facility Sanitation Policy, last reviewed ,d+[DATE], documented the food service area would be maintained in a clean and sanitary manner. Food service staff would be trained to maintain cleanliness throughout their work areas during all tasks and the Food Service Manager was responsible for scheduling staff for regular cleaning of the kitchen. The following observations were made in the coolers/freezers in the main kitchen: - on [DATE] at 11:17 AM, the fruit/cheese cooler floor was wet and slippery. - on [DATE] at 11:19 AM, the freezer had small chunks of ice scattered on the floor, a large block of ice on the left side of the compressor, and icicles on the ceiling were slowly dripping water onto the floor towards the back of the freezer. - on [DATE] at 10:50 AM, there was an unknown brown sticky liquid substance covering the floor to the entrance of the freezer. The freezer had small chunks of ice scattered on the floor, there was a large block of ice on the left side of the compressor, and icicles on the ceiling were dripping water onto a closed cardboard box on top of a milk crate. The following observations were made in the dry storage room in the main kitchen: - on [DATE] at 11:10 AM, there were eight 32-ounce bags of powdered sugar that expired on ,d+[DATE]. - on [DATE] at 11:12 AM, there was a box containing twelve bags of 32-ounce powdered sugar that expired on ,d+[DATE], and a box containing twelve bags of 32-ounce powdered sugar that expired on ,d+[DATE]. During an interview on [DATE] at 12:20 PM, Food Service Director #12 stated the kitchen was cleaned daily, every staff member was responsible for picking up and cleaning their area throughout their shift, and they had deep cleaning staff who also cleaned the kitchen throughout their shift. The freezer and coolers were cleaned, mopped, and swept daily. The freezer had not been defrosted in the 3 months they had worked at the facility. They stated the freezer should not have any ice buildup inside or on the compressor because it could cause a safety issue for slipping, an infection control issue if the food went bad, and the compressor could stop working properly. They rotated the food items in the dry storage room a few times each week and on truck delivery day to make sure food was sitting too long and expiring. They stated they looked at the expiration date on all food items before serving them to the residents. It was important not to serve expired food to prevent illness or food poisoning. During an interview on [DATE] at 12:29 PM, Kitchen Supervisor #13 stated they supervised all kitchen staff, made sure food was prepped properly, and assisted with scheduling. The kitchen was cleaned twice a day, each staff member was responsible for cleaning their own area, and they also had deep cleaning staff who were responsible for cleaning the ovens, walls, fryers, and assisted with stocking food on delivery days. The coolers and freezer were cleaned daily but sometimes when they were short staffed it did not get done. The freezer was defrosted every few months but there was no set schedule. There should not be any ice buildup inside the freezer because it could cause it to break or affect the temperatures. They noticed ice buildup by the compressor. They thought icicles could have developed inside the freezer if the door was not latched properly causing it to warm up inside. This could cause the food temperatures to rise, and it could become a safety or tripping hazard. They stated the dry food items were rotated a few times a week and they also checked for expired food. It was important not to have expired food items to reduce the risk of residents getting sick if the food was served to them. 10NYCRR 415.14(h)

Based on record review and interviews during the recertification and abbreviated (NY00326659) surveys conducted on 12/3/2024-12/10/2024, the facility did not provide specific services outside the facility when the facility did not employ a qualified professional to furnish the specific service for 1 of 2 residents (Resident #100) reviewed. Specifically, Resident #100 was referred to neurosurgery and pulmonology (lung specialist) and the facility did not follow up on these referrals in a timely manner. Findings include: The facility policy, Physicians-Consultations, revised 8/2019, documented the facility would ensure all residents received medical care in a timely manner. The attending physician would indicate the appropriate time frame within which the specialist would see the resident. A follow-up appointment was to be done within the time frame requested by the consultant and approved by the attending physician. The attending physician would consider the appropriateness of the consultant's recommendation and the provider approved orders based on consult recommendations if they were appropriate. Resident #100 had diagnoses including pulmonary toxoplasmosis (a serious lung infection), acute respiratory failure, and cerebral edema (swelling of the brain). The 11/4/2024 Minimum Data Set assessment documented the resident had severely impaired cognitive skills for daily decision making, was dependent for activities of daily living, had an active infection of pneumonia, and was on an antibiotic. The 5/1/2024 Comprehensive Care Plan documented the resident had an alteration in their respiratory system. Interventions included to use the incentive spirometry as ordered. The 9/17/2024 consult from an outside brain and spine clinic documented there was a concern for worsening hydrocephalus (spinal fluid buildup in the ventricles of the brain). The plan was to repeat magnetic resonance imaging of the brain to monitor; also concern for pneumonia given new productive cough. The plan was to refer the resident to neurosurgery clinic for a higher level of care as the resident was not an optimal surgical candidate. The consult was illegibly signed by a facility nurse. The medical provider review by the facility was blank and the section to check if new orders were obtained was not checked. The 9/18/2024 Nurse Practitioner #15 progress note documented the resident had a diagnosis of cerebral edema and went to a neurologist appointment. The neurologist felt the resident needed a higher level of care, a repeat magnetic resonance imaging and a referral was made by that office. The 9/20/2024 Nurse Practitioner #15 progress note documented resident was seen by the spine and brain clinic who recommended a referral to neurosurgery for monitoring of the resident's hydrocephalus. The resident was hospitalized [DATE]-[DATE] for bacterial pneumonia. The 10/2/2024 hospital discharge summary documented the resident was to have outpatient follow ups with pulmonology in one week, neurology in 1 week, and neurosurgery in 1 week. The After Visit Summary Instructions documented follow up with pulmonology in 1 week, neurology in 1 week, and neurosurgery in 1 week. There was a handwritten note documenting all orders in, a smiley face, and me. A 10/2/2024 at 9:11 PM Licensed Practical Nurse #41 progress note, cosigned by Registered Nurse Supervisor #43 documented the resident was readmitted to the facility from the hospital. There was no documented evidence of follow up on the discharge recommendations for pulmonology and neurosurgery. There was no documented evidence the facility scheduled follow up appointments with pulmonology or neurosurgery as recommended. During an interview on 12//4/2024 at 9:02 AM, Resident #100's significant other stated they had issues getting in touch with staff in charge of transportation. They stated the resident missed appointments with their brain and spine doctor as well as a follow up on a magnetic resonance imaging. They stated the resident had fluid on the brain and was supposed to have follow ups. During an interview on 12/06/2024 at 1:16 PM, Medical Records Staff #16 stated they took care of the transportation for resident appointments. They stated they worked with the Nurse Managers to schedule appointments as well. They were mainly responsible for reaching out to the outside providers to schedule appointments, however if a Nurse Manager scheduled an appointment, there was a form they filled out for transportation to be scheduled. They stated they were unaware the resident had a referral pending for neurosurgery and had not been followed up. They stated they were aware of the pulmonology referral from the resident's hospitalization on [DATE]. They attempted to get an appointment scheduled but was having trouble with the office accepting the appointment. They faxed the discharge summary to the office about a week after the resident had returned from the hospital in 10/2024 but they had not followed up since. They stated their procedure was to inform the Nurse Managers if they had issues with scheduling resident appointments. They did let the Nurse Manager know they had trouble scheduling the appointment. During an interview on 12/06/2024 at 1:28 PM, Corporate Resource Nurse (acting Unit Manager) #4 stated there had been a lot of turn over for Nurse Managers on the third floor. They stated they were unaware of the referral for neurosurgery for a higher level of care but that it was normally the spine and brain clinic that would make the referral. They had not heard anything about the referral. They stated they were unaware of there being difficulties with scheduling the resident's pulmonology appointment. They would have advised Medical Records staff #16 to try another office. During an interview on 12/09/2024 at 3:01 PM, the Director of Nursing stated they expected an outside consult would be followed up in the time frame directed by the office. They stated if a consult had been ordered or referred on 9/17/2024, the facility should have followed up on the referral by now. If there was an issue with scheduling a follow up, they expected the Nurse Managers and the medical providers be made aware. 10NYCRR 415.26(e)

Based on record review and interview during the abbreviated Survey (NY00323447), the facility did not immediately inform the resident's representative and did not consult with the physician when there was a significant change in the resident's physical status and/or a need to alter treatment significantly for 1 of 3 residents reviewed (Resident #1). Specifically, Resident #1 did not have capacity to make medical decisions and their health care proxy (HCP, person appointed to make healthcare decisions when the individual can no longer do so) was not notified when the resident had changes in their medical status and treatments. Additionally, the medical provider was not notified when the resident missed 2 diagnostic cardiology appointment and they were not rescheduled and the HCP was not notified of scheduled diagnostic tests. Findings include: The ,d+[DATE] Notifications Policy documented except in an emergency, the facility must consult with the resident immediately if the resident is competent, and notify the resident's physician and designated representative when: there is a significant improvement or decline in the resident's physical, mental, or psychological status; and a need to alter treatment significantly (i.e. a need to commence a new treatment). The nurse will promptly notify the resident or their representative of any changes in resident care or treatment including medication and treatment changes. The Physician-Consultations Policy revised ,d+[DATE] documented the attending physician was to indicate the appropriate time frame the resident should see the specialist. The attending physician was ultimately responsible for all orders and should remain involved with any aspect of care for which a consultant was involved. Resident #1 had diagnoses including traumatic subdural hemorrhage (bleed in the brain), developmental disorder of speech and language, and dementia. The [DATE] Minimum Data Set (MDS) assessment documented the resident had intact cognitive function and required assistance with their activities of daily living (ADL). The Incapacity Determination Form documented the resident lacked decision-making capacity for life-sustaining treatment orders. The resident's condition was expected to be permanent due to dementia. The form was singed the by resident's physician on [DATE]. The resident's Face Sheet, printed [DATE], documented the resident's healthcare proxy (HCP) was their spouse. The [DATE] licensed practical nurse (LPN) Manager #1's progress note documented the interdisciplinary team (IDT) met for a high-risk meeting due to the resident testing positive for COVID-19. In attendance were nursing, social services, and therapy. The resident was not appropriate to attend. There was no documentation related to family/HCP notification of the resident's COVID-19 diagnosis. The [DATE] nurse practitioner (NP) #2's progress note documented the resident tested positive for COVID-19 and had upper respiratory infection (URI) symptoms. Due to the resident's comorbidities and increased risk for complications, the plan was to administer molnupiravir (anti-viral medication) for 5 days. Nursing staff were to monitor vital signs every shift, push fluids, and monitor closely for signs of worsening infection. There was no documentation related to family/HCP notification about the resident's treatment or change in medical condition. The [DATE] NP #2's progress note documented the resident was seen for the last day of the anti-viral treatment for COVID-19. The resident stated they did not feel well and had a decreased appetite. They were ill-appearing and dehydrated. Intravenous (IV) fluids were ordered. There was no documentation related to family/HCP notification about the resident's condition or treatment. The [DATE] NP #2's progress note documented the resident was seen for follow-up for COVID-19 and dehydration. A chest x-ray was ordered. There was no documentation related to family/HCP notification about the resident's condition or diagnostic test being ordered. The cardiologist's office appointment notes documented: - on [DATE], the resident was scheduled for an echocardiogram (scan to look at the heart and nearby blood vessels), at 10:30 AM and the appointment was rescheduled. - On [DATE], the resident was scheduled for a follow-up visit with the cardiologist at 11:15 AM and the resident did not attend. - On [DATE], the resident had an appointment at 1:30 PM for an echocardiogram and the appointment was canceled by the facility's Medical Records Employee #4. - On [DATE], the cardiologist's office called the facility and left a message for Medical Records Employee #4 asking them to call back to reschedule the resident's appointment. The resident's medical record from [DATE] through [DATE] contained no documentation the resident's spouse was notified of the resident's change in condition related to COVID-19, the treatments ordered for COVID-19 and dehydration, the cardiology tests and appointments scheduled for [DATE] and [DATE], or that the resident did not go to the appointments. The resident's medical record contained no documented evidence the medical provider was notified of the resident's missed cardiology appointments on [DATE] and [DATE] and no documented evidence the medical provider was notified when the cardiology appointment was not rescheduled after [DATE]. The [DATE] physician's communication form documented the resident had a gastroscopy (procedure to view the upper digestive tract) completed. There was no documented evidence the resident's spouse was notified of the medical procedure on [DATE]. During an interview on [DATE] at 11:50 AM, the Director of Social Services stated Resident #1 did not have capacity to make their own healthcare decisions and the facility communicated with their spouse, who was their HCP. The Director of Social Services had no role in notifying family or resident representatives about the resident's medical condition or appointments. Nursing was responsible to notify of any changes including illnesses and treatments. The Director of Social Services was unaware of who was responsible to notify about outside appointments. During an interview with LPN Manager #1 on [DATE] at 1:47 PM, they stated Resident #1 could not make their own healthcare decisions and their spouse was involved in their care and treatment decisions. The LPN Manager #1 did not notify the resident's spouse when the resident had COVID-19 and did not notify them of the related treatments. When the resident was identified with COVID-19, it was discussed at a team meeting and a former (unidentified) social worker was to make the notification. LPN Manager #1 was unaware if the social worker understood the instructions or if they notified the resident's spouse. It was typically the responsibility of nursing to notify the resident's HCP of illnesses and treatments, unless other staff were directed to do so. When the resident required medications and IV fluids for treatment of COVID-19, the resident's HCP should have been notified by LPN Manager #1 and they could not recall if they did so. When appointments or procedures were scheduled, the HCP should be notified by nursing. Sometimes, if the appointment was scheduled by Medical Records Employee #4, they would let nursing know the appointment was made in order for nursing to notify the HCP. They could not recall if the cardiology appointments were communicated to the HCP. When a resident missed appointments with a specialist, LPN Manager #1 did not think their attending physician should be notified, rather, they were to reschedule the appointment. LPN Manager #1 was unaware of the reason the cardiology appointment was not rescheduled after the [DATE] cancellation. Medical Records Employee #4 managed the appointments and scheduling and would notify LPN Manager #1 when a new appointment was made. When the resident had a procedure scheduled on [DATE], LPN Manager #1 was unaware until the day prior and did not have time to notify the HCP before the hospital called them. They stated they expected it to be documented in progress notes if the resident had a change in condition, treatment, or appointment and that the resident's representative was notified. During an interview with the resident's spouse on [DATE] at 12:29 PM, they stated the resident was not able to make their own medical decisions due to dementia. They were very involved in the resident's care and wanted to be made aware of any changes in treatment or condition. When the resident developed COVID-19 in ,d+[DATE], they were not notified. The resident's spouse found out when they spoke to the resident near the end of their illness, when they were feeling better. The resident's spouse was not notified of the anti-viral medication or IV fluids that were administered when the resident was ill with COVID-19. When the resident had a procedure (gastroscopy) in ,d+[DATE], the resident's spouse was not notified by the facility. The hospital contacted them prior to the appointment and the resident's spouse had not given consent prior to that time. The resident's spouse preferred to accompany the resident to appointments and procedures, but did not make the arrangements, as the facility made the appoints and set up transportation due to the resident being in a wheelchair. Following the resident's passing in ,d+[DATE], the resident's spouse notified the cardiology office, and at that time, they informed the spouse that the resident had previous missed appointments. They were told the resident had an echocardiogram scheduled on [DATE], with an appointment with the cardiologist to follow the same day. That resident was a no-show for those appointments, and it was rescheduled for [DATE], and that appointment was canceled by the facility. There was no appointment scheduled after [DATE]. The resident's spouse stated the autopsy report showed the resident died from a heart attack due to 100% arterial blockage. They stated they felt if the resident attended the cardiology appointments, it was possible the blockages could have been identified and treated. During a telephone interview with Medical Records Employee #4 on [DATE] at 10:58 AM, they stated they had no role in notifying residents' family members or HCPs regarding upcoming appointments, cancelations, or rescheduled appointments. The information for appointments came from the nursing department and nursing was responsible to notify family. Medical Records Employee #4 sent a copy of the calendar to all nursing units every Friday with the following week's appointments. When the resident did not go to the cardiologist appointments on [DATE] and [DATE], that information to cancel came from the nursing department, and the nursing would be responsible to notify the HCP and physician. After the [DATE] appointment was canceled, they did not call the cardiologist back and reschedule since they saw that the resident had an appointment at the same provider in ,d+[DATE]. Nursing staff did not notify them that the ,d+[DATE] appointment was for a different reason, and they still needed to have the [DATE] appointment rescheduled. They had no role in notifying medical providers or clarifying reasons for appointments, as that would be handled by the nursing department. The procedure that was scheduled for [DATE], was in a letter sent by the provider. The letter about the appointment would have to have been received at least one week prior to the appointment, in order for the transportation to be set up. That appointment would have been on the calendar sent to the nursing units on [DATE] or [DATE]. 10NYCRR 415.3(e)(2)(ii)(b,c)

Based on observation, record review, and interview during the recertification survey conducted 11/28/22-12/2/22, the facility failed to provide a safe, clean, comfortable, and homelike environment for 7 facility areas (main kitchen, third floor elevator hallway, third floor common area near resident room [ROOM NUMBER], main laundry area, and resident rooms 102, 114, 116, and 302). Specifically, there were multiple stained/damaged solid ceilings tiles; damaged equipment in the main kitchen; the laundry lacked an appropriate hand washing sink; and resident rooms 102, 104, 116, and 302 had multiple stained, unclean, and damaged areas. Findings include: The facility policy Disinfecting/Cleaning Environmental Surfaces revised 3/2020, documented environmental surfaces would be disinfected (or cleaned) on a regular basis (e.g., daily, three times a week), and when surfaces were visibly soiled. 1. Stained Ceiling Tiles The following observations of stained ceiling tiles were made: - on 11/28/22 at 10:34 AM, the third floor common area near resident room [ROOM NUMBER] had water damage and water was coming from an overhead light and dripping on the floor. The ceiling area around the overhead light was damaged/stained and a section of this ceiling was of an unknown material. - on 11/28/22 at 10:35 AM, the main kitchen had stained ceiling tiles including; the dish machine area had a water damaged 2 feet x 4 feet ceiling tile and water was dripping into a plastic container that was located on top of the dish machine; the cooking area had multiple stained ceiling tiles. Approximately 60% of the ceiling tiles were unclean; and the pot area had two water damaged 2 feet x 4 feet ceiling tiles. - on 11/28/22 at 11:45 AM, the third floor electrical room ceiling had one wet ceiling tile; and there were multiple stained ceiling tiles in the third floor elevator lobby space. During an interview on 11/28/22 at 1:10 PM, the Maintenance Director stated that there were no work orders for the water dripping from the ceiling in the third floor common area near resident room [ROOM NUMBER]. During an observation on 11/30/22 at 11:29 AM, the main laundry room washer area had a 3 feet x 3 feet square section of solid ceiling that was damaged and resting on top of a fire sprinkler line. During an interview on 11/30/22 at 11:42 AM, laundry aide #28 stated that the damaged solid ceiling located in the laundry room had been that way since they were hired over a year ago. During an interview on 11/30/22 at 11:50 AM, the Housekeeping Director stated that the damaged section of solid ceiling in the main laundry room had been on top of the fire sprinkler line for over a year and had already been repaired once. They stated that they had told the previous Maintenance Director about the ceiling issue. During an interview on 12/01/22 at 12:02 PM, the Maintenance Director stated that they were not aware of the wet/stained ceiling tiles observed and no work orders had been created for the ceiling tiles. A third party vendor was onsite 5/5/2022 to repair the light area and ceiling in the third floor common area near resident room [ROOM NUMBER], and the vendor also repaired the laundry room solid ceiling that same day. The Maintenance Director stated that they were not made aware of the three stained ceiling tiles in the kitchen. They stated that the main kitchen and each resident unit had a work order book which was reviewed once a week by maintenance. The Maintenance Director stated that they were not sure how long the ceiling in the laundry room had been broken. They stated each unit, and the kitchen area had a binder for writing in work order requests and that any staff member could enter a work order. 2. Damaged Equipment During observations on 11/29/22 between 5:25 PM and 5:40 PM, the main kitchen had the following damaged equipment: - the spare steam table had a loose fitted and unsecured rectangular wall unit on/off switch installed on it. The wall unit switch was designed to be installed within walls and not on steam tables. The electrical cord for the spare steam table was frayed/damaged. - the ice machine had a section of electrical cord that that was wrapped with black electrical tape; and - cooler #5 had a frayed/damaged electrical cord. During an interview on 12/1/22 at 12:15 PM, the Maintenance Director stated that they had not been told about any electrical equipment issues in the main kitchen and they were not aware of these issues. They stated that there were no work orders, and that kitchen staff should have identified the issues and put in work orders. The Maintenance Director stated the damaged electrical equipment located in the main kitchen was not acceptable. During an interview on 12/1/22 at 2:47 PM, the Food Service Director stated that the main kitchen had a work order binder that could be filled out by any staff when needed. 3. Miscellaneous/Resident Rooms The following observations were made: - on 11/28/22 at 10:56 AM and 12/1/22 at 3:13 PM, resident room [ROOM NUMBER] had divider curtains stained with a brown substance and there were missing sections of window blinds. - on 11/28/22 at 1:06 PM, resident room [ROOM NUMBER] had a section of wall around an electrical outlet cover plate that was stained black. The black stain around the cover plate had a starburst pattern around it. - on 11/30/22 at 11:31 AM, the laundry area lacked a separate hand washing sink. Next to the slop/utility sink was a wall mounted soap dispenser and a wall mounted paper towel holder. - on 11/28/22 at 2:33 PM, 11/30/22 at 4:20 PM, and 12/1/22 at 12:08 PM, the bottom of the tube feeding pole in room [ROOM NUMBER] was unclean, and the floor around the bottom of tube feeding pole had brown spill/drip spots. During an interview on 11/30/22 at 11:42 AM, laundry aide #28 stated that they had been working at this facility for just over a year, had used the slop/utility sink to wash their hands and did not consider that a clean use type of sink. They stated that they had seen maintenance staff rinsing out brushes in the sink. During an interview on 11/30/22 at 11:50 AM, the Housekeeping Director stated the slop/utility sink was installed approximately 5 years ago to pre-rinse dirty/stained linens and should never be used for hand washing. During an interview on 12/1/22 at 12:24 PM, the Maintenance Director stated the electrical outlet in resident room [ROOM NUMBER] sparked on 11/16/22 and caused the wall to blacken around the outlet. The Director had never thought to return and touch up the wall. Unit nursing staff should have identified the discolored wall around the outlet and put a work order for maintenance to correct it. The Director was not aware that the housekeeping dirty slop sink was used for handwashing and that soap and towels were installed on the wall near that sink. The sink was in the dirty side of the laundry area. During an interview on 12/1/22 at 2:53 PM, housekeeper #27 stated that they would usually clean up the rooms and floors, but they did not clean medical equipment. They stated they did not clean or disinfect the tube feeding poles, and the floor under the tube feeding pole in room [ROOM NUMBER] had spots which the mop could not access. During an interview on 12/1/22 at 3:13 PM, the Housekeeping Director stated they were not aware that the divider curtains in resident room [ROOM NUMBER] were stained. They stated that all resident room curtains were periodically cleaned and annually removed and laundered. The Housekeeping Director stated that they would expect staff to document a stained curtain on the daily housekeeping checklist. Housekeeping staff had been told to complete a work order if they saw missing blinds in a resident room. They stated there was a schedule for cleaning resident room divider curtains and the first floor was the most recently completed unit. During an observation on 12/1/22 at 3:21 PM, resident room [ROOM NUMBER] had a 2 inch hole in one of the walls, and part of the resident bed frame was on the floor. During an interview on 12/1/22 at 4:51 PM, The Housekeeping Director stated that daytime housekeeping duties included cleaning all resident rooms and common areas. Housekeepers had a checklist that would be filled out daily and turned in to the Housekeeping Director. The Housekeeping Director stated that the daily tasks included cleaning the IV/tube feeding poles and that the floor under the tube feeding pole should be mopped daily. They stated that nursing staff should clean spills up when they occur, and housekeepers could then disinfect that area. During an interview on 12/1/22 at 5:02 PM, licensed practical nurse (LPN) #14 stated that if they had noticed a dirty tube feeding pole, they would clean it. The LPN had not noticed that the tube feeding pole in room [ROOM NUMBER] was dirty. LPN #14 stated that spilled tube feeding formula should be cleaned up immediately because the formula would harden like cement. During an interview on 12/2/22 at 10:36 AM, registered nurse (RN) #16 stated the poles should be wiped down by nursing staff and any spills should be cleaned up immediately. 10 NYCRR 415.29(j)(1) 44838

35045 40803 Based on observation, interview, and record review during the recertification survey conducted 11/28/22-12/2/22, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 6 of 7 residents (Residents #30, 50, 66, 76, 78, and 103) reviewed. Specifically, Residents #50 and 103 (who resided on the dementia unit), and Residents #30, 50, 76 and 78 were not offered meaningful activities and were not provided with activities of their choosing. Additionally, Resident #78's room was not personalized with individual activity items, such as television, radio, and/or reading materials. Findings include: The facility's undated Admission Agreement documented the facility would provide basic services including a therapeutic recreation (activities) program, including but not limited to a planned schedule of recreational, motivational, social, and other activities, along with the necessary materials and supplies to make the resident's life more meaningful. The facility policy Dementia Programming revised 5/2019 documented recreation services was responsible for providing residents with a diagnosis of dementia with a comprehensive activity program designed to meet their individual needs and preferences, and to provide a familiar routine and create social outlets. If the facility had a separate/ secure dementia unit, they would be provided with a separate calendar of on unit programs and activities appropriate to the population. The facility policy Recreation Services revised 5/2019 documented activities were not limited to formal activities being provided by activity staff. Other facility staff, volunteers, visitors, residents, and family members may also provide activities. Information regarding scheduled activities were to be posted on the bulletin board in the common area and provide in each resident's room. If the facility had a locked/ secured unit both group and individual activities would be offered daily. The facility did not have a November 2022 activity calendar. The last calendar provided to residents was for October 2022. There was no separate activity calendar for the dementia unit. 1) Resident #76 had diagnoses including schizoaffective disorder, psychosis, and anxiety. The 2/10/22 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition, depressive symptoms, required extensive assistance with most activities of daily living (ADLs), used a wheelchair, received anti-anxiety medication daily, and activity preferences such as music, reading, being in groups, favorite activities, being outside, and religious services were important. The 2/4/22, 2/10/22, 3/23/22, 4/14/22, and 7/6/22 activities progress notes documented recreation quarterly assessments had been completed. There were no additional activity progress notes and no documented evidence the activity assessments were completed. The 3/2/22 comprehensive care plan (CCP) documented the resident had behaviors such as pulling the fire alarm and was able to make activity preferences known. Interventions included to determine the cause of behaviors and remove the resident, provide monthly activities calendar, provide resident with independent leisure activity supplies. Activities included reading magazines, watching TV, and encourage the resident to participate in activities that promote exercise, physical activity, and improved mobility. The 8/2022 Resident #76 activities log documented the resident had movement, exercise, and TV/radio daily. There was no documentation the resident attended any group or facility provided activities. The 9/2022 Resident #76 activity log documented a handwritten note across the sheet discharged ,d+[DATE]. There were no documented activity logs for 10/2022, 11/2022, and 12/2022. There was no documented evidence the resident was discharged from the facility at any during 9/2022. When interviewed on 11/29/22 at 9:00 AM, the resident's family member stated there were multiple residents that waited in the first-floor elevator area for a long time just to go outside to smoke. There were not enough activities provided by the facility and the residents had nothing to do. Resident #76 did not smoke. The following observations were made of Resident #76: - on 11/28/22 at 11:21 AM, the resident was lying on their bed dressed and groomed. The TV was on, and the resident stated they got ignored. - on 11/29/22 at 10:24 AM, the resident was lying on their bed dressed and groomed with their eyes closed. The TV was on. At 2:08 PM, the resident wheeled down the hallway past the nursing station. There was no group activity being provided on the unit. - on 11/30/22 at 3:15 PM, the resident was sitting in a wheelchair in the hallway outside their room and was not engaged in any activity. - on 12/1/22 at 9:02 AM, the resident was lying on their bed dressed and groomed. The resident's eyes were closed, and the TV was on. At 1:51 PM, the resident was lying on their bed with their eyes closed and was easily aroused. The TV was still on. There was no group activity being provided on the unit. When interviewed on 12/2/22 at 9:23 AM, certified nurse aide (CNA) #29 stated the resident pulled the fire alarm a lot, called 911 daily, had a lot of behaviors, knew their actions, and slept a lot. There were not a lot of activities performed on the unit. The resident was more alert and had less behaviors when the facility offered more activities. Recently, the only activity the resident did was watch TV in their room. The CNA stated most residents looked forward to smoking outside as there was nothing else to do. Unit staff did not have activity supplies for the residents and could only get playing cards, which they could obtain from the activities department. The Activities Director had left the facility in 3/2022 and since then activity programs had severely decreased. There had been interim directors and there was no one in the role now. The only real activity was Bingo. The CNA stated all the talkative residents complained of boredom. Unit staff were able to do residents' nails and hair to provide some form of activity. They were also able to take the residents outside if time permitted. When observed and interviewed on 12/2/22 at 10:12 AM, the resident was lying on their bed with their eyes closed. The resident opened their eyes and sat up on the edge of the bed. The resident stated they used to go to a lot of activities but very little was offered now, and, in the past, they had signed up for activities, but staff did not come to get them to attend. The resident stated they slept a lot due to boredom. The only thing they did was watch TV. When interviewed on 12/2/22 at 10:14 AM, the Director of Social Work stated they worked closely with the activities department. The activities department performed social and coffee hours. Resident activity preferences were obtained from the resident and family during the admission assessment. Preferences were reviewed at least quarterly and included staff input. Activities were done to prevent resident depression. Many residents did not have family and activities were very important to them. Many residents went outside to smoke as an activity. There had not been a Director of Activities for about 4 weeks, and there had been 3 new directors within the last year. The social worker stated the resident's family did not visit often as they lived an hour away. When interviewed on 12/2/22 at 10:47 AM, activity aide #9 stated the department did not have an acting Director and the department only had 2 activity aides. The aide stated the last activity calendar made and given to residents was for October. They stated the 2 activity aides made up the resident activities schedule on a day-to-day basis. The aide stated administration just gave them a December calendar this past Wednesday or Thursday and the staff scheduler called to let them know it was done. The day-to-day activities were announced over the facility intercom. When interviewed on 12/2/22 at 10:54 AM, activity aide #10 stated the resident did not like group activities but liked the snacks staff brought them. The resident had refused independent activities in the past. Activities staff did not document refusals. When the activities aide viewed the activities log from 9/2022 with a handwritten discharged ,d+[DATE] statement on it, they stated they were unaware the resident was not discharged from the facility. The activity aide stated they were trained by another activity aide who told them to document on the log they performed an activity including if they walked past the resident's room and the TV or radio was on, even if they did not interact with the resident. The aide was also told to document an activity if the resident was wheeling themself in the hallway. The activity aide stated there was currently no Director and there were only 2 activity aides working in the department. 2) Resident #103 was admitted with diagnoses including dementia. The 8/31/22 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, had other behavioral symptoms not directed towards other 1-3 days during the assessment period, wandered 4- 6 days during the assessment period, felt it was somewhat important to have items to read and do their favorite activities and very important get fresh air when the weather was nice, and required supervision when ambulating both on and off the unit. The 8/30/22 Initial Recreation Assessment documented the resident showed some signs of confusion, but stated they enjoyed coloring and Bingo. The resident would be invited and escorted to activities of their choice. The 8/30/22 comprehensive care plan (CCP) documented the resident was able to make their activity and leisure pursuits known; their interests included coloring, Bingo, and socializing with their peers. Interventions included provide monthly calendar of events, invite/ escort to activities of choice, and provide personal 1:1 visits. The November 2022 Recreation Monthly Participation Record documented the resident participated in group exercise/ movement, strolling/ music appreciation room visits, and independently watched television/ listened to music for 30 of 30 days of the month. The undated care instructions documented the resident was to be provided with an activity calendar and staff were to assist the resident in finding activities of interest. On 11/28/22 at 10:28 AM, no activity calendar was observed in the common area of unit, the dry erase board was blank, and the previous weeks menu was posted. On 11/28/22 at 11:03 AM, at 11:47 AM, 12:07 AM, 1:37 PM, Resident #103 was observed ambulating independently throughout the unit. On 11/28/22 at 11:06 AM, activity aide #10 was observed passing out hot beverages to residents on the unit. The resident was offered coffee and sat down to drink it. During an observation on 11/29/22 at 8:46 AM, the resident's room did have an activity calendar. During an observation on 11/29/22 from 9:36 AM to 9:52 AM the resident was independently ambulating on the unit. The resident stated they missed their spouse. At 1:30 PM the resident was independently ambulating on the unit. On 11/29/22 at 1:41 PM and 11/30/22 at 9:28 AM no activity calendar was observed in the common area of nursing unit, the dry erase board was blank, and the previous weeks menu was posted. On 11/30/22 at 10:10 AM, the resident was observed to be independently ambulating on the unit. During an observation and interview on 11/30/22 at 11:17 AM activity aide #10 was observed on the unit with December 2022 activity calendars in their hand and posting the calendar in each resident's room. They stated the activity department would take the residents who were able to smoke outside at 10 AM and 3 PM. They also conducted group activities, including painting, board games, and Bingo on the 2nd floor in the activity room. There were currently only 2 activity aides and there was no Director of Activities. They stated they provided hot beverages and snacks to the residents on the 3rd floor but did not conduct any on unit activities. Since the department did not have a director, they were unsure what to put on the calendar and they just made stuff up. Someone from the facility's Administration office called them to tell them to provide the printed activity calendars to the unit. They stated the department was not receiving any help or guidance. During an observation on 11/30/22 at 11:27 AM, Resident #103 sat down, was tearful, and stated they missed their spouse. The resident stated they liked to go outdoors, cook, and paint. At 11:50 AM, Resident #103 asked another resident what was for supper. At 1:37 PM, Resident #103 and 4 other residents were seated at a table in the dining room with no staff in the area and were not participating in activities or engaging with one another. At 1:52 PM, an unidentified CNA was observed in the dining room charting on the computer Kiosk and did not engage with the residents. On 12/1/22 at 7:46 AM, no activity calendar was observed in the common area of unit, the dry erase board was blank, and the previous weeks menu was posted. During an observation on 12/01/22 at 9:07 AM, an unidentified resident brought a tablet (computer) to the dining room and was playing music. Multiple nearby residents began to nod their heads and sing along to the music. At 9:27 AM, the unidentified resident closed their tablet and went back to their room with their tablet. There were 9 residents observed sitting in the dining room with no staff interaction. On 12/1/22 at 11:04 AM, an unidentified staff member brought Resident #103 out to the dining room and told them to walk with the other residents and left. The resident started ambulating on the unit. On 12/1/22 at 1:21 PM, activity aide #10 was observed passing mail to the residents on the unit. There were 8 residents including Resident #103 seated in the dining room. At 1:22 PM, Resident #103 ambulated to activity aide #10 and asked them to come sit down with them. Activity aide #10 stated they were busy now but would return. At 2:45 PM, activity aide #10 had not returned to Resident #103. During an interview on 12/1/22 at 2:19 PM with licensed practical nurse (LPN) #11 they stated the unit was a behavior/ behavior/ dementia unit. They had not observed activities taking place on the unit for a while and had spoken to Administration about their concerns. They stated the residents who smoked were able to go outside twice a day with staff, but the nonsmokers did not go outside. Activity staff brought up a beverage cart and passed snacks, but that was it. They stated there was no music played on the unit and they thought the residents would enjoy some type of activity. They had spoken to the Unit Manager about the lack of staff interaction with the residents, but nothing changed. They felt the lack of activities on the unit affected the resident's quality of life. During an interview with activity aide #10 on 12/2/22 at 9:18 AM, they stated they forgot to go back and visit with Resident #103 and the resident would have enjoyed 1:1 conversation. During an interview with activity aide #9 on 12/2/22 at 9:20 AM, they stated Resident #103 attended Bingo and coloring activities in the past. They had not provided the resident with any coloring books for their room or for the unit. They stated there were only 2 activity staff members now, and when the previous Activities Director was at the facility the unit had different activities. The residents on the other units could attend activities in the 2nd floor activity room. They stated they did not bring Resident #103 down to any activities on the 2nd floor. During an interview with registered nurse (RN) #7 on 12/02/22 at 9:29 AM, they stated they oversaw the unit. They wanted the staff to be more social with the residents. Unit 3 was a special unit and they felt it should have an assigned activity aide. They stated last month they arranged to take several residents out for lunch. They stated not having activities on the unit could affect the resident's quality of life and cause boredom. 3) Resident #50 had diagnoses including manic bipolar, paranoid schizophrenia and insomnia. The 4/18/22 Minimum Data Set (MDS) assessment documented an interview for daily preference should not be conducted. The 10/1/22 MDS documented the resident had severely impaired cognitive skills for daily decision making, had fluctuating inattention and disorganized thinking, and required extensive assistance of 2 for walking in their room or in the corridor. The comprehensive care plan (CCP) initiated on 8/11/22 documented the resident was able to make recreation and leisure preferences known including drawing, painting, watching TV and listening to music. The goal was for the resident to attend all programs of interest during this review period. The interventions included to provide monthly calendar and schedule of activities, assist resident in finding programs of interest, provide resident with independent leisure supplies, provide personal 1:1 visit, and respect residents' refusals. The November 2022 Recreation Monthly Participation Record documented the resident participated in group exercise/ movement and strolling/ music appreciation room visits for 30 of 30 days of the month. The following observations were made of Resident #50: - on 11/29/22 at 9:00 AM, the resident was lying in bed, there was no TV on, and no music on. The room door, bathroom door and the resident walls had scribbled marking on them including Hospital, New York, New York on the walls and smoker on the bathroom door. Empty candy wrappers were taped to the bathroom walls. - on 11/29/22 at 2:31 PM, the resident was walking from their room, down the hallway with a cup, went to the ice machine, got some ice, and went back to their room. At 2:36 PM, the resident was resting in their bed. - on 11/30/22 at 9:46 AM, the resident was walking around their room going into the bathroom, and back out, turning the light on and off. The room door was opened. The resident put a cloth pad on the floor and began sprinkling baby powder on the floor. At 10:14 AM, the resident exited their room and began to talk with about their decorations of candy wrappers taped to wall and marker drawings on the wall. - on 12/1/22 at 8:38 AM, the resident was walking outside of their room and sat at a table in the dining room for breakfast. The resident was wearing a hospital gown and had red marker on their face, lips, and hands. During an interview on 12/2/22 at 9:18 AM, activity aide #10 stated they did not color with Resident #50 and had not provided them coloring books, markers, or crayons and the resident would most likely enjoy those things. They were aware Unit 3 was a dementia unit and was not instructed to post the weather and the date anywhere on the unit. They used to have a separate activity calendar for Unit 3 but currently the department was without a director and there has not been any special activities for Unit 3. During an interview on 12/2/22 at 8:25 AM, the Administrator stated the facility had been without a Director of Activities since October 4, 2022, and they had been the Acting Director of Activities. They stated Unit 3 was a dementia unit, and ideally the dementia unit residents would need more specialized attention. They stated currently on Unit 3 there was a certified nurse aide (CNA) assigned to provide 1:1 (1 staff to 1 resident) sitting attention to a resident due to behaviors. They explained when there was a need to have a 1:1 that indicated the unit could use more activities to address resident behaviors. The Administrator was not aware there was no visible documentation or signage with daily information for the residents, such as the date, the weather, schedule for meals, or a current menu. They stated this should be posted and would be helpful to keep residents oriented. The activity staff usually personalized the rooms for the residents with no family and personalized the units. They stated the lack of activities affected the quality of the residents' life and the residents needed human interaction. During an interview on 12/2/22 at 11:40 AM, the Director of Nursing (DON) stated since there were limited activity staff for Unit 3 the, CNAs should interact with residents when care was finished. They could paint fingernails, walk the residents, and chat with the residents. The staff should be engaging the residents and not sitting at the nursing station. Unit 3 was primarily residents with behaviors and dementia, and they should have engaging activities. The lack of activity was boring for residents, and it would affect their quality of their life. There should be one group activity a day on Unit 3. 10NYCRR 415.5(f)(1)

Based on observation, record review, and interview during the recertification survey conducted 11/28/22-12/2/22, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 7 residents (Residents #30 and 85) reviewed. Specifically, Resident #30 was not shaved and did not receive assistance or adaptive equipment at 2 meals as planned; Resident #85 was observed on multiple occasions with their call bell out of reach. Findings include: The facility policy Call Light System- Resident Response dated 12/2017 documented providing timely response to residents in need of assistance was essential to ensuring high quality resident outcomes. When the resident was in bed or confined to a chair, be sure the call bell was within easy reach of the resident. The facility policy Meal Tray Set-up and Assistance revised 5/2020, documented staff would review the resident's care plan, provide for any special needs of the resident, and assemble equipment and supplies needed. Staff would ensure that the necessary non-food items (i.e., silverware, napkin, special devices, straw etc.) were on the tray, report or replace missing items, arrange the dishes and silverware so that they could be easily reached by the resident, and assist the resident as necessary. Staff were also to encourage the resident to feed themselves as much as possible. The facility policy, ADL-Personal Hygiene revised 10/2021, documented resident baths or showers would be scheduled per resident preference at least weekly, mouth care and teeth brushing would be given, and facial hair was to be groomed as needed. The resident's care plan and Kardex (care instructions) should be reviewed for any special care or needs. 1)Resident #30 had diagnoses including dementia and glaucoma (an eye disease that can cause vision loss). The 10/9/22 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition, required limited assistance of 1 for personal hygiene including brushing teeth and shaving, and supervision with set up for eating, and did not use corrective lenses. The 3/16/22 physician order documented the resident was to receive a regular diet with thin liquids. The comprehensive care plan (CCP) updated 10/26/22 documented the resident required assistance with ADLs related to immobility and had impaired visual function related to glaucoma. Interventions included limited assistance of 1 for personal hygiene, and supervision and set up help for eating. Staff were to observe all eating/drinking for safety and give verbal prompts while eating or drinking, provide set up assistance by cutting up meat and opening containers at meals, give one food item at a time, arrange items per resident preferences, tell the resident where the items were, and be consistent. The CCP did not include use of adaptive feeding devices. The undated care card (care instructions) documented the resident required an adaptive feeding device of a divided plate for meals; supervision with eating; set up help including assistance with cutting meats and opening containers at meals and giving one food item at a time; and limited assistance of 1 staff member for personal hygiene. The ADL care report documented from 11/17/22 -11/30/22: - the divide plated was used for all 3 meals; and - personal hygiene was completed which included shaving and hair combing. The 11/28/22-12/1/22 Resident #30's meal tickets for breakfast and lunch documented the resident was to receive a regular diet with thin liquids, a divided plate, and food was to be cut up. The following observations were made of Resident #30: - On 11/28/22 at 10:49 AM, the resident was lying in bed with a partial beard. The resident stated they liked to be clean shaven and have their head shaved bald. The breakfast tray remained on a tray table and the resident did not have a divided plate; - On 11/29/22 at 9:16 AM, the resident was dressed and had a partial beard. - On 11/30/22 at 8:03 AM, the resident was being assisted by staff to wash their face and pick out clothing. The resident was not shaved. - On 11/30/22 at 12:16 PM, licensed practical nurse (LPN) #11 brought the resident their lunch tray and told the resident where the food items were on the divided plate. LPN #11 did not cut up the resident's fried chicken and the resident was left in their room with the door closed. The resident's meal ticket documented Yes Cut up. - On 12/01/22 at 8:36 AM, the resident was sitting in the dining room at a table with 2 other residents, the resident did not have a divided plate, and had two bowls placed on top of a regular plate. The resident was eating without assistance and no staff were at the table. The resident's meal ticket documented divided plate and Yes Cut up. The resident's sausage patty was not cut up. At 12:16 PM, the resident was sitting in a wheelchair in the hallway with a partial beard. At 12:39 PM, the resident's lunch was served on a regular plate and there was no divided plate. The resident was sitting in wheelchair at dining room table eating without assistance. The resident's sliced turkey was not cut up. The resident's meals ticket documented divided plate and Yes Cut Up. During an interview on 11/30/22 at 1:32 PM, certified nurse aide (CNA) #30 stated the resident was legally blind, had a hard time seeing things, and could see when staff were close. During an interview on 12/01/22 at 1:52 PM, CNA #6 stated Resident #30 was on their care assignment. The resident required set-up for care which included picking out their clothing. The resident washed themselves but needed staff assistance for shaving. CNA #6 stated the resident did not require assistance during meals, did not need their food cut up, did not receive a divided plate, fed themselves, and needed set up only. The CNA added the resident had some vision impairment, but gets around okay. The CNA stated staff should tell the resident what foods were on their plate and to keep checking on the resident. The CNA stated they did not shave the resident and would do so during the evening shift. During an interview on 12/02/22 at 8:41 AM, food service worker #33 stated their responsibility in the kitchen was to check the trays for adaptive equipment and correct meal items. The tray line checked for sippy cups, divided plates, and silver ware. Resident #30 was supposed to have a divided plated. The worker stated the kitchen had a shortage of products (divided plates and sippy cups), would send the products to the unit, and would not get them back. They would notify the Nursing Supervisor or Unit Manager if the items were not available. The worker stated it was important for the resident to have these items at mealtime so their eating needs were met. They did not remember if Resident #30 received a divided plate on 11/28/22 or 12/1/22. During an interview on 12/02/22 at 9:31 AM, registered nurse (RN) MDS Coordinator stated the resident required limited assistance for eating and should be set up properly in their room. The plates should be taken off the tray, all items opened, and food cut up. The staff should assist by checking on the resident frequently and lights should be on during mealtime. The RN stated that although the resident was legally blind, they should not have to eat in the dark. Staff were to complete shaving on shower days, but a CNA could shave the resident at any time, which was part of ADLs. The RN stated the facility was aware of lack of adaptive devices and had to order more. Any resident eating in the dining room was considered supervised because the unit nurses and CNAs were in there. If staff saw items missing from the resident tray, they should notify someone. During an interview on 12/02/22 at 11:03 AM, registered diet technician (DTR) #1 stated the resident fed themselves, was to receive a divided dish, and staff should cut up the resident's food and provide assistance. The divided plate was to be provided with all meals to assist with independent eating, and they were not aware that the resident was not receiving the divided plate. The DTR added the facility did audits on the unit to ensure residents were getting their ordered items. The resident may have difficulty eating if they did not have the divided plate. The resident needed assistance with opening things or cutting up items. The instructions Yes Cut Up on the meal ticket indicated that staff should pull the chicken off the bone and cut up the food. 2)Resident #85 had diagnoses including subarachnoid hemorrhage (brain bleed) and left sided hemiplegia (paralysis). The Minimum Data Set (MDS) assessment dated [DATE], documented the resident had severely impaired cognition, was totally dependent on 2 for bed mobility and transfers, and had functional limitation with one upper extremity. The comprehensive care plan initiated 10/6/21documented the resident required assistance with activities of daily living (ADLs) related to immobility. Interventions included encourage resident to use call bell for assistance. The resident was totally dependent for most ADLs. A 6/15/22 occupational therapy (OT) treatment encounter documented the resident attempted to use a pen to write. Improvement in range of motion (ROM) of the right upper extremity was noted during the activity. The following observations were made of Resident #85: - on 11/28/22 at 2:33 PM the adaptive call bell (pad) was sitting on the TV stand and was not in the resident's reach. - on 11/29/22 at 8:34 AM the resident was in bed with the pad call bell out of reach on the dresser. At 1:44 PM the resident was in bed with the call bell pad out of reach on the TV stand. - on 11/30/22 at 9:27 AM the resident was sitting up in a geri chair (reclining mobile chair) in their room. The call bell pad was out of reach on the TV stand. At 11:03 AM the resident remained in their geri chair with the call bell out of reach on the dresser by the television. - on 12/1/22 at 12:08 PM the resident was in bed with their eyes closed with the call bell on the dresser by the television, out of the resident's reach. During an interview on 12/1/22 at 4:18 PM registered nurse (RN) MDS Coordinator stated Resident #85's adaptive call bell needed to be in reach. It was the only way the resident was able to communicate if they needed help or assistance. During an interview on 12/1/22 at 5:02 PM licensed practical nurse (LPN) # 14 stated that call bells should always be within the resident's reach. During an interview on 12/2/22 at 9:44 AM certified nurse aide (CNA) #15 stated the call bell should be kept in the resident's reach. Most of the time it was their only way to get the staff 's attention. Resident #85 had a flat pressure pad call bell due to their limited range of motion. The CNA was not sure if the resident could use it now, they used to be able to. During an interview on 12/2/22 at 10:37AM RN Unit Manager #16 stated call bells should always be in reach of residents. Call bells provided a way for residents to communicate needs to staff. Resident #85 had a pressure sensitive call pad, and they were able to use it. The resident should always have it in reach. 10NYCRR 415.12(a)(3) 40803

Based on observation, record review and interview during the recertification survey conducted 11/28/22-12/02/22, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 1 resident (Resident #87) reviewed. Specifically, Resident #87 had a urinary catheter (a tube used to empty the bladder and collect urine in a drainage bag), complained of urinary tract symptoms, had a physician order for a urinalysis (U/A) and culture and sensitivity (C&S) and the urine specimen was not collected and submitted to the laboratory timely. Additionally, there was no medical rationale, physician order, or comprehensive care plan (CCP) for the use of a urinary catheter. Findings include: The facility policy Lab Procedure revised 5/2019 documented the purpose of the policy was to check a resident's specimen as ordered by the physician and to maintain a record of the results. The facility policy, Care Plans-Comprehensive revised 10/2019 documented the comprehensive person-centered care plan would include measurable objectives and timeframes and describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psycho-social well-being. Resident # 87 had diagnoses of end stage renal disease, urinary tract infection (UTIs) and cancer. The 10/18/22 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, required limited assistance of 1 with personal hygiene, extensive assistance of 1 with toileting, had an indwelling urinary catheter, and had a UTI in the last 30 days. The Care Area Assessment (CAA) Summary documented the care area of urinary incontinence and indwelling catheter was triggered and care planned. The 10/11/22 physician #31 History and Physical documented the resident had recently been treated at the hospital for a urinary tract infection. Review of systems was conducted. The physician documented under genitourinary the resident did not have a Foley (type of urinary catheter) catheter. Physician orders dated 10/14/22 documented Foley care every shift. The orders did not include a medical rationale for a urinary catheter or the size of the catheter to be used. The comprehensive care plan (CCP) initiated 11/2/22 documented the resident had bladder incontinence. Interventions included to monitor and document for signs and symptoms of a urinary tract infection (UTI) including pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, foul smelling urine, fever, chills, changes in behavior, and changes in eating patterns. The CCP did not document the presence of a urinary catheter. The 11/21/22 nurse practitioner (NP) #5 progress note documented Resident #87 was seen for complaints of urinary frequency and painful urination for 2 days. A U/A and C&S would be ordered to rule out infection. Upon assessment the resident had pain with bladder palpation. There was no documentation the resident had a urinary catheter. The 11/22/22 NP #5 medical order documented obtain urine sample per U/A and C&S for a urinary tract infection every shift and discontinue on 11/25/22 once obtained. The 11/22/22 nursing progress note by graduate practical nurse (GPN) #24 documented Resident #87 had complained of urinary frequency, urgency, penile burning, and they were afebrile (did not have a fever). There was a new order to obtain a urine sample for U/A, C&S. There were no nursing notes on 11/23/22. The resident's treatment administration record (TAR) documented obtain urine sample per U/A C&S, discontinue order once obtained with a start date of 11/22/22. The TAR was checked and initialed as being completed on 11/22/22 at 10:30 PM by LPN #39, on 11/23/22 at 6:30 AM by LPN #18, and 11/24/22 at 2:30 PM by RN #37. On 11/23/22 at 2:30 PM LPN #25 documented 9 and on 11/24/22 at 10:30 PM LPN # 40 documented 9 (9=other/see nurse note). The 11/24/22 nursing progress note by LPN #25 documented they were unable to get the resident's urine sample for a U/A C&S. A nursing progress note dated 11/25/22 at 5:50 AM by LPN #40 documented a U/A was already obtained. A medical order by NP #5 on 11/25/22 documented to discontinue Resident #87's urine sample for U/A C&S. There was no documented evidence of laboratory results for a U/A C&S the week of 11/22/22-11/25/22. During an interview on 11/28/22 at 9:15 AM with Resident #87, they stated they had UTI symptoms for approximately one week, had given a urine sample, and someone had lost their urine sample. The resident stated they had pain and burning sensation with urination, had penile discharge and was not being medically treated. The resident was observed: - on 11/28/22 at 10:55 AM, lying in bed telling GPN #24 they wished someone would help them with their urinary tract infection. - on 11/30/22 at 9:07 AM sitting on the edge of their bed eating breakfast. The resident stated they still had not been seen by a nurse for their urinary tract infection symptoms and they were leaving for dialysis at 11:00 AM. A hospital laboratory urinalysis report documented a urine specimen was received 11/29/22 at 9:19 PM and initialed by NP #5. A medical order by NP #5 documented to obtain a urine sample for a U/A C&S with a revision date of 11/30/22. During an interview on 11/30/22 at 10:53 AM with certified nurse aide (CNA) # 17, they stated Resident #87 was independent with their catheter care. The CNA stated they only emptied the urinary drainage bag and documented it in the electronic health record (EHR). During a telephone interview on 12/1/22 at 9:04 AM with hospital laboratory client service representative #23, they stated the laboratory turnaround time for a U/A was 24 hours and 48 hours for the C&S. The results were automatically faxed to the facility. The lab would pick up the urine specimens every day when the facility called them. During an interview on 12/1/22 at 11:53 AM with licensed practical nurse (LPN) #19, they stated an order for a urine sample for Resident #87 was in the computer on 11/22/22. They stated the orders were processed by a registered nurse (RN), and if ordered on a weekend then a licensed practical nurse (LPN) could take a verbal order. The urine sample was collected and brought to the first-floor refrigerator and the lab was called for a specimen pickup. LPN #19 stated if the treatment book was initialed, it meant that the treatment was completed. LPN #19 stated the lab results should be documented in the computer. They looked in the computer and stated no laboratory results were documented for Resident #87. During an interview on 12/01/22 at 10:07 AM with LPN # 21, they stated NP #5 put the orders in the computer and they were electronically transferred to the TAR. LPN #21 stated if initials were present on the TAR, it meant that the sample was collected. LPN # 21 stated the results were faxed over from the lab within 24 hours and the medical records person scanned them into the resident's chart. They stated they knew Resident 87's order was placed on 11/22/22 and it was not collected until 11/28/22. They stated the resident had a delay in treatment and it could cause urosepsis (a severe blood infection) if not treated timely. During an interview on 12/02/22 at 9:19AM, LPN #18 stated the resident performed their own catheter care, and on 11/22/22 they gave the resident a urine specimen cup to provide a urine sample but could not recall what happened to the specimen. During an interview on 12/1/22 at 10:37 AM with medical records staff #20, they stated results from the lab came directly to them via fax and they gave the original copy to NP #5 and a copy to all the Nurse Managers. After NP #5 signed the results, the medical records staff scanned them into the resident's chart. They stated if results were faxed over the weekend, they would process them on Monday morning. They stated that Resident #87 did not have U/A C&S results for the week of 11/22/22, and only had U/A results on 11/29/22. During an interview on 12/2/22 at 9:42 AM, the Assistant Director of Nursing (ADON) stated Resident #87 had a history of UTIs, had an indwelling catheter, and had an order for a urine sample on 11/22/22. The ADON stated there should not have been a delay in obtaining the urine sample and doing so could place the resident at a risk for infection or urosepsis. They stated the resident was not assessed for self-catheter care, should not be doing their own catheter care and the lack of a registered nurse (RN) on the unit could have contributed to the delay in obtaining a specimen. During an interview on 12/02/22 at 10:12 AM with NP #5, they stated they expected staff to sign and complete any orders in a timely manner. NP #5 stated they placed a urinalysis order for Resident #87 on 11/21/22, and there should never be a reason why an order was not completed unless a resident was hospitalized . They stated Resident #87 had a history of UTIs, had an indwelling catheter, and their order was not completed the week of 11/25/22. NP # 5 stated they did not see any results until Monday 11/28/22. NP # 5 stated the resident was currently being treated for a UTI, and that a delay in treatment put the resident at risk for urosepsis and could also compromise their immune system. 10NYCRR 415.12(d)(2).

Based on observation, record review, and interview during the recertification survey conducted 11/28/22-12/2/22, the facility failed to 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 1 of 2 residents (Resident #73) reviewed. Specifically, Resident #73 was observed not receiving oxygen as ordered. Findings included: The facility policy Oxygen Therapy revised 1/2020 documented oxygen should be regarded as a drug and required prescribing in all but emergency situations. Failure to administer oxygen appropriately could result in serious harm to the resident. Oxygen was administered according to the physician order. The facility policy Oxygen- Cylinders dated 1/2020 documented oxygen was administered by licensed nurses with a physician's order to provide sufficient oxygen to blood and tissues. Orders should specify the oxygen equipment and flow rate required as routine or as needed. Resident #73 had diagnoses including dementia and anxiety. The 10/2/22 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition, required extensive assistance of 2 for bed mobility, transfers, and toilet use, extensive assistance of 1 for dressing, limited assist of 1 for locomotion and hygiene, used a wheelchair, and received oxygen therapy. Physician orders documented: - on 8/11/22 supplemental oxygen via nasal cannula at 2 liters-per-minute (LPM) to maintain blood oxygen levels greater than 88% every shift and check levels every shift. - on 8/12/22 evaluate for shortness of breath every shift while lying flat. - on 8/17/22 oxygen equipment maintenance every night shift and as needed for tubing, mask, nasal cannula, humidifier bottle, storage bags. Wipe down concentrator every month on the 8th. The 9/19/22 and 10/19/22 nurse practitioner (NP) #5 progress notes documented the resident had poor respiratory control. The 11/2022 medication administration record (MAR) documented the resident received oxygen every shift from 11/28-11/30/22 at 2 LPM and had blood oxygen levels above 88%. All checks and oxygen equipment maintenance were completed as ordered. During an observation on 11/29/22 at 1:31 PM, Resident #73 was in the unit common area wearing a clear nasal cannula. The resident's oxygen tank was attached to their wheelchair. The gauge on the tank was above the red zone range indicating the tank had sufficient oxygen. The clear nasal cannula was not connected to the oxygen tank. The oxygen tank had a green colored nasal cannula connected to it. The resident stated, they keep taking me out of my room and appeared to be confused. Another resident wheeled Resident #73 back into their room and about the unit. The other resident approached licensed practical nurse (LPN) #11 and told the LPN Resident #73 was acting abnormal. LPN #11 approached Resident #73 and placed the nasal cannula attached to the oxygen tank on the resident. The LPN did not check the resident's oxygen levels. The resident was observed with no obvious signs of respiratory distress. During an observation on 11/30/22 at 9:21 AM, the resident was lying in bed. A nasal cannula was in their nose and connected to an oxygen concentrator. The oxygen concentrator was off, the gauge read 0 and the resident's lips appeared grayish in color. The resident's call bell was on the floor. At 9:43 AM, licensed practical nurse (LPN) #32 entered the resident's room and talked to Resident #73's roommate. At 9:44 AM, a CNA entered the room, exited a minute later along with LPN #32, and both went towards the nursing station. The CNA or LPN #32 did not check the resident or turn on the oxygen concentrator. The resident was observed with no obvious signs of respiratory distress. When interviewed on 11/30/22 at 1:59 PM, certified nurse aide (CNA) #6 stated CNAs were allowed to switch oxygen between the concentrators and portable tanks, but only licensed nurses could change tanks. The resident was unable to do so by themselves. The resident experienced no behaviors related to oxygen levels, was good about wearing their oxygen, and did not try to take it off by themself. When interviewed on 12/1/22 at 2:05 PM, CNA #12 stated Resident #73 was unable to manage their oxygen by themself. CNAs should be checking the portable tanks to ensure the tank contained enough oxygen and it was on. They should be checking the oxygen concentrators to ensure they were on, and the resident was receiving the ordered oxygen. The CNA stated therapy also was able to switch the resident from concentrator to tank and vice versa. The CNA stated they thought therapy switched the resident from concentrator to a portable tank on 11/29/22. When interviewed on 12/1/22 at 2:19 PM, LPN #11 stated Resident #73 was unable to manager their oxygen on their own. The resident always needed oxygen. The resident was still wearing the tubing for the oxygen concentrator tubing on 11/29/22 and staff should have ensured the correct tubing was connected to the oxygen delivering device when they were switched over. Grayish lips could have meant that a resident was lacking in body oxygen levels. The LPN stated they did not see the grayish lips on the resident, was not aware the concentrator was not turned on prior to the 11/30/22 episode, and the resident was unable to turn it off by themself. When interviewed on 12/2/22 at 9:29 AM, registered nurse (RN) MDS Coordinator stated they oversaw Unit 3 and Resident #73 was on long term oxygen therapy. The on-duty unit LPN should manage the oxygen therapy and turn on the portable tank when they switched over from the concentrator. Any nursing staff member could check the portable tanks for capacity and working condition and switch the resident from the concentrator to the portable tanks and vice versa. The resident's vital signs should have been taken, including oxygen levels, when the resident presented with grayish lips. The nurse needed to ensure the resident had oxygen levels greater than 88%. When interviewed on 12/2/22 at 10:33 AM, nurse practitioner (NP) #5 stated Resident #73 had an order for continuous oxygen therapy and required it for comfort and oxygenation. It was important that staff ensured the oxygen was on and working. Staff should have made the NP aware the resident had grayish lips and what the resident's vital signs were. 10 NYCRR 415.12(k)(6)

Based on record review and interview during the abbreviated survey (NY 248 and NY 363), the facility failed to thoroughly investigate all alleged violations of abuse, neglect, or mistreatment for 1 of 3 (Resident #1) residents reviewed. Specifically, Resident #1 was sent to the hospital and returned with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no Minimum Data Set (MDS) assessment completed prior to the resident's discharge. The comprehensive care plan (CCP), initiated 6/14/22, documented the resident was at risk for falls and had an actual fall related to [CONDITION(S)] (low blood pressure). Interventions included anticipate and meet resident needs. Nursing Progress notes included: - on 6/15/22 at 2:19 PM, licensed practical nurse (LPN) #18 documented the resident had confusion, ambulated independently, toileted themselves, wandered into other residents' rooms and was unable to be redirected due to hostility and unwillingness to follow directions. - On 6/17/22 at 10:44 PM, registered nurse (RN) #19 documented x-ray results of left hip showed no dislocation or obvious fracture. Recommended CT (computed tomography)/MRI (magnetic resonance imaging) if occult hip fracture remained a clinical consideration. Moderate arthritic change, [CONDITION(S)] disc disease of lowered lumbar spine, and [CONDITION(S)]. There was no documentation why the x-ray was completed. - On 6/19/22 at 2:21 PM, LPN #18 documented the resident was wandering in other residents' rooms, taking and wearing their clothing and setting off the door alarm by attempting to exit. Staff were unable to redirect as resident started to curse and hit the wall. - On 6/20/22 at 5:26 PM, RN #19 documented the resident left by stretcher with EMS (Emergency Medical Service) at approximately 4:55 PM for evaluation and treatment. There was no documenation what the resident was to be evaluated and treated for [MEDICAL RECORD OR PHYSICIAN ORDER] The hospital emergency room (ER) after visit summary dated 6/20/22 documented the the resident was seen for aggressive behavior and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was to have a neurology appointment scheduled as soon as possible. A 6/20/22 at 9:51 PM, progress note by RN #19 documented the resident returned from the hospital with new orders for [MEDICATION(S)] (antibiotic) 500 milligrams (mg) four times daily for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation why the resident was sent to the ER or a possible cause of the head injury. A 6/20/22 psychiatric nurse practitioner (NP) #25's progress note documented the resident was referred by the Nurse Manager. The resident was seen in the ER earlier that week. The resident was documented as having a head injury. A progress note by physician #24 dated 6/21/22 documented the resident was being seen for a History and Physical. The resident was seen in the ER due to possible [CONDITION(S)] and head injury and recommended neurosurgery follow-up. Physician #24 noted they did not have full physician notes form the ER. There was no further documentation of the resident's head injury or follow-up with neurology as recommended. There were no documented incident reports referencing the resident being sent to theER on [DATE] and subsequent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview with LPN Unit Manager #1 on 7/20/22 at 1:45 PM, they stated they thought the resident went to the hospital another time because of a fall. The resident was at risk for falls. LPN #1 thought the resident hit their head. They were unsure of the date or circumstances as they were not at the facility that day. There should have been follow-up by whoever was at the facility and an Accident and Incident report and family notification should have occurred. During an interview with the Director of Nursing (DON) on 7/22/22 at 11:20 AM, they stated the resident went to the hospital on 6/20/22 but there was no indication of a head injury, there was no accident at the facility, and no fall. They stated it was possible the hospital's mention of a head injury had been referring to a prior trip to the hospital before the resident was admitted to the facility. The resident did not have a head injury so there was nothing to investigate because nothing happened. They stated it must have been a mistake in the hospital paperwork. During an interview with RN #19 on 7/29/22 at 10:54 PM, they stated the resident was sent to the hospital for evaluation and treatment on 6/20/22 and returned with a head injury and [CONDITION(S)]. They were not aware of any issues with a head injury or a fall. The resident was ambulatory and steady. The hospital note did say a head injury from a fall the week prior but they could not recall that and did not know of any falls. A transfer to the hospital should include the reasons for a transfer and who was notified. 10NYCRR 415.4(b)(1)(ii)

Based on record review and interview during the abbreviated survey (NY 248 and NY 363), the facility failed to notify the resident and resident's representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood for 1 of 3 residents reviewed (Resident #1). Specifically, Resident #1 was discharged from the facility without the resident's representative being notified of the transfer or discharge and the reasons for the move in writing. Findings include: The facility policy Discharge-Transfer/Discharge Process revised 2/2019 documented: - When a resident was transferred or discharged from the facility, details of the transfer or discharge would be documented in the medical record and appropriate information would be communicated to the receiving health care facility or provider. - The resident's physician would determine if a transfer to the hospital was required for an urgent medical need or the resident's behavior posed a threat to their or others' safety or well-being. - A resident being transferred to a hospital for an urgent medical or psychiatric need would be provided the written notice at the time of the transfer to the hospital, and their representative would be provided the written notice as soon as practicable thereafter. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no Minimum Data Set (MDS) assessment completed prior to the resident's discharge. The resident's admission record listed a family member as emergency contact #1. The 6/16/22 nurse practitioner (NP) progress note documented the resident did not have capacity to make medical decisions. The 6/16/22 Social Services Assessment completed by social worker #17 documented the resident had severe cognitive impairment. The 6/27/22 at 3:30 AM nursing progress note entered by registered nurse (RN) #20 documented they were called to the unit to assess the resident, who went into another resident's room, was told by the other resident to leave and Resident #1 slapped the resident. The medical provider was notified. The paramedics were called, and they refused to take the resident to the emergency room (ER). The 6/27/22 hospital discharge summary documented the resident arrived at 8:40 AM via ambulance and accompanied by the police. The resident was evaluated, noted to be stable, and discharged back to the facility at 9:24 AM. There was no corresponding nursing note documenting the resident's transfer to the hospital or return to the facility. An email communication from medical transportation service driver #21 (dated 7/11/22 at 8:24 PM) documented the driver picked up the resident from the facility on 6/27/22 at 1:15 PM and transported them to the hospital ER (in a neighboring town). The 6/27/22 hospital ER (in a neighboring town) report documented the resident arrived at 2:50 PM. The 6/27/22 at 3:21 PM nursing progress note entered by LPN Unit Manager #1 documented they called and talked to family (not identified) about the resident's behaviors and the resident was sent to the ER. The family requested a call back with updates. The 6/27/22 Notice of Transfer/Discharge documented the resident was transferred/discharged to 2 hospitals. The local hospital was named as well as the hospital in the neighboring town. The resident's family member/representative was noted as being notified via telephone. The form was signed by LPN Manager #1. There was no documented evidence the written notice of discharge with appeal rights was sent to the resident's representative. During an interview with LPN Manager #1 on 7/20/22 at 1:45 PM, they stated on 6/27/22, LPN #1 was made aware the resident had an altercation with another resident overnight and refused to go to the ER. The LPN obtained the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The LPN did not notify the resident's family/representative at that time or complete a Notice of Transfer/Discharge form. When the resident came back from the hospital, the LPN was advised by Administration the resident was to be sent out to a different hospital. The LPN Manager did not notify the family until after the resident was sent to the second hospital. At that time, the LPN Manager completed the Notice of Transfer/Discharge and was not aware if a copy had been mailed to the family or if they were advised of the appeal process. They stated they were not responsible for mailing the form, the social worker handled mailing the forms. During a telephone interview with RN #19 on 7/29/22 at 10:54 AM, they stated anytime a resident was sent out to the hospital the resident's representative should be notified and a Notice of Transfer/Discharge form should be completed. The RN could not recall if they notified the representative or completed the form, if they did, it would be documented in the resident's medical record. During a telephone interview with the resident's representative on 7/29/22 at 1:24 PM, they stated they were never notified of the 6/27/22 hospital admissions and had not received any written Notice of Transfer/Discharge. The family/representative were unaware the resident was sent to the hospital due to behaviors and psychiatric concerns that required a 9.45 order and were not made aware a private transport company brought the resident alone to another hospital later on 6/27/22. During a telephone interview with the Director of Social Services on 8/2/22 at 2:25 PM, they stated they did not have a role in completing discharge notices for resident's discharged to the hospital. Nursing was responsible for preparing notices and they were uncertain if they mailed them to families. The Director of Social Services did not speak to the resident's family or mail then a notice following their discharge. 10NYCRR415(h)(1)(iii)(a-c)

Based on record review and interview during the abbreviated survey (NY 248 and NY 363), the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility and provide orientation in a form and manner that the resident could understand for 1 of 3 (Resident #1) residents reviewed. Specifically, Resident #1 had severe cognitive impairment and was transferred to a hospital unaccompanied in a medical taxi. Findings include: The facility policy Discharge-Transfer /Discharge Process revised 2/2019 documented: - When a resident was transferred or discharged from the facility, details of the transfer or discharge would be documented in the medical record and appropriate information would be communicated to the receiving health care facility or provider. - The resident's physician would determine if a transfer to the hospital was required for an urgent medical need or the resident's behavior posed a threat to their or others' safety or well-being. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no Minimum Data Set (MDS) assessment completed prior to the resident's discharge. The 6/16/22 nurse practitioner (NP) progress note documented the resident did not have capacity to make medical decisions. The 6/16/22 Social Services Assessment completed by social worker #17 documented the resident had severe cognitive impairment. The 6/27/22 at 1:30 PM nursing progress note entered by licensed practical nurse (LPN) Unit Manager #1 documented the resident did not display behaviors and staff intervention was not necessary. The resident was in the emergency room (ER) due to behaviors on the overnight shift. There was no documented nursing, social work, medical, or psychiatric provider progress notes related to the resident's transfer to the hospital including referral, hospital, or family contact prior to their discharge. An email communication from the medical transportation service driver #21 (dated 7/11/22 at 8:24 PM) documented the driver picked up the resident from the facility on 6/27/22 at 1:15 PM and the resident was taken to the hospital ER in a neighboring city (approximately 25 minute drive time). The 6/27/22 hospital ER report documented: - The resident was triaged in the ER at 2:55 PM. - A note entered by the social worker at 6:05 PM documented the resident arrived by private vehicle/unknown transport and was found in the ER with papers from the facility. The resident had dementia and did not know how they got there or the reason they were there. The ER staff called the facility multiple times and had not yet spoken to anyone who knew why or how the resident got there. - The facility was called at 4:15 PM and 6:20 PM. - The facility Administrator called the hospital at 6:24 PM. The physician spoke to the facility Administrator and the resident wanted to go home. The 6/30/22 hospital history and physical documented the resident was dropped off in the waiting room from the nursing facility for behavioral issues. The ER staff called the facility for transfer back as there was no medical issue that needed to be treated. The nursing facility declined to take the resident back. Prior to this ER admission, the resident was sent to another hospital, was not admitted , and was sent back to the nursing home. The resident was then dropped off in the waiting room of this hospital's ER. During an interview with LPN Unit Manager #1 on 7/20/22 at 1:45 PM, they stated the resident had behaviors including wandering into other residents' rooms, taking others' belongings, exit seeking, had eloped, was very confused, difficult to redirect, and was potentially aggressive when redirected. On 6/27/22, during the overnight shift, the resident had an incident where they slapped another resident. Resident #1 was sent to the local ER later that morning for evaluation and the ER sent the resident back to the facility. When the resident returned, there was a plan to send the resident to another ER in a neighboring town. LPN Manager #1 did not see the resident upon their return from the first hospital and did not have any involvement in their discharge planning for the trip to the second hospital. LPN Manager #1 stated they did not call the receiving hospital for nurse-to-nurse report and did not review any paperwork that was sent with the resident. LPN #1 stated typically, when a resident was sent to the hospital it was via ambulance and their paperwork was verified to include advance directives, contacts, and medications and the receiving facility would be called to be advised of the situation. LPN #1 stated they were told Administration was coordinating the transfer and they thought someone else would have taken care of the transfer notification and documentation. During an interview with the Director of Nursing (DON) on 7/22/22 at 11:20 AM, they stated the resident was at risk for elopement, was on a secured unit, had aggressive behaviors, dementia, confusion, and wandered about the unit in and out of other residents' rooms. The DON stated when the resident was transferred to the hospital for the second time on 6/27/22, it was non-emergent and the ambulance would only bring them to hospitals in the area, as they would not be routed to the hospital in the neighboring city. Typically, a resident with dementia would not be sent alone in a taxi because it was not safe. The receiving hospital should have received nurse-to-nurse report to ensure they were aware of the resident's needs, and they did not. The DON was unaware of the reasons no report was made and it was usually the responsibility of the nurse from the resident's unit. The resident had some paperwork with them, and the DON was unsure of what information was provided to the hospital. The family was not made aware the resident was to sent alone to the ER in a taxi During an interview with the Administrator on 7/22/22 at 11:25 AM, they stated it was a corporate decision to send the resident to the hospital in a taxi. The Administrator spoke to the driver to make sure they registered the resident in the ER. The resident was not accompanied by a staff member because directives from the corporate office included a plan to have the resident stay at the hospital to be evaluated in their behavioral unit. The Administrator was not aware of the referral process for the hospital and did not contact the hospital or the resident's providers for referral. During a telephone interview on 7/28/22 at 11:24 AM, the hospital's Director of Care Transitions stated when the resident was dropped off in the ER, there was no information available. The ER staff had difficulty contacting anyone from the facility initially and were eventually told the facility would not take the resident back. 10NYCRR415.11(d)(3)

Based on observation, record review, and interview conducted during the extended survey, it was determined for 7 of 31 resident rooms (rooms 112, 120, 121, 122, 212, 221, and 320), that had packaged terminal air conditioner (PTAC, performs heating and air conditioning) units, the facility failed to ensure the resident environment was maintained as free of accident hazards as possible and failed to ensure staff followed fire safety procedures. Specifically, for Rooms 212, 221, and 320 when the PTAC units malfunctioned resulting in melted plastic covers, melted plugs, burning odors, charred outlets and/or black soot around the outlet, staff failed to activate the fire alarm and implement the facility's fire response procedures, and the facility failed to conduct an investigation to determine whether there was proper response to the incidents. Additionally the facility failed to repair/replace the malfunctioning PTAC units, there were 31 units currently in use in resident rooms, and the PTAC units in resident rooms 112, 120, 121, and 122 were malfunctioning when observed. This resulted in no actual harm with potential for serious harm that is Immediate Jeopardy to the health and safety and Substandard Quality of Care. This had the potential to affect all residents in the facility. Findings include: 1) Resident #17 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact. At the resident group meeting on 12/15/2014 between 2:30 PM and 3:20 PM, the Resident #17 stated there was a heater malfunction in her room within the last month that caused fumes in her room and the hallway. She stated the plastic on the top of the heater melted, and the fire department did not respond. The resident stated she received a new heater the next day. Resident #3, who lived down the hallway from the resident, stated he smelled the fumes in his room. The facility's incident investigations for 9/2014 - 12/2014 did not document an incident involving the PTAC unit in resident room 212. On 12/16/2014 at 12:10 PM, the state-wide incident reporting system was reviewed. There were no incidents involving environmental issues or malfunctioning equipment reported by the facility in 2014. There was no documented evidence in the resident's medical record, including the nursing progress notes dated 10/2014 - 12/2014, that there had been a problem with the resident's PTAC unit. When interviewed on 12/16/2014 at 12:38 PM, the Director of Maintenance stated he received a call on a recent weekend regarding the PTAC unit in room 212, and responded to the facility within 15 minutes. He stated the caller informed him a resident room PTAC unit had a hot cord and smelled like plastic. The Director stated when he arrived it smelled like someone blew a candle out, the fire alarm was not activated, and the facility's fire procedure was not followed or implemented by staff. The malfunctioning PTAC unit from room 212 was observed on 12/16/2014 at 1:10 PM, outside on a facility truck. The plastic grate on the unit had two melted areas approximately 2 - 3 inches in diameter. When interviewed on 12/16/2014 at 3:05 PM, registered nurse (RN) Manager #15 stated she was the Supervisor on duty the previous week when she was notified of a "shrunk" plug from a PTAC unit in room 212. She stated the residents were removed from the room, she called maintenance, and the maintenance director came in. She stated the staff unplugged the PTAC unit prior to her arrival, the fire alarm had not been activated, and the facility did not implement its fire response procedures. When interviewed on 12/16/2014 at 4:30 PM, the Administrator stated he was aware there was an incident with the PTAC unit in room 212. He stated if a burning odor was permeating a nursing unit, he expected staff to implement the facility's fire procedures and call a code red. 2) When interviewed on 12/16/2014 at 1:10 PM, maintenance staff #27 stated he changed the plug and outlet from the PTAC unit in room 221 after he received a page from a certified nurse aide (CNA) about a faulty heating unit. He stated the plug was melted and charred; the outlet showed signs of charring; there was black soot on the wall around the outlet; and the outlet was not hot. He stated the fire alarm was not activated and the facility's fire response procedure was not implemented. On 12/16/2014 at 2:13 PM, the new PTAC unit in resident room 221 was observed. The Director of Maintenance stated in an interview at that time, there was black soot on the wall that was cleaned off, and the outlet and cover were replaced when the new unit was installed. He stated there were pictures of the room's wall and the melted plug. The Director of Maintenance stated he told the Administrator about the incident and had not shown him the pictures. When interviewed on 12/16/2014 at 2:15 PM maintenance staff #26 stated the PTAC unit in resident room 221 was replaced on 12/10/2014. When interviewed on 12/16/2014 at 4:30 PM, the Administrator stated he was aware there was an incident in resident room 221 where the PTAC unit overheated. He stated it was his understanding the outlet was charred and the circuit breaker had kicked the unit off. The Administrator stated he had not seen pictures of the wall or the melted plug. 3) The facility's maintenance work order log documented on 10/19/2014 in room 320, there was a burning smell, there was a short in the plug to the PTAC unit, the unit was unplugged, and a new cord was installed. On 12/16/2014 at 4:00 PM, the Director of Maintenance stated in an interview, there was an incident on 10/19/2014 with the PTAC unit in room 320 and the cord was replaced. On 11/27/2014, there were further issues with the unit, and the entire PTAC unit was replaced on 12/10/2014. When interviewed on 12/16/2014 at 4:30 PM, the Administrator stated he was not aware there was a burning odor, and a problem with the cord of the PTAC unit in room 320 on 10/19/2014. On 12/16/2014 at 12:38 PM, the Director of Maintenance stated in an interview, the facility had been replacing 2 - 3 PTAC units every few weeks and planned to replace the remaining 31 PTAC units at the same rate. On 12/16/2014 at 12:50 PM, the PTAC unit in resident room 122 was observed. When the PTAC unit was turned on, it made a buzzing sound, the fan did not turn on, the surveyor held his hand over the unit, and the heating coil become extremely hot. At that time, the Director of Maintenance stated the fan motor was seized, and should have popped the circuit breaker before the unit got too hot. He stated it was a fire risk when the circuit breaker did not pop, and he would not document that PTAC unit as being safe. On 12/16/2014 between 12:56 PM and 1:10 PM, the following was observed: - in resident room 121, the PTAC unit fan motor was not functioning; and - in resident room 120, the PTAC unit fan motor was pulsating and not functioning properly. On 12/16/2014 at 1:20 PM, resident room 112 was observed. The PTAC unit fan was not functioning, the heater was on and felt hot. When interviewed on 12/16/2014 at 2:15 PM and 3:00 PM, the Director of Maintenance stated: - there were daily walk-throughs of the resident rooms and anything wrong was entered in the maintenance logs . - All 31 PTAC units were checked within the last week and were operational. - He personally replaced all of the melted outlets and did not allow his staff to do electrical work. - There were 31 old PTAC units in use in the facility. - The PTAC units had been failing since the weather got colder and use increased. During an interview on 12/16/2014 at 3:40 PM, the Director of Maintenance provided a list of 31 resident rooms which he stated had older PTAC units. He stated the facility was replacing 2 - 3 units every few weeks, and were in the process of ordering replacements. When interviewed on 12/16/2014 at 4:30 PM, the Administrator stated he was not aware of other issues involving PTAC units since he started working at the facility three months ago such as burning plastic or melted cords. The Administrator stated if a burning odor was permeating a resident unit, he expected staff to implement the facility's fire procedures and call a code red. When interviewed on 12/16/2014 at 6:48 PM, the Administrator stated that 31 new PTAC units were going to be ordered tomorrow morning. 10NYCRR 415.12(h)

Based on interview and record review conducted during the extended survey, it was determined for 9 of 12 staff (Staff #4, 6, 11, 14, 15, 20, 21,24, and 25) interviewed regarding fire procedure, and for 3 of 3 fire events (resident rooms [ROOM NUMBER]) involving packaged terminal air conditioner (PTAC, provides heating and air conditioning) units, the facility failed to ensure employees were trained in fire procedures. Specifically, Staff #4, 6, 11, 14, 15, 20, 21, 24, and 25 did not know how to respond appropriately to a fire event upon interview; when fire incidents occurred in rooms 212, 221, 320, staff did not implement the facility's fire procedures, and the facility did not provide re-training to ensure appropriate response. This resulted in no actual harm with potential for serious harm that is Immediate Jeopardy to the health and safety of all residents residing in the facility. Findings include: The facility's current undated fire plan Policy documented to remove the resident to safety while calling out "Code Red, (location....)." Close door to fire room/area and any room connecting doors. Activate fire alarm. Call receptionist (0) to advise of location and nature of fire. Accident and incident investigation forms for 9/2014 - 12/2014 contained no documentation related to fire related incidents with resident room PTAC units. On 12/15/2014 during the resident group meeting held at 2:30 PM, Resident #17 (who resided in room [ROOM NUMBER]) stated there were fumes in her room and in the hall, from her heater. She stated the plastic on the top of the heater melted, and the fire department did not respond. Resident #3, who lived down the hall, stated he smelled the fumes in his room. On 12/16/2014 at 12:10 PM, the state-wide incident reporting system was reviewed. No incidents involving environmental issues or malfunctioning equipment were reported in 2014. When interviewed on 12/16/2014 at 12:38 PM, the Director of Maintenance stated he received a call on a recent weekend regarding the PTAC unit in room [ROOM NUMBER] and responded to the facility within 15 minutes. He stated the caller informed him Resident #17's PTAC unit had a hot cord and smelled like plastic. The Director said when he arrived, it smelled like someone blew a candle out. He stated staff did not activate the fire alarm. When interviewed on 12/16/2014 at 1:10 PM, maintenance staff #27 stated he replaced the PTAC Unit in 221 in 12/2014 following an incident where the plug was melted and charred, the outlet showed signs of charring, black soot surrounded the outlet on the wall, and the outlet was not hot. He stated staff did not activate the fire alarm. On 12/16/2014 at 2:13 PM, during an observation of the PTAC unit in resident room [ROOM NUMBER], the Director of Maintenance stated there was black soot on the wall that was cleaned off, and the outlet and cover were replaced when the new unit was installed. The work order log was reviewed on 12/16/2014 between 2:15 PM and 3:00 PM with the Director of Maintenance and the log documented on 10/19/2014 in room [ROOM NUMBER], there was a burning smell, the plug to the PTAC unit was shorting, the unit was unplugged, and a new cord was installed, During interviews conducted on 12/16/2015 from 2:50 PM - 3:15 PM: - registered nurse (RN) Managers #4 and 15 and licensed practical nurses (LPN) #6 and 25, stated if they saw a charred wall or melted electrical plug they would call maintenance. - Certified nurses aides (CNA) #10, 14, 20, 21, and 24, stated they would not pull the fire alarm if they saw a charred wall or melted electrical plug, and would notify a nurse and maintenance. When interviewed on 12/16/2014 at 3:00 PM, the RN Staff Educator stated she conducted the facility wide fire training in 6/2014 and that consisted of an educational board set-up for staff to review during the month. She stated after staff reviewed the information on the board they took a test. The board was observed by the surveyor at that time and contained information on fire (code red), code blue (unresponsive resident), smoking, and elopement. The RN stated when fire drills occurred, she participated in them like all other staff. She stated she had not been asked to provide staff training for fire procedure following any of the facility's fire drills. She stated she had not provided fire safety training for staff since 6/2014. The 2014 "Mandatory In-Service" test documented two questions related to fire safety. Identification of the facility's code for fire as code red and identification of R.A.C.E. (rescue, alarm, contain, evacuate). When interviewed on 12/16/2014 at 3:05 PM, RN Manager #15 stated she was the Supervisor on duty and was notified of a "shrunk" plug from a PTAC unit in resident room [ROOM NUMBER]. She stated the residents were removed from the room, she called maintenance, and the Maintenance Director came in. She stated the staff unplugged the PTAC unit prior to her arrival, and did not activate the fire alarm. When interviewed on 12/16/2014 at 3:15 PM, RN Manager #4 stated if smoke was visible she would have moved the resident, closed the resident room doors, and called Dr. Firestone. When interviewed on 12/16/2014 at 4:30 PM, the Administrator stated: - he had been employed by the facility for three months. - He was aware there was an incident in room [ROOM NUMBER] where the PTAC unit overheated, and it was his understanding the outlet was charred and the circuit breaker kicked off. - He was not aware of other issues involving PTAC units since he started working at the facility such as burning plastic or melted cords. - If a burning odor was permeating a resident unit, he expected staff to implement facility fire procedures and call a code red. - He stated if staff smelled melting plastic, it should be investigated and if it looked like it was related to fire, a code red was to be called. - He was not aware there was a burning odor and an issue with the cord of the PTAC unit in room [ROOM NUMBER] in 10/2014. - He was aware there had been some issues with staff response during fire drills and had spoke with the previous Director of Maintenance about the need for staff training. - The facility had been conducing more fire drills then in the past. and - He planned to review the drills, look for trends, and tailor staff training to the needs identified. 10NYCRR 415.26(f)(1)

Based on observation, staff interviews, family interviews and medical record review during a partial extended abbreviated survey (Case #NY 604), it was determined for seven (Resident #'s 1, 2, 3, 4, 5, 6 and 7) of seven residents reviewed, the facility failed to have systems in place to adequately monitor and supervise residents with unsafe wandering behaviors that have been identified as elopement risks, and to thoroughly assess and plan to protect residents from unsafe wandering. The facility also failed to ensure a system was implemented to ascertain the whereabouts of all residents at all times. Specifically, a resident with Alzheimer's Disease who routinely removed his wanderguard bracelet, was able to exit the facility and was undetected for approximately 4.5 hours. The resident was found by the police 2 to 3 miles from the facility in a stranger's home and notified his son. The facility was unaware that the resident was missing until contacted by the resident's son. Staff were aware that other residents were removing their wanderguard bracelets. No changes were made to the residents' comprehensive care plans (CCP) and no new interventions were implemented. After the elopement, the facility recognized there were problems with its system to prevent elopement and developed the following corrective measures: audits of Wanderguard (WG) checks; WGs were to be checked every shift rather than once a day; verification of WG documentation; and staff to visualize residents at the beginning of each shift. Investigation revealed that WGs were not being checked consistently and CCPs were not updated to reflect that some residents were removing their wanderguard. Certified Nurse Aides (CNA) were not aware of the new policy to visualize the whereabouts of residents at the change of shift. This resulted in no actual harm with the potential for serious harm that is Immediate Jeopardy to the health and safety of residents and Substandard Quality of Care. This is a repeat deficiency from a partial extended abbreviated survey of 4/12/10. This had the potential to affect 26 residents at risk for elopement. This was evidenced by: Finding: The Policy and Procedure (P&P) for Wandering/Elopement Risk dated 8/8/05, with revision dates of 4/10 and 4/11, documented that if a resident was assessed to be at risk for wandering, several actions were to be taken. A comprehensive care plan (CCP) was to be initiated to address factors that could contribute to the risk of wandering or elopement, with particular attention to the resident's past history and usual patterns and routines. CCP's were to be revised as needed when wandering/elopement behaviors changed, or when planned interventions were no longer effective in managing behavior. The CCP was to be reviewed if there was an event that might indicate the resident was not safe. The resident's wandering/elopement risk was to be updated on the Certified Nursing Assistant (CNA) Kardex, which the staff used to know what care each resident required. The P&P for Wanderguard System Equipment dated 12/27/10, documented that the night shift Registered Nurse Supervisor (RNS) was to check each resident's WG on a weekly basis to ensure that they were working properly and document the check in the WG Log. Each resident with a WG was to be checked once a day by the night shift Licensed Practical Nurse (LPN) to ensure that the WG was in place. This was to be documented on the Medication Administration Record (MAR). Resident #1: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident to have moderately impaired cognitive decision making skills, and was able to walk independently. The P&P for Wanderguard System Equipment dated 12/27/10 was reviewed. The Wanderguard (WG) is an alarm system usually installed on exterior doors, in hallways or on elevator doors. If a resident wearing a bracelet signaling device passes through a monitored area, an alarm sounds to alert staff of a possible departure. The P&P documented that the night shift Registered Nurse Supervisor (RNS) was to check each resident's WG on a weekly basis to ensure that they were working properly and document the check in the WG Log. Each resident with a WG was to be checked once a day by the night shift Licensed Practical Nurse (LPN) to ensure that the WG was in place. This was to be documented on the Medication Administration Record (MAR). The Elopement Risk Data form dated 2/15/11 documented that this resident was independently mobile and had a history of [REDACTED]. It was also documented that the resident paced and/or looked for relatives and expressed the need to perform outside activities. The resident was also cognitively impaired and/or demonstrated impaired decision-making skills, had verbalized that he wanted to leave the facility and that the resident tried to, or did, wander off his unit. The resident was assessed to be at risk for elopement and interventions were to be reviewed. Interventions were to be documented on the CCP and the CNA Kardex. The CCP for Cognitive Loss related to short and long-term memory loss dated 11/24/09, documented that the resident was to receive regular supervision. The CCP for Potential for Elopement dated February 2011, documented that a WG was placed on this resident on 2/15/11 because the resident had made statements that he wanted to leave the facility to see his father. Interventions on the CCP included a WG to alert staff when an elopement was in progress, staff to redirect the resident when attempts to elope were made, and to immediately initiate a missing resident alert (Code White) in case he was missing. It was also documented that the resident eloped from the facility on 3/30/11. The undated CNA Kardex documented that on 3/30/11, the resident's use of a WG was added to the document. A physician's Periodic Review note dated 3/19/11 documented that the resident had a WG placed on 2/25/11 due to an increased level of anxiety and stating that he wanted to go home. A nurses note dated 2/14/11 documented that the resident had stated that he wanted, "to go back to the hills." The resident was redirected. Review of the 24 Hour report for 2/14/11 revealed that there was no documentation that the resident had voiced thoughts of leaving the facility. A Social Services Progress Note dated 2/15/11, documented that on 2/14/11, the Social Worker (SW) spoke with this resident because he was wanting to take clothes to his father and to leave the facility. A WG was placed on the resident. A nurses note dated 2/25/11 at 2:00 pm, documented that the resident had expressed anxiety, wanted to pack his belongings and go home. A WG was applied to the resident. A Social Services Progress Note dated 2/25/11, documented that the resident was packing his belongings and stating that he wanted to leave the facility. When the SW spoke to the resident, he was confused and stated that he wanted to leave. It was also documented that the resident's WG was placed back on him because the resident had removed his WG bracelet, and security was notified. Review of the 24 Hour report for 2/25/11 revealed that there was no documentation that the resident had voiced thoughts of leaving the facility. The Weekly Wander Guard Check log dated 2/27/11 documented that there was no WG on the resident. Review of the 24 Hour report for 2/27/11 revealed that there was no WG was located on the resident. There was no evidence in the medical record that a nurses note was written to document that the resident was found on 2/27/11 to be missing the WG. Review of the Incident and Accident (I&A) Reports for 2/27/11 revealed that no report had been completed that this resident was found without a WG. The MAR dated 2/2011 revealed that there was no documentation of staff checking the resident ' s WG. A nurses note dated 3/30/11 at 5:40 pm, documented that the resident's son had notified the facility that the police were in custody of the resident, who had left the building. A nurses note dated 3/30/11 at 5:50 pm, documented that the resident was returned to the facility by the police. The resident stated that he had gone for a long walk. He was assessed by the RNS and there were no apparent injuries. A WG was to be applied to the resident. A Social Services Progress Note dated 3/31/11, documented that the resident had eloped from the facility on 3/30/11. The resident had been found in someone's home. The city police had been notified who, in turn, notified the resident's family. The resident's son then called to notify the facility, and the resident was returned safely to the facility. The resident was reminded to leave his WG on for his own safety. It was also documented that the resident had a history of [REDACTED]. A nurses note dated 3/31/11 at 6:00 am, documented that the resident was found attempting to remove his WG. The resident was redirected and the fingernail clippers he was using to attempt to remove the WG were removed from the resident. There was no documentation on the 24 Hour report for 3/31/11 that the resident had been found using fingernail clippers to attempt to remove his WG. Review of the Incident and Accident (I&A) Reports for 3/2011 revealed that no report had been completed that this resident was found attempting to remove his WG with fingernail clippers. The MAR dated 3/2011 revealed that there was no documentation of staff checking the resident ' s WG. The facility Investigation dated 3/30/11 documented that on that date, this resident was out of the building without the knowledge of the staff, from approximately 1:20 pm until 5:35 pm. The facility received a call from the resident's son at 5:35 pm on 3/30/11. The resident's son stated that the police had called him to inform him that the resident was out of the facility. The resident was returned to the facility at 5:50 pm. When the Administrator spoke to the police officer, she was informed that the resident had been found in a stranger's house approximately 2 to 3 miles away from the facility. The investigation also documented that the resident had Alzheimer's Disease and some short-term memory loss. A WG had been placed on the resident on 2/15/11 because he had voiced ideas of leaving the facility. The investigation revealed that the last time this resident could be accounted for on 3/30/11 was at 1:20 pm. The day shift CNA, CNA#1, did not check on the resident before leaving at the end of shift at 2:30 pm. CNA#2, the evening shift CNA, stated that when she arrived on shift, she checked all her residents, but did not see this resident and she assumed that he was on another floor having coffee. Under the Root Cause and Action Plan portion of the investigation, no root cause of the resident's elopement from the facility was identified. Actions that the facility were to take to prevent further elopements included: WG's were checked on all residents, audits were conducted for WG checks, the WG P&P was changed to reflect that WG placement was to be checked by LPN's every shift instead of once a day. It was also documented that the WG documentation was checked. In a written statement from a housekeeper dated 3/31/11, he documented that on that date, the resident's WG was found in the trash on 3/30/11. A memorandum dated 4/1/11 to all staff from the Administrator and the Director of Nursing (DON), documented that WG's were to be checked every shift by the LPN's. Checks were to be made while giving medications and were to be documented on the MAR's, and the WG's were already on the MAR's. If a WG was missing, it was to be replaced and a supervisor or nurse manager was to be notified. It was also documented that all staff were responsible for their assigned residents for the entire shift. CNA's were to check each of their residents when they arrive for the shift and if a resident was not present for meals, medications or on the unit at the start of a shift, the resident was to be found and accounted for. The MAR dated 4/2011 documented that the WG placement was to be checked every shift. For 41 shifts available through 4/14/11, there was no documentation of staff checking the resident's WG placement on 16 shifts. A written statement from CNA#2 dated 4/14/11, documented that she was this resident's CNA on 3/30/11. When she checked resident rooms at the beginning of the evening shift (2:30 pm), this resident was not in his room. The residents CNA Kardex did not indicate that the resident had a WG or was at risk for elopement. During an interview on 4/14/11 at 10:37 am, CNA#3 stated that before this resident eloped from the facility on 3/30/11, he frequently made statements that he wanted to leave the facility and that on several occasions prior to 3/30/11, the resident had removed his WG. When he found the resident without his WG, CNA#3 made sure that a new WG was placed on the resident. CNA#3 also stated that, to the best of his knowledge, WG placement was checked once a day. He also stated that he tried to check the whereabouts of his residents at the beginning and end of his shift, but many residents participated in activities and were often off the unit. He did not visualize residents if they were not on the unit when he checked if he knew the resident and if it was part of their routine to be at an activity or if they routinely left the unit to visit with other residents. During an interview on 4/14/11 at 10:53 am, LPN#1 stated that this resident was known to frequently remove his WG. He stated that prior to 3/30/11, the resident removed his WG frequently and he had to replace it a couple times because he could not find it. LPN#1 also stated that, while he always tried to keep track of the whereabouts of his residents, there was no requirement that residents had to be seen at any particular interval or at change of shift. During an interview on 4/14/11 at 10:44 am, RNM#1 stated that prior to this resident's elopement on 3/30/11, she only knew of 2 occasions when the resident had removed his WG bracelet. She stated that on those occasions she ensured that the WG was replaced on the resident. She did not document this on nurses notes, the 24 Hour Report or in an Incident Report because the WG was replaced and the resident had not left the facility or made an attempt to leave prior to 3/30/11. RNM#1 also stated that she did not update the resident's CCP at that time. During an interview on 4/15/11 at 4:00 pm, the DON stated that prior to 3/30/11, she was aware that this resident had been removing his WG. She stated that interventions should have been put in place and documented on the CCP because he was getting clever about removing the WG. She also stated that another contributing factor in this resident eloping on 3/30/11 was that the WG had not been documented on the CNA Kardex. CNA#2 did not usually work on this resident's unit, and the CNA told her that she always check the CNA Kardex at the beginning of her shift. When this resident was not on the unit at the beginning of the evening shift on 3/30/11, CNA#2 checked the Kardex and, because the WG was not documented, she did not know he was an elopement risk. The DON also stated that there was no P&P stating when or how often staff were to account for residents, but that it was a standard of practice to check residents at the change of shift and to know where they were. There was also no P&P in place to direct staff to obtain a head count of each resident in the facility in the event of an elopement. The DON also stated that when it was noted on the Weekly Wander Guard Check log dated 2/27/11, that there was no WG on the resident, it should have been documented on the 24 Hour Report and an I&A initiated. After the resident eloped on 3/30/11, the facility policy for checking placement of WG's was changed from once a day to every shift. She was not aware that there was no documentation of this resident's WG being checked for placement in the months of 2/11 and 3/11, or that as of 4/15/11, 16 shifts had not been documented for the month of 4/11. During an interview on 4/16/11 at 8:25 am, the Administrator stated that when the resident's son called to report that the resident had eloped from the facility and that the police were returning him to the facility, she immediately told the RNS to search the facility to see if Resident #1 was in the facility. At the same time she directed the 2nd Floor to do a head count to account for all the residents. She stated that the other units were not instructed to do a head count because the concern was the unit that the resident resided on. The Administrator also said that at the time that the resident was returned to the facility she did not know how the resident had gotten out of the building, so she directed the maintenance department to inspect and test the WG receivers and alarms mounted near the doors and they were found to be in proper working order. She stated that it did not occur to her at the time that there was a possibility that another resident could have left the facility too. A P&P was in place for staff to know what to do if a resident could not be found, but there was no P&P to do a head count once it was identified that there had been an elopement. The Administrator stated that the facility's security cameras were unable to assist in determining how the resident got out of the building. After his return to the facility, the resident repeatedly stated that he walked out the front door. The Administrator reviewed portions of the security video but not the entire video because it was too long. The Administrator's assistant reviewed the video but was unable to determine how the resident exited the building. The assistant did not take notes of the observations of the video. There were 13 security cameras around the facility, but the recording only stayed on the system for a couple days and there was no way to save or record the video. The Administrator also stated that, as the investigation into this resident's elopement developed, it became apparent that the there were problems with the facility's wandering prevention system so she implemented interventions to try to prevent recurrence of a similar incident. She stated that WG placement checks were changed from once a day to every shift by the LPN's and that these checks were to be documented on the MAR's. If a WG was missing, it was to be replaced and a supervisor or nurse manager was to be notified. She said that she would expect that the RNM's were reviewing MAR's, and that RNM#1 should have identified that, after the resident's incident on 3/30/11 there were still 16 shifts unsigned on the 4/2011 MAR for WG placement checks. The Administrator also stated that there was no P&P that directed staff to visualize or otherwise account for their residents at any particular times or intervals prior to this resident's elopement on 3/30/11. One of the facility's immediate interventions after the incident was to distribute a memorandum that documented that all staff were responsible for their assigned residents for the entire shift. CNA's were to check each of their residents when they arrive for the shift and if a resident was not present for meals, medications or on the unit at the start of a shift, the resident was to be found and accounted for. The Administrator stated that it was a standard of practice for staff to visualize residents at the very least at the beginning and end of their shift. Resident #6: The facility failed to develop a CCP with interventions to prevent potential elopement after the resident was identified to have been removing his WG. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Elopement Risk Data form dated 3/7/11 documented that this resident was independently mobile and that the resident paced and/or looked for relatives and expressed the need to perform outside activities. The resident also wandered on the unit, was cognitively impaired and/or demonstrated impaired decision-making skills, and objected to being placed in the facility. The resident was assessed to be at risk for elopement and interventions were to be reviewed. Interventions were to be documented on the CCP and the CNA Kardex. The CCP for Potential for Elopement dated 12/10, documented that a WG was placed on this resident on 12/28/10 and that he was moved to an unlocked unit. Interventions on the CCP included a WG to alert staff when an elopement was in progress, staff to redirect the resident when attempts to elope were made, and to immediately initiate a missing resident alert (Code White) in case he was missing. The undated CNA Kardex documented that on 3/8/11, the resident's use of a WG was added to the document. An untimed Social Services Note dated 2/8/11, documented that the resident had been assessed by psychiatry for suicidal thoughts. The assessment determined that the resident was not acutely suicidal, but that he was adjusting to his past lifestyle and freedoms. A nurses note dated 2/11/11 at 10:30 pm, documented that the resident was upset because he could not remain outside unattended. An untimed Social Services Note dated 3/8/11, documented that the returned from the hospital's behavioral unit. The resident stated that he was happy to be back but that he was bored. A nurses note dated 3/21/11 at 3:40 pm, documented that the resident was having increased confusion. He was removing clothes from his closet and asking where his car was. A nurses note dated 4/3/11 at 4:30 am, documented that the resident was out of bed several times, was cleaning his room and walking around the unit. The LPN was unable to redirect the resident back to bed. A nurses note dated 4/6/11 at 3:45 pm, documented that the resident continued to wander the unit during that shift. A nurses note dated 4/3/11 at 8:00 pm, documented that the resident's confusion continued and that he slept on and off through the shift. The resident refused to be redirected back to his room and he spoke of, "another place and time." An untimed Social Services Note dated 4/11/11, documented that over the weekend the resident was confused and wandering and looking for the keys to his car. The resident continued to wear a WG for safety. During an interview on 4/15/11 at 9:00 am, CNA#4 stated that this resident removed his WG at least once or twice a week. She stated that as recently as the beginning of this week, he removed his WG and tried to leave the unit. CNA#4 saw him walking away so she redirected him back to the unit and put the WG back on him. During an interview on 4/15/11 at 9:01 am, CNA#5 stated that this resident frequently removed his WG. The resident seemed to know that the WG would cause an alarm, so he would take the WG off and, "make a run for it." She stated that, to her knowledge, the resident had never actually made it off the unit. During an interview on 4/15/11 at 9:05 am, LPN#2 stated that this resident frequently removed his WG. She stated that the resident seemed to have been some kind of outdoorsman and that he frequently stated that he wanted out of the building. She also stated that the resident frequently asked for his car keys and that he wanted to leave in his car. During an interview on 4/15/11 at 2:42 pm, RNM#2 stated that before this resident went to the hospital's behavioral unit in 2/11, he was removing his WG. When he removed the WG's, they often could not be found and a new one had to be issued for him. RNM#2 stated that in 2/11 she found three WG's in this resident's dresser drawer. She stated that when a resident removed a WG, the WG's were immediately replaced. A nurses note should have been written and it should have been documented on the CCP with interventions to prevent possible elopement, but this had not been done with this resident. RNM#2 reviewed the medical record but could not provide documentation that the resident had removed his WG or that 3 of them had been found in his dresser in 2/11. During an interview on 4/15/11 at 4:00 pm, the DON stated that she was not aware that this resident had been removing his WG. She stated that if staff knew this was occurring, there should have been a nurses note, an I&A should have been completed and it should have been put on the 24 Hour Report so that it could have been discussed in morning meeting. She also stated that the RNS or RNM should have updated the CCP and CNA Kardex so that staff would know that the resident did this. Resident #5: The facility failed to develop a CCP with interventions to prevent potential elopement after the resident was identified to have been removing her WG. The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE], assessed the resident to have moderately impaired cognitive decision making skills. The Weekly Wander Guard Check log for the month of 1/2011 documented that a WG was placed on the resident on 1/24/11. The Weekly Wander Guard Check log for the month of 3/2011 documented that the resident's WG was in place and working properly on 2/6/11, 2/13/11 and 2/20/11. On 2/27/11 it was documented that the WG was not on the resident. The Weekly Wander Guard Check log for the month of 3/2011 documented that the resident's WG was in place and working properly on 3/6/11, and 3/13/11. On 3/20/11 and 3/27/11, it was documented that the WG was not on the resident. In the comments section of the log, it was documented that the resident kept cutting off the WG. The Elopement Risk Data form dated 3/31/11, documented that this resident was independently mobile and that the resident paced and/or looked for relatives and expressed the need to perform outside activities. The resident was also on a wandering unit, was cognitively impaired and/or demonstrated impaired decision-making skills and had a mental illness making her unpredictable. The resident was assessed to be at risk for elopement and interventions were to be reviewed. Interventions were to be documented on the CCP and the CNA Kardex. The undated CNA Kardex documented that the resident was to have a WG. It was also documented that the resident used a wheeled walker, and was independent in her wheel chair going to the dining room and long distances. The CCP for Potential for Elopement dated 4/14/11, documented that a WG was placed on this resident because of the Elopement Risk assessment and because she had expressed wishes to go home. It was also documented that the resident self-propelled in her wheel chair. Interventions on the CCP included a WG to alert staff when an elopement was in progress, staff to redirect the resident when attempts to elope were made, and to immediately initiate a missing resident alert (Code White) in case he was missing. It was also documented on 4/14/11, that on 3/21/11, the resident had been removing her WG. During an interview on 4/15/11 at 3:05 pm, CNA#6 stated that this resident occasionally removed her WG. She stated that this resident did not walk well anymore but she moved around the unit very well in her wheel chair. CNA#6 said that when the resident removed her WG, she put it back on the resident, but did not know it had to be reported to anyone. During an observation on 4/15/11 at 3:06 pm, this resident was wheeling herself around the unit in her wheel chair. The resident's WG was on her right wrist and she was observed pulling at the band that held the WG. The WG band was stretched out and was loosely hanging around her right wrist. During an interview on 4/15/11 at 3:15 pm, RNM#1 stated that she knew this resident occasionally removed her WG. She stated that she wrote the CCP for Elopement Risk on 4/14/11 because she was supposed to have written one before that time. She stated that she did not realize prior to 4/14/11 that this resident did not have a CCP for Elopement Risk and did not realize that it was not on her CNA Kardex. She also stated that on prior occasions when the resident removed her WG, she did not document it in a nurses note and did not complete an I&A because she was not aware that an I&A was necessary. During an interview on 4/14/11 at 2:00 pm, the DON stated that, after the Department of Health arrived on 4/14/11, she noticed that this resident did not have a CCP and she instructed RNM#1 to put one in place. The DON stated that she did not know why previous audits of this resident's medical record did not identify that the resident did not have an elopement CCP in place, or that it was not on the resident's CNA Kardex. The DON stated that after Resident#1 eloped on 3/30/11, RNM's were supposed to audit the wandering prevention system to include assessments, CCP's, MAR's and CNA Kardexes. She did not realize that this had not been thoroughly accomplished. Resident #3: The facility failed to ensure that the resident's WG was checked for placement in accordance with P&P. The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE], assessed the resident to be cognitively intact. After Resident #1 eloped on 3/30/11, the Administration and the DON issued a memorandum to all staff dated 4/1/11. The memorandum documented that WG's were to be checked every shift by the LPN's. Checks were to be made while giving medications and were to be documented on the MAR's, and the WG's were already on the MAR's. If a WG was missing, it was to be replaced and a supervisor or nurse manager was to be notified. The P&P for Wanderguard System Equipment dated 4/1/11, documented that each resident with a WG was to be checked every shift by an LPN to ensure that the WG was in place. This was to be documented on the MAR. The Elopement Risk Data form dated 3/2/11 documented that this resident scored 15 points on this assessment. A score greater than 5 points indicated that a resident was assessed to be at risk for elopement and interventions were to be reviewed. Interventions were to be documented on the CCP and the CNA Kardex. The CCP for Potential for Elopement dated 4/14/11, documented that a WG was placed on this resident on 3/2/11. Interventions on the CCP included a WG to alert staff when an elopement was in progress, staff to redirect the resident when attempts to elope were made, and to immediately initiate a missing resident alert (Code White) in case he was missing. The undated CNA Kardex documented that the resident was independent with mobility in her wheel chair and was to have a WG in place. The resident was also compulsive, resistive to care, and the resident was to be checked hourly. The MAR dated 4/2011 documented that the WG placement was to be checked every night. There was no documentation of staff checking the resident's WG placement on 4/8, 9, 11, 12, and 13. The MAR was not updated to reflect the change in P&P to WG placement being checked every shift until 4/14/11. During an interview on 4/15/11 at 3:15 pm, RNM#1 stated that after Resident#1 eloped on 3/30/11, interventions were put in place to try to prevent similar incidents. One of the interventions was that WG's were to be checked every shift instead of once a day. She stated that she did not check the MAR's on her unit because other staff had been assigned to do that. She stated that it had been reported to her that when the MAR's were reviewed, resident's WG's were being checked every shift. She also stated that she did not realize this resident did not have a CCP for Elopement Risk until 4/14/11. During an interview on 4/16/11 at 8:25 am, the Administrator stated that after Resident#1 eloped from the facility on 3/30/11, interventions were immediately put in place to try to prevent a similar occurrence. One of the interventions was that WG's were to be checked every shift instead of once a day. After the elopement, the facility was in crisis mode and she divided various tasks to staff, including RN

Based on observation, record review and staff interview, the administrator failed to ensure that the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well being for each resident, during a partial extended abbreviated survey (#NY 604). Specifically, a resident with [MEDICAL CONDITION] who routinely removed his wanderguard bracelet, was able to exit the facility and was undetected for approximately 4.5 hours. The resident was found by the police 2 to 3 miles from the facility in a stranger's home and notified his son. The facility was unaware that the resident was missing until contacted by the resident's son. The facility recognized there were problems with its system to prevent elopement and took the following corrective measures: audits of wanderguard checks; Wanderguards to be checked once per shift rather than once per day; verification of wanderguard documentation; and staff to visualize residents at the beginning of each shift. Investigation revealed that Wanderguards are not being checked consistently and Comprehensive Care Plans (CCPs) were not updated to reflect that some residents are removing their wanderguard (WG). Certified nurse aides (CNA) were not aware of the new policy to visualize the whereabouts of residents at the change of shift. Neither the Administrator nor the Director of Nursing were aware that interventions that were put in place on 4/1/11 were not being implemented. This resulted in no actual harm but had the potential for serious harm that is Immediate Jeopardy to residents health and safety and Substandard Quality of Care. This is a repeat deficiency from a partial extended abbreviated survey from 4/12/10. This had the potential to affect 26 residents at risk for elopement. This is evidenced by: Accidents and Supervision - F323 Scope/Severity K After Resident #1 eloped from the facility on 3/30/11, a memorandum dated 4/1/11 to all staff from the Administrator and the Director of Nursing (DON), documented that WG's were to be checked every shift by the LPN's. The WG was to be checked while giving medications and were to be documented on the MAR's. If a WG was missing, it was to be replaced and a supervisor or nurse manager was to be notified. It was also documented that all staff were responsible for their assigned residents for the entire shift. CNA's were to check each of their residents when they arrive for the shift and if a resident was not present for meals, medications or on the unit at the start of a shift, the resident was to be found and accounted for. During an interview on 4/15/11 at 4:00 pm, the DON stated that there was no P&P stating when or how often staff were to account for residents, but that it was a standard of practice to check residents at the change of shift and to know where they were. There was also no P&P in place to direct staff to obtain a head count of each resident in the facility in the event of an elopement. The DON also stated that after Resident #1 eloped on 3/30/11, the facility policy for checking placement of WG's was changed from once a day to every shift. She was not aware that there was no documentation of this Resident #1's WG being checked for placement in the months of 2/11 and 3/11, or that as of 4/15/11, 16 shifts had not been documented for the month of 4/11. During an interview on 4/16/11 at 8:25 am, the Administrator stated that, as the investigation into Resident #1's elopement developed, it became apparent that the there were problems with the facility's wandering prevention system so she implemented interventions to try to prevent recurrence of a similar incident. She stated that WG placement checks were changed from once a day to being checked every shift by the LPN's and that these checks were to be documented on the MAR's. If a WG was missing, it was to be replaced and a supervisor or nurse manager was to be notified. She said that she would expect that the RNM's were reviewing MAR's, CCP's and CNA Kardexes to ensure consistent and thorough documentation. The Administrator also stated that there was no P&P that directed staff to visualize or otherwise account for their residents at any particular time or intervals prior to this resident's elopement on 3/30/11. One of the facility's immediate interventions after the incident was to distribute a memorandum that documented that all staff were responsible for their assigned residents for the entire shift. CNA's were to check each of their residents when they arrive for the shift and if a resident was not present for meals, medications or on the unit at the start of a shift, the resident was to be found and accounted for. The Administrator stated that it was a standard of practice for staff to visualize residents at the very least at the beginning and end of their shift. 10NYCRR415.26

Based on record review and staff interview, the facility failed to have a Quality Assurance(QA) program that readily identified issues that have the potential to cause serious harm to residents reviewed during a partial extended abbreviated survey (Case #NY 604). Specifically, for 7 (#'s 1, 2, 3, 4, 5, 6 and 7) of 7 residents reviewed, the facility failed to ensure that effective Quality Assurance systems were in place to monitor the effectiveness of facility policies and practices related to unsafe wandering. This resulted in Immediate Jeopardy and Substandard Quality of Care to the health and safety of residents and had the potential to effect all 26 residents assessed to be at risk for elopement. The findings were as follows: Accidents and Supervision F 323 Scope and Severity K During an interview on 4/16/11 at 8:25 am, the Administrator stated that she was the head of the QA Committee. She stated that QA initiatives relative to elopement in the past year had focused on ensuring that the Wanderguard (WG) system was working properly, staff were educated on knowing what to do if a WG alarm sounded, and elopement drills. After Resident #1 eloped from the facility on 3/30/11, a memorandum dated 4/1/11 to all staff from the Administrator and the Director of Nursing (DON), documented that WG's were to be checked every shift by the LPN's. The WG was to be checked while giving medications and were to be documented on the MAR's. If a WG was missing, it was to be replaced and a supervisor or nurse manager was to be notified. It was also documented that all staff were responsible for their assigned residents for the entire shift. CNA's were to check each of their residents when they arrive for the shift and if a resident was not present for meals, medications or on the unit at the start of a shift, the resident was to be found and accounted for. The Administrator also stated that after these interventions were put in place, the QA Committee did not develop an audit tool or assess the implementation of the interventions until the Department of Health arrived in the facility on 4/14/11 10 NYCRR 415.27(a-c)