Every finding on record at Palm Gardens Center for Nursing and Rehabilitation

Based on record review and interviews conducted during the Recertification survey, the facility did not ensure there was sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the Payroll Based Journal Staffing Data report for 3rd Quarter 2025 triggered for low weekend staffing and review of staffing indicated that actual staffing levels were not maintained at par levels indicated in the Facility Assessment.The findings are:The facility policy titled Staffing Levels with review date of 08/2025 stated it is the policy of the facility that staffing levels in Palm Gardens will be adequate to provide nursing care to our residents 24/7.The Payroll Based Journal (PBJ) Staffing Data Report dated Fiscal Year (FY) Quarter 3 2025 (April 1- June 30) documented the facility triggered for the metric of excessively low weekend staffing.The facility document titled Facility Assessment Tool, dated 09/2025, documented a staff to resident ratio with the number of staff required to work on each unit. The Facility Assessment Tool also documented the par level of staffing to ensure a sufficient number of qualified staff are available to meet each resident's needs and the Unit Staffing as follows: 7:00 AM to 3:00 PM shift:2nd floor unit staffing: 2 Registered Nurses, 2 Licensed Practical Nurses, and 6 Certified Nursing Assistants3rd floor unit staffing: 1-2 Registered Nurses, 2 Licensed Practical Nurses, and 6 Certified Nursing Assistants4th floor unit staffing: 1 Registered Nurse, 2 Licensed Practical Nurses, and 5-6 Certified Nursing Assistants5th floor unit staffing: 1 Registered Nurse, 1 Licensed Practical Nurse, and 5-6 Certified Nursing Assistants 6th floor unit staffing: 1 Registered Nurse, 1 Licensed Practical Nurse, and 5-6 Certified Nursing Assistants7th floor unit staffing: 1 Registered Nurse, 2 Licensed Practical Nurses, and 5-6 Certified Nursing Assistants. 3:00 PM to 11:00 PM shift:2nd floor unit staffing: 1 Registered Nurse, 2 Licensed Practical Nurses and 6 Certified Nursing Assistants3rd floor unit staffing: 1 Registered Nurse, 2 Licensed Practical Nurses, 5 Certified Nursing Assistants4th floor unit staffing: 2 Registered Nurses or 2 Licensed Practical Nurses and 5-6 Certified Nursing Assistants5th floor unit staffing: 1 Registered Nurse or 1 Licensed Practical Nurses and 5 Certified Nursing Assistants6th floor unit staffing: 1 Registered Nurse or 1 Licensed Practical Nurse and 5 Certified Nursing Assistants7th floor unit staffing: 2 Registered Nurses or 2 Licensed Practical Nurses and 5 Certified Nursing Assistants. 11:00 PM to 7:00 AM shift:2nd floor unit staffing: 1 Registered Nurse, 2 Licensed Practical Nurses, and 4 Certified Nursing Assistants3rd floor unit staffing: 1 Registered Nurse, 2 Licensed Practical Nurses and 4 Certified Nursing Assistants4th floor unit staffing: 2 Registered Nurses or 2 Licensed Practical Nurses, and 4 Certified Nursing Assistants5th floor unit staffing: 1 Registered Nurse or 1 Licensed Practical Nurse and 3 Certified Nursing Assistants6th floor unit staffing: 1 Registered Nurse or 1 Licensed Practical Nurse and 3 Certified Nursing Assistants7th floor unit staffing: 1 Registered Nurse or 1 Licensed Practical Nurse and 3 Certified Nursing Assistants Review of staffing information dated 04/05/2025 to 04/27/2025 documented the following: On 04/05/2025 on the 7:00 AM to 3:00 PM, shift the 2nd Floor and 4th floor were short 1 Licensed Practical Nurse. On 04/06/2025 on the 7:00 AM to 3:00 PM shift, the 2nd floor was short 1 Registered Nurse.On 04/06/2025 on the 3:00 PM to 11:00 PM shift, the 2nd floor and 3rd floor were short 1 Licensed Practical Nurse.On 04/06/2025 on the 11:00 PM to 7:00 AM shift, the 2nd floor and 3rd floor were short 1 Licensed Practical Nurse.On 04/12/2025 on the 7:00 AM to 3:00 PM shift, the 2nd floor was short 1 Registered Nurse, and the 3rd floor was short 1 Licensed Practical Nurse.On 04/12/2025 on the 3:00 PM to 11:00 PM shift, the 3rd floor was short 1 Licensed Practical Nurse.On 04/13/2025 on the 7:00 AM to 3:00 PM shift, the 2nd floor was short 1 Registered Nurse.On 04/13/2025 on the 3:00 PM to 11:00 PM shift, the 2nd floor was short 1 Licensed Practical Nurse.On 04/13/2025 on the 11:00 PM to 7:00 AM shift, the 2nd floor was short 1 Licensed Practical Nurse.On 04/19/2025 on the 7:00 AM to 3:00 PM shift, the 2nd floor was short 1 Registered Nurse, the 3rd floor was short 2 Registered Nurses, and the 4th floor was short 1 Licensed Practical Nurse.On 04/19/2025 on the 3:00 PM to 11:00 PM shift, the 2nd floor was short 1 Licensed Practical Nurse, and the 3rd floor was short 1 Registered Nurse.On 04/19/2025 on the 11:00 PM to 7:00 AM shift, the 2nd floor was short 1 Licensed Practical Nurse.On 04/20/2025 on the 7:00 AM to 3:00 PM shift, the 2nd floor was short 1 Registered Nurse, the 3rd floor and 6th floor were short 1 Certified Nursing Assistant, and the 7th floor was short 2 Certified Nursing Assistants. On 04/20/2025 on the 3:00 PM to 11:00 PM shift, the 2nd floor and 3rd floor were short 1 Licensed Practical Nurse, and the 3rd and 4th floor were short 1 Certified Nursing Assistant. On 04/20/2025 on the 11:00 PM to 7:00 AM shift, the 2nd floor 3rd floor were short 1 Licensed Practical Nurses, and the 5th floor and 6th floor were short 1 Certified Nursing Assistant. On 04/26/2025 on the 3:00 PM to 11:00 PM shift, the 3rd floor was short 1 Licensed Practical Nurse.On 04/26/2025 on the 11:00 PM to 7:00 AM shift, the 3rd floor was short 1 Licensed Practical Nurse, and the 4th floor was short 1 Certified Nursing Assistant.On 04/27/2025 on the 3:00 PM to 11:00 PM shift, the 2nd floor and 3rd floor were short 1 Licensed Practical Nurse.On 04/27/2025 on the 11 PM to 7:00 AM shift, the 2nd floor was short 1 Licensed Practical Nurse, and the 3rd floor was short 1 Registered Nurse. Review of staffing information dated 05/03/2025 to 05/31/2025 documented the following: On 05/03/2025 on the 7:00 AM to 3:00 PM shift, the 2nd floor was short 1 Licensed Practical Nurse and 1 Registered Nurse, and the 5th floor was short 1 Certified Nursing Assistant.On 05/03/2025 on the 3:00 PM to 11:00 PM shift, the 5th floor was short 1 Certified Nursing Assistant. On 05/04/2025 on the 7:00 AM to 3:00 PM shift, the 3rd floor was short 1 Certified Nursing Assistant. On 05/04/2025 on the 3:00 PM to 11:00 PM shift, the 3rd floor was short 1 Registered Nurse.On 05/04/2025 on the 11:00 PM to 7:00 AM shift, the 3rd floor was short 1 Registered Nurses, and the 4th floor was short 1 Certified Nursing Assistant. On 05/10/2025 on the 7:00 AM to 3:00 PM shift, the 2nd floor was short 1 Licensed Practical Nurse.On 05/10/2025 on the 3:00 PM to 11:00 PM shift, the 2nd floor was short 1 Registered Nurse, and the 3rd floor was short 1 Licensed Practical Nurse.On 05/10/2025 on the 11:00 PM to 7:00 AM shift, the 4th floor was short 1 Certified Nursing Assistant. On 05/11/2025 on the 3:00 PM to 11:00 PM shift, the 2nd floor and 3rd floor were short 1 Licensed Practical Nurses, and the 7th floor was short 1 Certified Nursing Assistant. On 05/11/2025 on the 11:00 PM to 7:00 AM shift, the 3rd floor was short 1 Registered Nurse, 2 Licensed Practical Nurses, and 1 Certified Nursing Assistant. On 05/12/2025 on the 3:00 PM to 11:00 PM shift, the 2nd floor was short 1 Licensed Practical Nurse.On 05/12/2025 on the 11:00 PM to 7:00 AM shift, the 2nd floor was short 1 Licensed Practical Nurse. On 05/17/2025 on the 7:00 AM to 3:00 PM shift, the 2nd floor and 3rd floor were short 1 Licensed Practical Nurse. On 05/18/2025 on the 7:00 AM to 3:00 PM shift, the 2nd floor was short 1 Licensed Practical Nurse, and the 3rd floor was short 1 Registered Nurse. On 05/18/2025 on the 3:00 PM to 11:00 PM shift, the 2nd floor and 3rd floor were short 1 Licensed Practical Nurse, and the 7th floor was short 1 Certified Nursing Assistant. On 05/11/2025 on the 11:00 PM to 7:00 AM shift, the 2nd floor and 3rd floor were short 1 Licensed Practical Nurse, and the 4th floor, 5th floor, 6th floor were short 1 Certified Nursing Assistant. On 05/24/2025 on the 3:00 PM to 11:00 PM shift, the 2nd floor and 4th floor were short 1 Certified Nursing Assistant. On 05/25/2025 on the 11:00 PM to 7:00 AM shift, the 3rd floor was short 1 Licensed Practical Nurse.On 05/31/2025 on the 7:00 AM to 3:00 PM shift, the 2nd and 4th floor were short 1 Licensed Practical Nurse.On 05/31/2025 on the 3:00 PM to 11:00 PM shift, the 7th floor was short 1 Certified Nursing Assistant.On 05/31/2025 on the 11:00 PM to 7:00 AM shift, the 2nd floor was short 1 Licensed Practical Nurses, and the 4th floor and 6th floor were short 1 Certified Nursing Assistant. Review of staffing information dated 06/01/2025 to 06/29/2025 documented the following: On 06/01/2025 on the 3:00 PM to 11:00 PM shift, the 7th floor was short 1 Certified Nursing Assistant. On 06/01/2025 on the 11:00 PM to 7:00 AM shift, the 2nd floor was short 1 Licensed Practical Nurse, and the 3rd floor was short 1 Registered Nurse.On 06/07/2025 on the 7:00 AM to 3:00 PM shift, the 2nd floor, 3rd floor, and 4th floor were short 1 Licensed Practical Nurses, and the 3rd floor was short 1 Certified Nursing Assistant.On 06/07/2025 on the 3:00 PM to 11:00 PM shift, the 2nd floor and 3rd floor were short 1 Licensed Practical Nurse.On 06/07/2025 on the 11 PM to 7:00 AM shift, the 4th floor and 7th floor were short 1 Certified Nursing Assistant. On 06/08/2025 on the 7:00 AM to 3:00 PM shift, the 2nd floor was short 1 Registered Nurse.On 06/08/2025 on the 3:00 PM to 11:00 PM shift, the 3rd floor was short 1 Certified Nursing Assistants, and 1 Licensed Practical Nurse.On 06/08/2025 on the 11:00 PM to 7:00 AM shift, the 2nd floor was short 1 Licensed Practical Nurse, the 3rd floor was short 1 Registered Nurse, and the 4th floor was short 1 Certified Nursing Assistant. On 06/14/2025 on the 3:00 PM to 11:00 PM shift, the 2nd floor was short 1 Licensed Practical Nurse. On 06/14/2025 on the 11:00 PM to 7:00 AM shift, the 4th floor was short 1 Certified Nursing Assistant.On 06/15/2025 on the 7:00 AM to 3:00 PM shift, the 2nd floor was short 1 Licensed Practical Nurse.On 06/22/2025 on the 3:00 PM to 11:00 PM shift, the 2nd floor was short 1 Licensed Practical Nurse.On 06/22/2025 on the 11:00 PM to 7:00 AM shift, the 3rd floor was short 1 Licensed Practical Nurse.On 06/28/2025 on the 3:00 PM to 11:00 PM shift, the 2nd floor was short 1 Licensed Practical Nurse, and the 3rd floor was short 1 Registered Nurse.On 06/28/2025 on the 3:00 PM to 11:00 PM shift, the 2nd floor was short 1 Licensed Practical Nurse and the 3rd floor was short 1 Registered Nurse.On 06/28/2025 on the 11:00 PM to 7:00 AM shift, the 2nd floor was short 1 Licensed Practical Nurse.On 06/29/2025 on the 7:00 AM to 3:00 PM shift, the 2nd floor was short 1 Licensed Practical Nurse, and the 3rd floor was short 2 Registered Nurses. On 06/29/2025 on the 3:00 PM to 11:00 PM shift, the 2nd floor was short 1 Licensed Practical Nurse. On 09/16/2025 at 9:59 AM, the Staffing Coordinator was interviewed and stated in the morning they check to see if there were any sick calls and work on the monthly schedule and find replacement if there are call outs. The Staffing Coordinator also stated if there is a shortage of nursing staff, the certified nurse assistants will get moved around from different floors depending on the census; a replacement cannot be found every time so we sometimes will work short. The Staffing Coordinator further stated sick calls happen mostly on the weekends and they have been trying to schedule extra people, so the weekend shortage is better now than it was before. The Staffing Coordinator stated between April and June of 2025, the facility had been working short of staff as the registered nurses and certified nurse assistants were leaving or resigning and going to other places. Facility staff was doing double shifts, and more agency staff were used and this worked for a little bit, but then sometimes the staff would call out at the last minute. The Staffing Coordinator also stated they work with the administrator and the Director of Nursing to look for agency staff to accommodate the shortage. On 09/18/2025 at 12:31 PM, the Director of Nursing was interviewed and stated the facility has the same amount of staffing on weekends as during the week, and the only thing they can think of is that there were call outs and staff taking off for vacation, but they tried to replace the staff. The Director of Nursing also stated on the weekend the supervisors try to replace the call outs but if it is more than 3 call outs, it may be difficult to replace all 3 of the call outs. The Director of Nursing further stated they have some nursing staff that work only on the weekends, and some staff do double shifts, and the facility is always trying to recruit staff but when they are trained and put on the floor, they will leave and never come back. The Director of Nursing stated the facility works with 11 different contracted agencies, and they have daily interviews, and the Staffing Coordinator works very hard to make sure that the facility is fully staffed. 10 NYCRR 415.13(a)(1)(i-iii)

Based on observation and interviews conducted during the Recertification survey, the facility did not ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety. This was evident during the Kitchen task. Specifically, Dietary staff were observed not wearing hair restraint appropriately while performing tasks in the kitchen. The findings include:The facility policy on Dietary Uniform Code with a revised date of 06/15/2025 stated all employees when working in the dietary department will wear a hairnet/hair restraint as per policy. This hairnet/hair restraint will cover all hair. [NAME] and facial hair should be contained. On 09/14/2025 at 09:23 AM, the Food Service Director was observed wearing a baseball cap with some hair sticking out of the baseball cap. On 09/14/2025 at 09:25 AM, [NAME] #1, was near the kitchen table assisting in wrapping tuna sandwiches. [NAME] #1 was observed wearing a baseball hat that ended above both ears and all of their hair was not restrained and was sticking out under the baseball cap. On 09/14/2025 at 09: 35 AM, Dietary Aide #1 was standing adjacent to the kitchen table assisting in wrapping sandwiches. Dietary Aide #1 was observed wearing a baseball cap and all of their hair was not restrained and was sticking out under the baseball cap.On 09/14/2025 at 09:37 AM, Dietary Aide #2 was standing near an open pot on the stove. Dietary Aide #2 was observed wearing a baseball cap and all of their hair was not restrained and was sticking out under the baseball cap.On 09/14/2025 at 09:44 AM, Dietary Aides #3 and #4 were observed near the kitchen door carrying food containers. Neither dietary aide was wearing a hair restraint. A box of hair nets was observed on a wall at the entrance to the Kitchen.On 09/15/2025 at 10:55 AM, the Food Service Director was interviewed and stated they always wear a baseball hat and did not realize some hair was not covered, however they will use the hair net to completely cover their hair. The Food Service Director also stated to ensure compliance they randomly check their staff to ensure correct application of hair nets or hair coverings that must fully cover the entire hair. On 09/16/2025 at 11:45 AM, [NAME] #1 was interviewed and stated they thought a baseball cap was acceptable to wear in the kitchen since they see the Food Service Director wear a baseball cap.On 09/16/2025 at 12:04 PM, Dietary Aide #1 was interviewed and stated they thought the baseball hat is acceptable to wear while helping in the kitchen and did not realize some of their hair was sticking out of the baseball hat. On 09/16/2025 at 12:10 PM, Dietary Aide #2 was interviewed and stated they were wearing baseball cap but when they saw the surveyor they changed it immediately to a hairnet.On 09/19/2025 at 01:24 PM, the Administrator was interviewed stated they were made aware that some kitchen staff were not wearing appropriate hair covering while preparing food for the residents which is not acceptable. The Administrator further stated the Food Service Director must ensure kitchen staff wears appropriate and complete hair covering at all times while in the kitchen for safety and to avoid hair accidentally falling while preparing food. 10 NYCRR 415.14 (h)

Based on observations and staff interviews conducted during the Recertification survey, the facility did not ensure that each resident was treated with respect, dignity and care in a manner that promotes maintenance or enhancement of their quality of life and recognizes each resident's individuality. This was evident for one (1) out of six (6) units (Unit 7) observed. Specifically, 6 (six) out of 38 residents (Resident #64, #85, #38, #245, #248 and #11) on the 7th floor, were served meals in a disposable 3 (three) compartment white colored foam containers with disposable plastic cutlery. The findings are:The facility policy titled Resident Rights, with review date of 08/2025, stated the resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. The admission Minimum Data Set 3.0 assessment for Resident #64 dated 07/21/2025 documented Resident #64 had moderate cognitive impairment and required dependent assistance with eating. The Quarterly Minimum Data Set 3.0 assessment dated [DATE] documented Resident #85 had severe cognitive impairment and required dependent assistance with eating. The Quarterly Minimum Data Set 3.0 assessment dated [DATE] documented Resident #38 had severe cognitive impairment and required supervision or touching assistance with eating.The Quarterly Minimum Data Set 3.0 assessment dated [DATE] documented Resident #248 had severe cognitive impairment and required supervision or touching assistance with eating.The admission Minimum Data Set 3.0 assessment dated [DATE] documented Resident #113 had intact cognition and required set up assistance with eating. There was no documented evidence Residents #64, #85, #38, #248 or #11 required the use of plastic or disposable dinnerware for medical or behavioral reasons. On 09/14/2025 at 12:12 PM, during an observation of the lunch meal on the 7th floor, 1 (one) meal truck with 11(eleven) lunch trays arrived on the unit. 4 (four) of the 11 (eleven) meal trays had a white foam 3 (three) compartment disposable container, white colored plastic utensils in a plastic seal, cold liquids that were poured into white foam disposable cups, and white foam disposable bowls that contained soup. On 9/15/2025 at 12:20 PM, during another observation of the lunch meal on the 7th floor, the meal truck was observed to have 4 (four) white foam containers that contained pureed/chopped food, along with plastic eating utensils (spoon, fork, knife, and napkin) and white foam cups and bowls that had hot and cold liquids inside.On 09/15/2025 at 12:30 PM, the 2nd food truck arrived on the 7th floor and was observed to have 3 (three) white foam 3 (three) compartment containers that had pureed/chopped food. Residents were observed using white plastic utensils and drinking liquids out of a white foam cups and white foam bowls holding soup.On 09/17/2025 at 10:16 AM, in the hallway near the kitchen 10 (ten) brown cardboard boxes that contained multiple 3-part compartment Styrofoam containers were observed.On 09/17/2025 at 11:30 AM, the lunch meal tray line was observed in the kitchen and some meals were plated in a white foam 3 (three) compartment disposable containers, other meals were plated on ceramic plates, and hot soup was placed in white foam containers and covered with a plastic lid. In addition, 4 in 1 plastic disposable utensil kits that contained a spoon, knife, fork, and napkin were placed on all meal trays. On 09/17/2025 at 09:52 AM, Certified Nursing Assistant #2 was interviewed and stated residents always use plastic forks and eat out of the plastic containers. Certified Nursing Assistant #2 also stated the residents who require chopped and puree food receive their meals in plastic containers. Certified Nursing Assistant #2 further stated they had worked at the facility for 10 years, and meals had always been served this way. On 09/17/2025 at 10:02 AM, Registered Nurse #2 was interviewed and stated residents have always received soup and hot cereal in plastic bowls, water in plastic cups and meals in white foam compartment containers. Registered Nurse #2 also stated meals have always been served this way and it may be for safety reasons. The Significant Change in Status Minimum Data Set 3.0 assessment dated [DATE] documented Resident #245 was cognitively intact and required partial/moderate assistance with eating.On 09/17/2025 at 12:30 PM, Resident #245 was interviewed and stated that this is the way meals are served at the facility. On 09/17/2025 at 11:45 AM, the Food Service Director was interviewed and stated that the facility has been using the plastic disposable cutlery and dishware since the COVID-19 pandemic. The Food Service Director also stated the 3-compartment food container is used for pureed food because the food runs into each other when on a regular plate. The Food Service Director further stated this item is also used for residents on contact isolation and for visitors. On 09/17/2025 at 2:07 PM, the Director of Nursing was interviewed and stated during the COVID-19 pandemic the facility was using the disposable dishware and utensils. The Director of Nursing also stated they were not sure why they continued to use disposable food items. On 09/18/2025 at 10:45 AM, the Registered Dietitian was interviewed and stated residents have not complained about using the disposable utensils/dishware during Resident Council meetings. The Registered Dietitian also stated disposable utensils have been in use for the eight years they have been at the facility. The Registered Dietitian further stated most residents receive their food on a ceramic plate with the dome covering, and resident's receiving a pureed diet get the three (3) compartment disposable containers and disposable utensils.On 09/18/2025 at 11:54 AM, the Administrator was interviewed and stated the residents complained the pureed foods were getting mixed up/running into each other when on a regular plate, so they tried to purchase plates that had sections, but they did not fit under the dome to keep the food hot. The Administrator also stated the residents requested this and they had not complained about using disposable dishware/utensils. 10 NYCRR 415.3 (d)(1)(i)

Number of residents sampled: 5Number of residents cited: 1 Based on record review and interviews conducted during the Recertification survey the facility did not ensure that the drug regimen of each resident was reviewed at least once a month by a Licensed Pharmacist. This was evident for 1 of 5 residents (Resident #14) reviewed for Unnecessary Meds, Chemical Restraints/Psychotropic Meds, and Med Regimen Review out of an investigative sample of 38 residents. Specifically, there was no documented evidence the Medication Regimen Review for Resident #14 was completed in August 2025.The findings are:The facility's policy entitled Medication Regimen Review last reviewed 8/2025 stated the drug regimen of each resident must be reviewed at least once a month by a Licensed Pharmacist. The policy further stated the review must include a review of the resident's chart, including residents on psychotropic medications. Resident #14 was admitted to the facility with diagnosis including Larynx Cancer, Heart Failure, Seizure Disorder Depression, and Schizophrenia. The Significant Change in Status Minimum Data Set assessment dated [DATE] documented Resident #14 was moderately impaired and was receiving antipsychotic, antianxiety, antidepressant, antiplatelet, hypoglycemic, and anticonvulsant medication. The Physician orders last reviewed 08/27/2025 documented orders for Risperidone 1 mg tablet give two tablets (2 mg) by oral route every 12 hour for Schizophrenia, Lantus Solostar U-100 Insulin 100 unit/mL (3 mL) subcutaneous pen inject 20 units by subcutaneous route once daily at bedtime, and Venlafaxine 100 mg tablet give 1 tablet (100 mg) by oral route 2 times per day. The Pharmacy progress notes dated 3/22/2025, 4/28/2025, 05/26/2025, 06/19/2025, 7/31/2025, and 9/16/2025 documented based upon the information available at the time of the review, and assuming the accuracy and completeness of such information it is my professional judgment that at such time, the resident's medication regimen contained no new irregularities. There was no documented evidence a pharmacy review had been completed for Resident #14 in August 2025. During a telephone interview on 09/17/2025 at 10:18 AM, the Consultant Pharmacist stated they are responsible for doing monthly, admission, and readmission medication reviews for the facility. The Consultant Pharmacist also stated they usually check the medical records, and when reviewing for Resident #14 they noticed the review was not documented in the medical record. The Consultant Pharmacist further stated they recall looking at Resident #14's chart and there were no irregularities, but they forgot to document in the medical record. The Consultant Pharmacist stated this was just a human error. During an interview on 09/16/2025 at 10:15 AM, the Director of Nursing stated the Pharmacy Consultant comes every month and reviews the charts of the residents. The Director of Nursing also stated the Pharmacist was in the building, and they are not sure what happened with the review of Resident #14's and why it was missed. The Director of Nursing further stated the Consultant Pharmacist comes every month and they did not know the review was missed until the surveyor brought this issue to their attention. 10 NYCRR 415.18(c)(2)

Number of residents sampled: 4Number of residents cited: 1 Based on observation, record review, and interviews conducted during the Recertification survey, the facility did not ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice. This was evident for one (1) out of four (4) residents (Resident #33) reviewed for Respiratory Care out of 38 sampled residents. Specifically, Resident #33 was observed on multiple occasions using oxygen with an undated nasal cannula. The findings are: The facility's policy titled Oxygen Administration last reviewed 08/2025 stated oxygen tubing is changed weekly. The policy also stated the facility will provide the means to safely administer oxygen therapy to those residents requiring it.Resident #33 had diagnoses which included Heart failure and Essential Hypertension. The admission Minimum Data Set, dated [DATE] documented Resident #33 was cognitively intact and received oxygen therapy while residing at the facility. The Interdisciplinary Care Plan titled 'Alteration in Cardiovascular Function or Decrease in Cardiac Output' with effective date 06/25/2025 documented to provide oxygen as ordered by medical doctor and teach oxygen conservation techniques. The Physician's Order dated 06/24/2025 documented Resident #33 was to receive oxygen via nasal cannula at a rate of 2 liters per minute continuously. On 09/14/2025 at 10:46 AM, Resident #33 was observed resting in bed and wearing an undated nasal cannula attached to the concentrator next to the right side of bed while receiving oxygen at a rate of 2 liters per minute. Resident #33 was interviewed and stated that they could not recall the last time their nasal cannula was changed. During multiple observations from 09/14/2025 at 10:46 AM to 09/15/2025 at 12:14 PM, Resident #33 was observed resting in their bed and wearing an undated nasal cannula attached to the concentrator on the right side of their bed.On 09/15/2025 at 12:15 PM, Licensed Practical Nurse #1 was interviewed and stated Resident #33 received oxygen therapy due to heart failure. Licensed Practical Nurse #1 also stated the nasal cannula tubing had to be changed every three (3) days, and they were not aware the nasal cannula tubing had to be dated. Licensed Practical Nurse #1 further stated they did not know when the nasal cannula tubing was last changed. Licensed Practical Nurse #1 stated they worked on the unit yesterday 09/14/2025 and today 09/15/2025 and would change the nasal cannula tubing by the end of the shift.On 09/15/2025 at 12:39 PM, Registered Nurse #1 was interviewed and stated Resident #33 had an order to receive continuous oxygen at a rate of 2 liters per minute. Registered Nurse #1 also stated the night shift nurse was responsible to change and date the nasal cannula tubing once a week on Sunday night or as per doctor's order for infection control purposes. Registered Nurse #1 further stated any nurse who observed undated nasal cannula tubing or soiled tubing was to change the tubing as needed, and it should be dated every time the tubing was changed. Registered Nurse #1 went to Resident #33's room with surveyor and observed the nasal cannula tubing was undated. Registered Nurse #1 was unable to provide an explanation for why Resident #33's nasal cannula tubing was undated. 09/17/2025 at 12:14 PM, the Director of Nursing was interviewed and stated the nasal cannula tubing is to be dated when it was changed so staff were aware when it needed to be changed next. The Director of Nursing also stated they made round on the units once a day and looked for resident care and safety, cleanliness of medication cart, and environment. The Director of Nursing further stated they did not look at the nasal cannula tubing when making rounds at the units. 10 NYCRR 415.12(k)(6)

Based on observation, record review, and interviews conducted during the Recertification survey, the facility failed to ensure the nursing staff information was posted as required. Specifically, the daily nurse staffing information posting did not include the resident census, total number and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift and was not maintained for a minimum of 18 months. The findings include:The facility policy titled Staffing Level with review date of 08/2025 stated it is the policy of the facility that the daily schedule will be posted before the beginning of each shift to guide the staff members on their assignments for the day. The policy also stated Nurse staffing information will be posted detailing the number of licensed nursing staff including registered nurses, licensed practical nurses, and nurses' aides on duty for every shift every day.On 09/14/2025 at 09:06 AM, upon entrance into the facility a Daily Staffing sheet dated 09/12/2025 was posted which documented the number of registered nurses, licensed practical nurses and certified nurse aides, but did not include the resident census, the total number and actual hours worked by the staff.On 09/14/2025 at 2:20 PM, the Director of Nursing was interviewed and stated they are aware the Daily Staffing posting was dated 09/12/2025, and this is because the Staffing Coordinator is not in the building on the weekends. The Director of Nursing also stated they are aware the Daily Staffing information had not been posted since 09/12/2025. On 09/16/2025 at 09:59 AM, the Staffing Coordinator was interviewed and stated they are responsible for posting the Daily Staffing information in the morning which includes the projected hours, projected staff numbers and the par level needed on the unit. The Staffing Coordinator also stated if they are not in the facility, the Human Resources Assistant will write out the Daily Staffing information that is prepared for the weekend and post it. The Staffing Coordinator further stated the nursing supervisor is supposed to put up the posting on the weekends once in the morning during the day shift. The Staffing Coordinator also stated they include the current date, do not include the census, and enters the projected hours and not the actual hours worked. The Staffing Coordinator also stated they did not know they were supposed to store the staffing posting information for at least 18 months and they had been discarding the staffing posting information. On 09/16/2025 at 10:47 AM, the Director of Nursing was re-interviewed and stated the posting of the staffing which consists of the registered nurses, licensed practical nurses, and certified nurse aides is posted daily for each shift on the wall in the lobby and includes the census and the hours and numbers on the Daily Staff information posting are projected numbers and hours and not the actual numbers and hours worked. The Director of Nursing also stated they were not aware the daily staffing posting was being posted inaccurately and did not pay attention. On 09/16/2025 at 10:58 AM, the Human Resources Assistant was interviewed and stated they were told to place registered nurses, licensed practical nurses and certified nurse aides on the sheet along with the number working on each shift and the hours they would be working. The Human Resources Assistant also stated they do not have access to the electronic medical record, so they are not able to retrieve the census. The Human Resources Assistant further stated when the Staffing Coordinator is off on the weekends, they do not post the Daily Staff information. 10 NYCRR 415.13

Based on observations and interviews conducted during the Recertification survey, the facility did not ensure notice of the availability of the survey results were posted in areas of the facility that are prominent and accessible to the residents and the public. Specifically, there were no posted notices throughout the six (6) resident floors of the facility about the availability of survey results.The findings are:The facility's policy titled Residents' Rights with a reviewed date 08/2025 stated the resident has a right to examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility. During multiple building observations conducted between 09/14/2025 at 09:18 AM and 09/16/2025 at 09:41 AM, survey results were observed in a binder at the security station in the lobby area. There were no notices posted to inform the residents and the public on any of six (6) resident units about where the survey results could be located. During the Resident Council meeting held on 09/16/2025 at 10:32 AM, ten (10) residents were in attendance, and nine (9) out of ten (10) residents (Residents #20, #44, #62, #159, #163, #183, #195, #233, and #235) stated they did not know where to find the survey results and that they have not seen any notice telling them where to find the survey results. The minutes of the Resident Council Meetings held on 06/26/2025, 07/31/2025, and 08/28/2025 had no documentation that information was provided to the residents on where to locate survey results. On 09/17/2025 at 12:19 PM, the Administrator was interviewed and stated they posted signage where to find state survey results by elevators on all six (6) resident floors. The Administrator also stated they had wall painting on the resident floors recently and the signage about where to find the survey results might have dropped off. The Administrator further stated they made rounds to all six (6) resident floors every day, and they did not pay attention to the signage about where to find the survey results. The Administrator made rounds with the surveyor to all six (6) resident units and was not able to locate any signage indicating where the survey results were located on any of the six (6) resident floors. 10 NYCRR 415.3 (d)(1)(v)

Based on observation, record review, and interviews during the recertification survey from 8/24/23 - 8/31/23 the facility did not ensure that a surety bond was purchased to assure the security of all personal funds of residents deposited with the facility. This was evident for 60 residents with personal needs accounts (PNA) of 226 total residents. Specifically, the facility had a surety bond for an amount less than the total of all resident PNAs being held by the facility. The findings are: The facility policy titled Access and Management of Resident's Funds dated 08/2022 documented resident funds/accounts shall be safeguarded, properly managed. The facility Resident PNA Balance dated 8/7/2023 documented 60 resident accounts held by the facility totaled $212,913.77. The Surety Bond dated 4/2/2022 documented the resident PNAs were insured for $100,000.00. There was no documented evidence the facility had a surety bond to cover the PNA total being managed by the facility. On 08/31/2023 at 10:35 AM, an interview was conducted with the PNA Coordinator who stated, they do not know what the amount the facility's surety bond should be. The billing company is responsible for the surety bond. On 08/31/2023 at 12:03 PM, an interview was conducted with the Administrator who stated there have been a lot of admissions of residents on ventilators and this made the PNA accounts total more than the facility's surety bond amount. It was an oversight to not update the facility's surety bond to cover the current balance. 10 NYCRR 415.26(h)(5)(v)

Based on observation, record review, and interviews conducted during the recertification survey from 8/24/2023 to 8/31/2023, the facility did not ensure an account of all controlled drugs was maintained and periodically reconciled. This was evident for 1 of 6 units (Unit 6) observed for Medication Storage. Specifically, a Licensed Nurse (LPN) on Unit 6 did not reconcile a narcotics supply count for Resident #184. The findings are: The facility policy titled Individual Narcotic Record dated 8/2022 documented the facility was to maintain a narcotic record. All medications are counted on each tour of duty by the nurse coming on duty with the nurse going off duty. The nurse in charge is responsible for making entries when medications are taken. Entries must be accurate. The nurse giving the narcotic shall enter the date & time it was administered, number of tablets given, route, nurses signature and amount remaining. Resident #184 had diagnoses of Narcolepsy and non-Alzheimer's Dementia. On 08/29/2023 at 12:14 PM, an observation of the medication cart on Unit 6 was made with Licensed Practical Nurse (LPN) #1. The narcotic record for Resident #184 documented there were 23 tablets of Modafinil currently left. The blister pack of Resident #184's Modafinil was observed with 24 pills remaining. LPN #1 stated they administered Resident #184 a tablet of Modafinil in the morning and must have miscounted the pills remaining in the blister pack. A Physician's Order dated 09/14/2022 documented Resident #184 was ordered to receive Modafinil 100 mg once daily. The Medication Administration Record (MAR) dated 8/29/2023 documented Resident #184 was given 1 tablet of Modafinil 100mg at 9:00 AM. On 08/29/2023 at 02:37 PM, the Assistant Director of Nursing (ADON) was interviewed and stated they were informed of the narcotics medication count discrepancy for Resident #184. The ADON stated they called the doctor who ordered a 1 time only dose of the medication to be administered. The nurse should check the resident, check the order, medication, route, adverse reactions before taking the medication from the blister pack to give to the resident and documenting in the MAR. On 08/30/2023 at 03:12 PM, the Director of Nursing (DON) was interviewed and stated that LPN #1 has worked at the facility for a very long time and never had any issues or write-ups. LPN #1 informed the DON that a CNA asked them a question as they were about to administer the Modafinil to Resident #184, and they got distracted. The facility has a system for counting the narcotics to check for errors. Education was given to LPN #1. 415.18(b)(1)(2)(3)

Based on observation, record reviews, and staff interviews during the Recertification / Complaint Survey, the facility did not ensure that residents were free from unnecessary antipsychotic medications. This was evident for 2 of 5 residents reviewed for Unnecessary Medications out of 35 sample residents. (Residents #199, and #206) Specifically, (1) Resident #199 was given antipsychotic medication (Quetiapine) for a documented indication of anxiety when the medication was being used for dementia-related behaviors without documented evidence of ongoing behaviors and the effectiveness of nonpharmacological interventions applied address them. Resident #199 did not receive a gradual dosage reduction of Quetiapine when the psychiatrist first recommended it, and there were no behaviors or rationale documented to explain why the reducation was not done. The findings are: The facility Policy and Procedure for Psychoactive medications dated 3/15/16, last revised 08/2022 documented: Each resident will receive only those medications, in doses and for the duration clinically indicated to treat the resident's assessed conditions .Each resident's drug regimen must be free from unnecessary drug. An unnecessary drug is any drug when used: in excessive dose; or without adequate monitoring; or without adequate indication for its use. 1) Resident #199 was admitted to the facility 01/31/2023, with diagnoses that included Non-Alzheimer's Dementia, Depression, and Insomnia. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severely impaired cognition with long and short-term memory problems. The resident displayed no hallucinations, delusions, mood symptoms, or behavior symptoms. The resident had diagnoses of Depression and Non-Alzheimer's Dementia, and they received Antipsychotic and Antidepressant medication daily. The last Gradual Dose Reduction (GDR) was done 7/10/23. The Comprehensive Care Plan (CCP) for Dementia Care dated 1/31/2023 documented that Resident #199 had dementia as evidenced by short-term memory problems, long-term memory problems, and moderately impaired decision-making skills. No behaviors secondary to dementia were selected on the CCP. The CCP goas were for Resident #199 to make minor decisions in (Activities of Daily Living) ADLs and assist in self-care in ADLs within limitations. The interventions included: Provide ongoing assessment of cognitive needs; Monitor changes in functioning level; Review psychotropic drug profile; Positive reinforcement, reassurance, and support; Maintain calm environment. The Comprehensive Care Plan (CCP) for Psychoactive Medication dated 1/31/2023 documented that Resident received Psychotropic medication related to Anxiety, Depression, and Insomnia. The CCP goals were for the resident to be on the lowest therapeutic dose and to be free from side effects of psych meds x 90 days. The interventions (effective since 2/5/2023) included: Administer medications per MD order, obtain a psychiatry consult and follow up, observe for side effects of meds, review psych meds monthly, and recreational activities. The Comprehensive Care Plan (CCP) for Behavior (Actual) dated 2/06/3023 documented Resident #199 was physically abusive (hitting) and resisted ADL (Activities of Daily Living) assistance (refusing tube feeding) related to Diagnoses of Anxiety, Depression, Schizophrenia, and bipolar disorder. The CCP goals were for Resident #199 to not harm self or others, demonstrate acceptable coping behavior, and understand the risks versus benefits of their treatment/care. The interventions included ongoing assessment of the behaviors, administer medication as ordered, assess response to the medication, anticipate needs/interests, psychiatric follow-up, and social services intervention. On 08/28/23 at 09:19 AM, Resident #199 was observed sitting in the hallway in front of their room. The resident was alert and verbally responsive. Resident #199 stated they have been in the facility for a while and would like to go home. The resident's behavior was consistent with Dementia. Resident #199 was observed further during the survey period, and they were calm with no agitation or behavior problems observed. The Physician's renewal orders dated 8/23/2023 documented Resident #199 received the following: Quetiapine 25 milligrams (mg) by gastronomy tube (GT) once daily at 9:00 AM for restlessness and agitation (initiated 8/22/23). Quetiapine 50 mg by GT once daily at bedtime (HS) for anxiety disorder (initiated 1/31/23). Mirtazapine 7.5 mg tablet by GT once daily at bedtime for Major depressive disorder, single episode, unspecified (initiated 7/3/23). Valproic acid (as sodium salt) 250 mg/5 mL (milliliters) oral solution 2.5 milliliters (125 mg) by GT every 8 hours for psych disorder not due to a substance or known physiological condition (initiated 2/13/23). Memantine 10 milligrams (mg) tablet by GT once daily (OD) for Alzheimer's disease. The Physician's Order detail documented Resident #199 previously received Quetiapine 50 mg by GT once daily at 9:00 AM from 1/31/2023 to 7/10/1013 for anxiety disorder, unspecified. Quetiapine is an antipsychotic medication used to treat Schizophrenia and Bipolar Disorder. The Food and Drug Administration (FDA) black box warning for Quetiapine documents there is increased mortality in elderly patients with dementia-related psychosis, and Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Quetiapine is not approved for use in elderly patients with dementia-related psychosis. Anxiety disorder, restlessness, and agitation are not accepted indications for Quetiapine per the FDA. A Nursing Note dated 2/6/2023 at 2:07 PM documented Resident #199 was combative and swung at the nurse. The resident refused all medications and bolus feeding. A Nursing Behavioral Note dated 2/6/2023 at 1:55pm documented the nurse contacted Resident #199's family because the resident was very combative, verbally aggressive, and refused all bolus feeding. The family member was aware of the behavior and reported Resident #199 had this behavior at their previous skilled nursing facility. A Nursing Behavior Note dated 2/7/2023 at 2:28 AM documented Resident #199 refused bolus feeding at 6 AM, and they were very combative, displaying punching, hitting, and kicking. Resident #199 did not want to be touched and threatened to call the police. There were no attempted nonpharmacological interventions documented in these nursing notes to address the resident's behaviors. A Psychiatry Consult dated 2/13/2023 documented Resident #199 was evaluated for agitation. Resident #199's current medications were Quetiapine 50 mg am and HS, Donepezil 10 mg daily, Memantine 10 mg daily, Melatonin 3 mg HS, and Mirtazapine 7.5 mg HS, and the resident had a history of Dementia and agitation. Resident #199 had agitated behavior refusing bolus feeding and an anxious and angry mood. The Hallucination section was left blank. Resident #199 was diagnosed with Psychosis Not Otherwise Specified (NOS), Neurocognitive Disorder with agitation, and Depression. The psychiatrist recommended adding Valproic acid (VPA) 125 mg via GT every 8 hours, lowering Quetiapine to 25 mg twice per day (BID), and continuing other psychiatric medication. There was no documented evidence that resident's Quetiapine was reduced to 25 mg BID per the psychiatrist's recommendations, and there was no documented reason why the recommendations were not followed. A Nursing Behavior Note dated 3/21/2023 documented Resident #199 calm and quiet in bed. The resident received Melatonin 3 mg via GT at bedtime for Insomnia, Namenda 10mg daily for Alzheimer's disease, Quetiapine 50 mg 9 am and 9pm for Anxiety disorder, Valproic Acid 5ml every 8 hours (q8hrs) for other Psych disorder. The Nursing Behavior Notes from 03/2023 to 08/31/2023 contained no documented evidence Resident #199 displayed ongoing behavior problems since 2/7/2023 to justify continued use of psychotropic medications to manage the resident's dementia-related behaviors. A Psychiatry Consult dated 4/03/2023 documented Resident #199 was seen and evaluated for agitation/poor appetite. Resident #199's current psychotropic medications were: Quetiapine 50 mg am and HS, Donepezil 10 mg daily, Memantine 10 mg daily, Melatonin 3 mg HS, and VPA 125 mg q8hrs. Resident #199 had agitated behavior and refused bolus feeding. Their mood was described as anxious and angry. The hallucination section was blank. Resident #199's diagnoses remained Psychosis NOS, Neurocognitive Disorder with agitation, and Depression. The psychiatrist recommended adding Mirtazapine 7.5 mg HS. A Psychiatry Consult dated 5/22/2023 documented Resident #199 was evaluated for agitation, poor appetite, anxiety. Resident #199's current medications were Quetiapine 50 mg BID, Donepezil 10 mg daily, Memantine 10 mg daily, Melatonin 6 mg HS, VPA 125 mg via GT q 8hrs, and Mirtazapine 7.5 mg HS. Resident #199 had agitated behavior with anxious and angry mood. The psychiatrist recommended to continue the current medications for Depressive Disorder NOS, Neurocognitive Disorder with agitation, and Insomnia. On 06/26/2023, the Pharmacy Medication Regimen Review, MRR documented: Quetiapine is ordered for Dx Anxiety as per MD order. This DX does not agree with 5/23/Psych Dx MDD. There was no documented evidence that in the resident's medical record that the identified irregularity was reviewed and what if any, action was taken to address it. A Psychiatry Consult dated 07/10/2023 documented Resident #199 was seen and evaluated by for agitation, poor appetite, and anxiety. Resident #199's current Psychoactive Medications were Quetiapine 50 mg BID, Donepezil 10 mg qd, Memantine 10 mg qd, Melatonin 6 mg HS, VPA 125 mg via GT q 8hrs, Mirtazapine 7.5 mg HS. Resident #199 had agitation with angry and anxious mood. Resident #199 was diagnosed with Depressive Disorder NOS, Neurocognitive Disorder with agitation, and Insomnia. The psychiatrist recommended lowering Quetiapine to 25 mg in the AM and continue other medications. Quetiapine 25 mg by GT once daily at 9:00 AM was ordered from 7/10/2023 to 8/22/2023 for anxiety disorder, unspecified and other psych disorder not due to a substance or known physiological condition. On 08/28/23 at 09:40 AM, an interview was conducted with Certifies Nursing Assistant CNA #3. CNA #3 they have been taking care of the resident for about 5 months, Resident is given care, washed, showered, and taken out of bed every morning, on GT, and also eat by mouth, able to feed self with tray set up. CNA stated that resident sometimes refuses care, when resident is noted to be agitating during care, it is reported to the nurse, and will later return to resident when resident is calm. On 08/28/23 at 09:45 AM, an interview was conducted with LPN #2. LPN #2 stated that they have been taking care of the resident for about 2 months; LPN stated that resident likes to talk, will be calling mama, mama, do you want me to do laundry; LPN stated that resident has not been displaying any aggressive behavior, has not noticed resident refusing care for the last 2 months. On 08/28/23 at 09:51 AM, an interview was conducted with the Nursing Supervisor/Assistant Director of Nursing, (ADON). ADON stated that resident has dementia, agitation and anxiety, emotional support given to the resident, talks to the resident when noticed with agitation, redirected, offer some fluid, family involved in talking to the resident. Sometimes resident is very restless, trying to get up from chair/bed unassisted; ADON further stated that resident was admitted with Seroquel 50 mg in the morning and 50mg night, was seen by Psych MD in February for initial assessment/evaluation, recommended to start on Valproic Acid low dose, Resident is being monitored by Psychiatrist, Seroquel has been reduced from 50mg to 25mg in the morning, and is being monitored for further reduction when behavior improves. ADON was unable to state why there was no behavior notes in the Nursing progress notes and, in the Resident's, MDS assessment documentation to justify continuous use of Antipsychotic medications. On 08/30/23 at 12:31 PM, an interview was conducted with the Psychiatrist. The Psychiatrist stated that resident was admitted with Quetiapine 50mg at 9am and 9pm, resident has dementia and refusing the bolus feed, and also have agitative behavior that could not be managed with non-pharmacology; They tried to lower the Seroquel but agitation behavior got worse, and has to put resident back on 50 mg; Resident was seen again in April and May, Seroquel was reduced to 25mg in AM and 50mg HS; and will be followed up to see if it can be tapered off. The Psychiatrist further stated that Quetiapine is supposed to be used for diagnosis of psychosis, they are not aware of the pharmacy recommendation, and could not recall seeing the pharmacy medication Regimen Review (MRR). The Psychiatrist was unable to explain why Quetiapine was still being documented for diagnosis of Anxiety in the current Physician's order and Medication Administration order. On 08/30/23 at 02:39 PM. The Attending Physician was interviewed, stated that the medication was not being used for anxiety as wrongly indicated in the order, but is used for delusional and agitational behavior which place the resident at risk of causing injury to self or to the staff. Attending Physician stated that they were notified of the MRR by the nurse, it was an error to keep on documenting that the medication is used for anxiety. The attending Physician stated that resident has psychosis and they belief benefits of Seroquel being administered to resident outweigh the risks. The Attending Physician was unable to state why there was no behavior notes in the progress notes and, in the Resident's, MDS assessment documentation to justify continuous use of Antipsychotic medications. On 08/31/23 at 11:53 AM, an interview was conducted with the Director of Nursing DNS. DNS stated that Pharmacy's recommendation is sent via email, it is printed out and given to the Nursing Supervisor to give and discuss it with the physician. The physician is expected to act on the recommendation, will accept or reject the recommendation and may give telephone order to the effect. DNS stated that the Physicians are responsible for proper documentation of adequate indication of the medication ordered. DNS was unable to explain why there was no documentation in the resident's medical record for the action taken on pharmacy recommendation. 415.12(1)(2)(i)(a-d)(ii)

Based on observation, record review and interview conducted during the recertification and abbreviated survey, the facility did not ensure that the Minimum Data Set 3.0 (MDS) assessment accurately reflected a resident's status. This was evident for 1 of 1 Residents reviewed for position and mobility out of a sample of 35 residents (Resident #12). Specifically, Resident #12's left upper extremity Range of Motion (ROM) impairment was not captured in the annual MDS assessment. The findings are: The facility policy and procedure titled Completion and Transmission of MDS Assessment, last revised January 2023, documented that each staff member assesses, codes and completes their assigned portion of the MDS to the best of their ability Resident #12 was admitted to the facility on [DATE] with diagnoses of Cerebral infarction affecting the left non dominant side, Multiple Sclerosis, and Paraplegia. The annual Minimum Data Set (MDS) dated [DATE] documented that the Resident #12 had severely impaired cognition. The MDS further documented that the resident required the total assist of 2 people for bed mobility, transfer, dressing and toilet use. The MDS further documented the resident had no range of motion impairment in the upper extremities. On 8/29/23 at 10:10 AM and 8/30/23 at 10:32 AM, Resident #12 was observed with left upper extremity impairment. The Comprehensive Care Plan, last reviewed on 7/13/23, documented Resident #12 was admitted with a left hand contracture related to a Cerebrovascular accident. On 8/31/23 at 10:54 AM, the Physical Therapist Assistant was interviewed and stated that Resident #12 has ROM impairment on the left upper extremity. The MDS says no impairment which is a mistake. On 8/31/23 at 11:09 AM, the MDS Coordinator was interviewed and agreed that the resident's left upper extremity ROM impairment was not captured which is a mistake. 415.11(b)

Based on observations, interviews, and record review during the recertification and abbreviated survey, the facility did not ensure that a resident with limited mobility received appropriate services and assistance to prevent further contractures. This was evident for 1 of 1 resident reviewed for positioning and mobility (Resident #12). Specifically, Resident #12, a resident with a left hand contracture, was observed without a left palm grip hand roll (dole roll) in place as ordered. The findings are: The facility Policy and Procedure titled Special Devices-Rehab reviewed in August 2023 documented: the unit Coordinator/Charge Nurse is responsible for checking daily that all Residents with prescribed special devices have them and are being applied as ordered. Nursing staff will follow instructions and/wear schedule as the Rehab Therapist recommended. Resident #12 was admitted to the facility on [DATE] with diagnoses of Cerebral infarction affecting the left non dominant side, Multiple Sclerosis, and Paraplegia. The annual Minimum Data Set (MDS) dated [DATE] documented that the Resident #12 had severely impaired cognition. The MDS further documented that the resident required the total assist of 2 people for bed mobility, transfer, dressing and toilet use. The MDS further documented the resident had no range of motion impairment in the upper extremities. A Comprehensive Care Plan (CCP) last updated on 7/13/23 documented Resident #12 was admitted with a contracture of left hand related to a Cerebrovascular Accident (CVA), and the Resident was at risk for further contracture. The goal was to prevent further contracture. The CCP intervention was to apply a plam grip hand roll at all times, and remove for skin check, hygiene and range of motion. On 8/29/23 at 10:10 AM, Resident #12 was observed in a lounge chair in the hallway with the left hand contracted. There was no left palm grip hand roll in place. On 8/30/23 at 10:32 AM, Resident #12 was observed in bed sleeping with the left hand contracted. There was no left palm grip hand roll in place. Physician Orders dated 8/16/23 documented a palm grip hand roll (dole roll) should be applied to the left hand, and the roll shuld be worn at all times and removed for skin checks and hygiene to prevent further contracture. On 8/31/23 at 10:54 AM, an interview was conducted with the Physical Therapist Assistant (PTA) who stated, Resident #12 has an impairment on the left hand. Resident #12 has an order to have a hand roll on the left hand to prevent further contracture. The roll should be worn at all times and removed for skin checks and hygiene. On 8/31/23 at 2:18 PM, an interview was conducted with Registered Nurse (RN #3) who stated that the hand roll is usually put in the Resident's hand in the morning. RN #3 further stated that maybe it was removed during care. 415.12(e)(2)

Based on record review and staff interviews conducted during the Recertification/Complaint survey, the facility did not ensure that irregularities identified by the pharmacist and forwarded to the facility were acted upon. Specifically, the facility failed to document in the resident's medical record that irregularities identified by the Consultant Pharmacist had been reviewed and what, if any, action has been taken to address the issues. This was evident for 1 out of 5 residents reviewed for Unnecessary Medications out of a sample of 35 residents. (Resident # 199) The finding is: The facility's Policy and procedure for Medication Regimen Review dated 11/28/2017, last revised 08/2022 documented: .The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist .The pharmacist must report any irregularities to the attending physician's, medical director and director of nursing, and the reports must be acted upon .The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what if any, action has been taken to address it. Resident #199 was admitted to the facility 01/31/2023, with diagnoses that included Anemia, Atrial Fibrillation, Non-Alzheimer's Dementia, Depression and Insomnia. The Quarterly Minimum Data Set (MDS), dated [DATE] documented the resident had severe impairment in cognition with long and short-term memory problems, had adequate hearing, sometimes understands - responds adequately to simple, direct communication only, able to recall color after cueing; MDS also documented that Antipsychotic and Antidepressant were being administered on a routine basis. The Comprehensive Care Plan (CCP) for Dementia dated 1/31/2023 documented that Resident had Potential/Actual dementia as evidenced by short and long-term term memory problems and moderately impaired decision making skills. The CCP goals included: Resident will make minor decisions in ADLs (Activities of Daily Living) and assist in self-care ADLs within limitations. Interventions included: - Provide ongoing assessment of cognitive needs; Monitor changes in functioning level; Review psychotropic drug profile; Positive reinforcement/reassurance/support; Maintain calm environment The Comprehensive Care Plan (CCP) for Psychoactive Medication dated 1/31/2023 documented that Resident needs to use Psychotropic medication related to Anxiety, Depression, Sleep disorder. Goals included: - Resident will be on the lowest therapeutic dose of psych meds x 90 days. Interventions included: - Administer meds as per MD order; Obtain a psychiatry consult and follow up; Observe for side effects of meds; Review psych meds monthly. The Comprehensive Care Plan (CCP) for Behavior dated 2/06/3023 documented that resident has behavior of physically abusive; resist ADL assistance, related to Dx of Anxiety, Depression, Goals included: - Resident will not harm self or others; Will demonstrate acceptable coping behavior; Will understand risk versus benefits of treatment/care. Physician's order dated 8/23/2023 documented: Mirtazapine 7.5 mg tablet1 tablet (7.5 mg) by g-tube route once daily at bedtime for Major depressive disorder, single episode, unspecified Namenda 10 mg tablet by g-tube route once daily for Alzheimer's disease, unspecified Quetiapine 25 mg 1 tablet (25 mg) by g-tube route once daily for Restlessness and agitation Quetiapine 50 mg 1 tablet (50 mg) by g-tube route once daily at bedtime Valproic acid (as sodium salt) 250 mg/5 mL oral solution 2.5 milliliters (125 mg) by g-tube route every 8 hours for psych disorder. On 06/26/2023, the Pharmacy Medication Regimen Review (MRR) documented: Quetiapine is ordered for Dx Anxiety as per MD order. This DX does not agree with 5/23/Psych Dx MDD. There was no documented evidence that in the resident's medical record that the identified irregularity has been reviewed and what if any, action has been taken to address it. Physician's order renewed 08/23/2023 8:31 PM documented Quetiapine 50 mg tab via g-tube route at bedtime for Diagnosis of Anxiety disorder, unspecified; Original Order date: 01/31/2023. On 08/28/23 at 09:51 AM, an interview was conducted with the Assistant Director of Nursing, (ADON). ADON stated that when Pharmacy recommendation is collected from the DON, the Nursing on the floor calls the attending physician and the psychiatrist to let them know about the recommendation. DON stated that the Physicians were notified of the pharmacy recommendation, they just forget to document it in the resident's medical record. On 08/30/23 at 12:31 PM, an interview was conducted with the Psychiatrist. The Psychiatrist stated that Quetiapine is supposed to be used for diagnosis psychosis, they are not aware of the pharmacy recommendation, and could not recall seeing the pharmacy medication Regimen Review (MRR). On 08/30/23 at 02:39 PM. The Attending Physician was interviewed, stated that the medication was not being used for anxiety as wrongly indicated in the order but is used for delusional and agitational behavior which place the resident at risk of injury self or the staff. Attending Physician stated that they were notified of the MRR by the nurse, it was an error to keep on documenting that the medication is used for anxiety. On 08/31/23 at 11:53 AM, an interview was conducted with the Director of Nursing DNS. DNS stated that Pharmacy's recommendation is sent via email, it is printed out and given to the Nursing Supervisor to give and discuss it with the physician. The physician is expected to act on the recommendation, will accept or reject the recommendation and may give telephone order to the effect. DNS was unable to explain why there was no documentation in the resident's medical record for the action taken on pharmacy recommendation. 415.18 (c)(2)

Based on interviews and record review conducted during an abbreviated survey (NY00320077), the facility failed to provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. This was evident in 15 of 18 sampled residents (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, and #15). Specifically, the facility was not in compliance with the New York (NY) Education Law Section 6512 Unauthorized Practice of a Profession and NY Education Law 6509 Professional Misconduct. On 07/10/2023, Certified Nursing Assistant #1 (CNA #1) identified themself as a Licensed Practical Nurse (LPN). Registered Nurse Supervisor #1 (RNS #1) did not verify CNA #1's job title and did not check the staffing schedule. RNS #1 permitted CNA #1 to perform licensed nurse activities. The electronic Medication Administration Record (eMAR) for Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, and #15 documented that CNA #1 administered their medications for the evening shift on 07/10/2023. CNA #1 used their username and password to log-in to the CNA kiosk to access the eMAR. The findings are: The NY State Education Law Section 6512 states that it is a felony for anyone who practices or offers to practice or holds themselves out as being able to practice any profession in which a license is a prerequisite to the practice of the acts. The NY State Education Law Section 6509 states that permitting an unlicensed person to perform activities requiring a license is professional misconduct. The facility policy titled Medication Administration with review date of 08/2022 stated that only licensed Registered Nurse (RN) and Licensed Practical Nurse (LPN) are assigned responsibility for preparing, administering, and recording of medications. Only RN and LPN are permitted access to the drug storage at each nursing station. Only RN and LPN shall be permitted to administer medications to residents. A Nursing Schedule dated 07/10/2023 documented that CNA #1 was scheduled for the day shift (7:00 AM - 3:00 PM) and evening shift (3:00 PM - 11:00 PM) to work as a CNA. A review of CNA #1's personnel file and the Office of Professions (OP) License Verification Search revealed that CNA #1 did not possess a nursing license. Resident #1 was admitted to the facility on [DATE] with diagnoses of Respiratory Failure, Tracheostomy, and Diabetes. The Minimum Data Set, (MDS, a resident assessment tool) dated 06/12/2023 documented that Resident is severely impaired in cognition. The eMAR dated 07/10/2023 documented that CNA #1 administered 8 medications to Resident #1 including Heparin 5000-unit injection, Humalog U-100 Insulin Subcutaneous (SQ) solution, Levemir U-100 Insulin SQ, Keppra 100 mg/ml oral solution, and Metoprolol Tartrate 50 mg tablet via Gastric tube (GT). Resident #2 was admitted to the facility on [DATE] with diagnoses of Tracheostomy, Diabetes, and Cerebral Infarction. The MDS dated [DATE] documented that Resident is severely impaired in cognition. The eMAR dated 07/10/2023 documented that CNA #1 administered 8 medications to Resident #2 including NovoLog U-100 Insulin SQ, and Levetiracetam oral solution, Valproic Acid 500mg/10ml oral solution, and Vimpat 100 mg tablet via GT. Resident #3 was admitted to the facility on [DATE] with diagnoses of Tracheostomy, Chronic Atrial Fibrillation, and Seizure. The MDS dated [DATE] documented that Resident is moderately impaired in cognition. The eMAR dated 07/10/2023 documented that CNA #1 administered 6 medications to Resident #3 including and Humalog U-100 insulin SQ and Clonazepam 0.25 mg tablet via GT. Resident #4 was admitted to the facility on [DATE] with diagnoses of Tracheostomy, Diabetes, and Respiratory Failure. The MDS dated [DATE] documented that Resident is severely impaired in cognition. The eMAR dated 07/10/2023 documented that CNA #1 administered 8 medications to Resident #4 including Heparin 5000 injection and Novolin U-100 Insulin, and Metoprolol Tartrate 25 mg, Clonazepam 0.5 mg tablet via GT. Resident #5 was initially admitted to the facility on [DATE] with diagnoses of Tracheostomy, Myocardial Infarction and Diabetes. The MDS dated [DATE] documented that Resident is severely impaired in cognition. The eMAR dated 07/10/2023 documented that CNA #1 administered 5 medications to Resident #5 including Admelog and Basaglar Kwik Pen Insulin SQ, and Ferrous Sulfate 220 mg via GT. Resident #6 was admitted to the facility on [DATE] with diagnoses of Tracheostomy, Chronic Obstructive Pulmonary Disease (COPD), and Parkinson's Disease. The MDS dated [DATE] documented that Resident is cognitively intact. The eMAR dated 07/10/2023 documented that CNA #1 administered 9 medications to Resident #6 including Alprazolam 0.5 mg and Midodrine 10 tablet via GT. Resident #7 was admitted to the facility on [DATE] with diagnoses of Tracheostomy, Diabetes and Seizure. The MDS dated [DATE] documented that Resident is severely impaired in cognition. The eMAR dated 07/10/2023 documented that CNA #1 administered 8 medications to Resident #7 including Carbidopa 25 mg-levodopa 100 mg tablet, Eliquis 2.5 mg, Levetiracetam 100 mg/ml oral solution, and Metoprolol Tartrate 25 mg tablet via GT. Resident #8 was admitted to the facility on [DATE] with diagnoses of Tracheostomy and Anoxic Brain Damage. The MDS dated [DATE] documented that Resident is severely impaired in cognition. The eMAR dated 07/10/2023 documented that CNA #1 administered 9 medications to Resident #8 including Synthroid 88 mcg tablet, and Keppra 100mg/ml solution via GT. Resident #9 was admitted to the facility on [DATE] with diagnoses of Tracheostomy, Bipolar Disorder, and Major Depressive Disorder. The MDS dated [DATE] documented that Resident is severely impaired in cognition. The eMAR dated 07/10/2023 documented that CNA #1 administered 5 medications to Resident #9 including Heparin 5,000 unit/ml subcutaneously and Clonazepam 2 mg tablet, Quetiapine 100 mg tablet, Valproic acid 250 mg/5ml oral solution via GT. Resident #10 was admitted to the facility on [DATE] with diagnoses of Tracheostomy, Cerebral Infarction and COPD. The MDS dated [DATE] documented that Resident is severely impaired in cognition. The eMAR dated 07/10/2023 documented that CNA #1 administered 6 medications to Resident #10 including Levothyroxine 500 mcg tablet and Metoprolol Tartrate 50 mg tablet via GT. Resident #11 was admitted to the facility on [DATE] with diagnoses of Tracheostomy, Diabetes, and Alzheimer's Disease. The MDS dated [DATE] documented that Resident is severely impaired in cognition. The eMAR dated 07/10/2023 documented that CNA #1 administered 6 medications to Resident #11 including Carvedilol 3.125 mg tablet and Eliquis 5 mg tablet via GT. Resident#12 was admitted to the facility on [DATE] with diagnoses of Tracheostomy, Diabetes, and Anoxic Brain Damage. The MDS dated [DATE] documented that Resident is severely impaired in cognition. The eMAR dated 07/10/2023 documented that CNA #1 administered 7 medications to Resident #12 including Admelog U-100 Insulin, Desmopressin 4 mcg/ml injections and Latanoprost 0.005% eye drops. Resident #13 was initially admitted to the facility on [DATE] with diagnoses of Tracheostomy, Cardiac Arrest, and Diabetes. The MDS dated [DATE] documented that Resident is severely impaired in cognition. The eMAR dated 07/10/2023 documented that CNA #1 administered 4 medications to Resident #13 including Carbidopa 25 mg-levodopa 2100 mg tablet via GT. Resident #14 was admitted to the facility on [DATE] with diagnoses of Tracheostomy, COPD, and Schizophrenia. The MDS dated [DATE] documented resident is severely impaired in cognition. The eMAR dated 07/10/2023 documented that CNA #1 administered 10 medications to Resident #14 including Humalog U-100 Insulin SQ, Clonazepam 1 mg tablet, and Levetiracetam 100 mg/ml SQ solution via GT. Resident #15 was admitted to the facility on [DATE] with diagnoses of Tracheostomy, Anxiety Disorder, and Diabetes. The MDS dated [DATE] documented that Resident is severely impaired in cognition. The eMAR dated 07/10/2023 documented that CNA #1 administered 4 medications to Resident #15 including Novolin U-100 insulin SQ, Metoprolol Tartrate 50 mg tablet and Levetiracetam 500 mg/5ml via GT. During a telephone interview on 07/23/2023 at 7:00 PM, RNS #1 stated that on 07/10/2023 at approximately 3:20 pm, while they were doing their rounds, CNA #1 approached them and identified themself as a nurse who was scheduled to work on the 2nd floor. RNS #1 stated that they did not observe CNA #1 wearing their ID, they did not ask CNA #1 to show their identification (ID) badge, and did not check the staffing book to verify CNA #1. RNS #1 stated that they instructed CNA #1 to administer medication on the low side of the unit. During a telephone interview on 07/23/2023 at 6:29 PM, CNA #1 stated that they worked the morning shift on 07/10/2023 on the 2nd floor and that they agreed to stay for the 3:00 pm - 11:00 pm shift on the same unit. CNA #1 stated that RNS #1 came to the unit and told them that they will be assisting LPN #1 in administering medication on the lower side. CNA #1 stated that they informed RNS #1 that they are a CNA and that RNS #1 walked away and left them with LPN #1. CNA #1 stated that they were wearing an ID badge while speaking with RNS #1. CNA #1 denied telling LPN #1 that they were a nurse. CNA #1 stated that LPN #1 showed them how to hang the feedings and that they hang 5 tube feedings by themself. CNA #1 stated that LPN #1 showed them how to locate residents' medications on the medication cart and that they administered narcotics to the residents. CNA #1 stated that they do not recall how many residents they administered medications to. CNA #1 stated that they agreed to work as a nurse knowing that they do not have the license. During a follow-up interview with CNA #1 on 07/24/2023 at 4:11 PM, CNA #1 stated that they logged in the eMAR with the same username and password they use to access the CNA kiosk. CNA #1 stated that when they logged in, they were able to see all residents' medications. CNA #1 stated that LPN #1 showed them how to navigate the eMAR, how to sign for the medications, and how to open and take medications from the medication cart. During a telephone interview on 07/23/2023 at 8:30 PM, RN #1 stated that on 07/10/2023 at approximately 3:25 PM, CNA #1 came to the unit and introduced themself as a nurse and that they were sent by RNS #1 to work on the unit. RN #1 stated that CNA #1 was not wearing an ID badge and that they asked CNA #1 if they were a nurse and CNA #1 replied yes. During an interview on 07/24/2023 at 10:47 AM, LPN #1 stated that on 07/10/2023 (could not recall time), RNS #1 came to inform them that another nurse is coming to administer medications and that they will be covering the desk. LPN #1 stated that CNA #1 arrived in the unit and introduced themself as a nurse and that they received their LPN license in July 2023. LPN #1 stated that they gave CNA #1 the keys and directed CNA #1 how to administer medications including narcotic. During a follow-up interview on 07/25/2023 at 3:21 PM, LPN #1 stated that CNA #1 took out the medications from the medication cart, narcotic box, and from the blister packs, and administered them to the residents. LPN #1 stated that CNA #1 administered the medications that they signed for on the eMAR. During an interview on 07/24/2023 at 12:30 PM, the Assistant Director of Nursing (ADON) stated that all RNS's must check the staff members' names against the nursing schedule to ensure who the staff are and what unit they are assigned to. During an interview on 08/31/2023 at 12:30PM, the Director of Nursing (DON) stated that all nursing staff must check with the RNS prior to going to their assigned unit. RNS must look at the schedule to verify the staff name, job title, and their assigned floor. During an interview on 07/24/2023 at 3:32 PM, the Administrator stated that all staff members who are doing double shifts are supposed to go the nursing office and check with the RNS on duty. The RNS must verify the staff name, job title, and to know which floor they are working on. 10NYCRR 400.2

Based on interviews and record review conducted during an abbreviated survey (NY00320077), the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Social Security Act. Additionally, the facility failed to ensure that a reasonable suspicion of a crime against a resident or an individual receiving care from the facility was reported not later than 24 hours to the State Survey Agency, New York State Department of Health (NYSDOH). This was evident in 15 of 18 sampled residents (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, and #15). Specifically, on 07/10/2023, the Administrator and the Director of Nursing received a report stating that Certified Nursing Assistant #1 (CNA #1) administered medications to 15 residents without a nursing license. The facility reported the incident to the NYSDOH on 07/14/2023, 4 days after the incident occurred. The facility did not report the incident to local law enforcement. The findings are: The NY State Education Law Section 6512 Unauthorized Practice a Crime states that it is a felony for anyone who practices or offers to practice or holds themselves out as being able to practice any profession in which a license is a prerequisite to the practice of the acts. The facility's Policy and Procedure titled Reporting Abuse to State Agencies and Other Entities/Individuals with a revised date of 10/2022 documented that all alleged/suspected violations or crimes and all substantiated incidents of abuse will be promptly reported to appropriate state agencies and other entities, or individuals as required by law. Resident #1 was admitted to the facility on [DATE] with diagnoses of Respiratory Failure, Tracheostomy, and Diabetes. The Minimum Data Set, (MDS, a resident assessment tool) dated 06/12/2023 documented that Resident is severely impaired in cognition. Resident #2 was admitted to the facility on [DATE] with diagnoses of Tracheostomy, Diabetes, and Cerebral Infarction. The MDS dated [DATE] documented that Resident is severely impaired in cognition. Resident #3 was admitted to the facility on [DATE] with diagnoses of Tracheostomy, Chronic Atrial Fibrillation, and Seizure. The MDS dated [DATE] documented that Resident is moderately impaired in cognition. Resident #4 was admitted to the facility on [DATE] with diagnoses of Tracheostomy, Diabetes, and Respiratory Failure. The MDS dated [DATE] documented that Resident is severely impaired in cognition. Resident #5 was initially admitted to the facility on [DATE] with diagnoses of Tracheostomy, Myocardial Infarction and Diabetes. The MDS dated [DATE] documented that Resident is severely impaired in cognition. Resident #6 was admitted to the facility on [DATE] with diagnoses of Tracheostomy, Chronic Obstructive Pulmonary Disease (COPD), and Parkinson's Disease. The MDS dated [DATE] documented that Resident is cognitively intact. Resident #7 was admitted to the facility on [DATE] with diagnoses of Tracheostomy, Diabetes and Seizure. The MDS dated [DATE] documented that Resident is severely impaired in cognition. Resident #8 was admitted to the facility on [DATE] with diagnoses of Tracheostomy and Anoxic Brain Damage. The MDS dated [DATE] documented that Resident is severely impaired in cognition. Resident #9 was admitted to the facility on [DATE] with diagnoses of Tracheostomy, Bipolar Disorder, and Major Depressive Disorder. The MDS dated [DATE] documented that Resident is severely impaired in cognition. Resident #10 was admitted to the facility on [DATE] with diagnoses of Tracheostomy, Cerebral Infarction and COPD. The MDS dated [DATE] documented that Resident is severely impaired in cognition. Resident #11 was admitted to the facility on [DATE] with diagnoses of Tracheostomy, Diabetes, and Alzheimer's Disease. The MDS dated [DATE] documented that Resident is severely impaired in cognition. Resident#12 was admitted to the facility on [DATE] with diagnoses of Tracheostomy, Diabetes, and Anoxic Brain Damage. The MDS dated [DATE] documented that Resident is severely impaired in cognition. Resident #13 was initially admitted to the facility on [DATE] with diagnoses of Tracheostomy, Cardiac Arrest, and Diabetes. The MDS dated [DATE] documented that Resident is severely impaired in cognition. Resident #14 was admitted to the facility on [DATE] with diagnoses of Tracheostomy, COPD, and Schizophrenia. The MDS dated [DATE] documented resident is severely impaired in cognition. Resident #15 was admitted to the facility on [DATE] with diagnoses of Tracheostomy, Anxiety Disorder, and Diabetes. The MDS dated [DATE] documented that Resident is severely impaired in cognition. Review of the electronic Medication Administration Record (eMAR) for 07/10/2023 revealed that CNA #1 administered medications to 15 residents, a total of 106 medications. CNA #1 used their username and password to log in to CNA kiosk to access the eMAR. The facility summary of investigation dated 07/22/2023 documented that on 07/10/2023 around 10:00pm, the DON were notified by RNS #1 that CNA #1 was performing duties as a licensed nurse on the 2nd floor 3:00pm-11:00 pm shift on the low side. The facility investigated the incident and concluded that CNA #1 posed as a Nurse and proceeded to give care to residents. CNA #1 was terminated. Residents had no evidence of abuse, neglect, or mistreatment. There was no documented evidence that the facility reported the allegation to local law enforcement. During an interview on 07/25/2023 at 10:00AM, the Director of Nursing (DON) stated that the incident was not reported to the local law enforcement. The DON stated that they never knew that they were supposed to report the incident to local law enforcement. The DON stated that they were of the impression that they have five days to report the incident to the NYSDOH not 24 hours. During an interview on 07/24/2023 at 3:32PM, the Administrator stated that they did not report the incident to the local law enforcement. The Administrator stated that CNA #1 was an Agency staff. Therefore, they reported the incident to the agency with the assumption that the agency would report the incident to local law enforcement and other agencies. The Administrator stated that they thought the incident falls under reported accident in which they have 5 days to do the initial report. 10NYCRR 415.4(b)

Based on observation, interviews and record review conducted during an abbreviated survey (NY 672) on 10/21/2021, the facility did not ensure that a resident receive adequate supervision to prevent elopement. This was evident in 1 of 3 residents sampled (Resident #1). Specifically, Resident #1 was assessed as at a high risk for elopement and Resident #1 made 2 prior attempts to leave the facility before 08/19/2021. On 08/19/2021 at around 12:10 AM, Resident #1 attempted to leave the unit again through the southwest C stairwell exit door and CNA #1 stopped him/her after the alarm sounded. No changes were made to Resident #1's plan of care and around 12:45 AM Resident #1 was able to elope from the facility. Resident #1 was discovered missing by facility staff on 08/19/2021 at 1:00 AM. Resident #1 was not found until 1:00 PM on a public street. The findings are: Review of the facility's policy and procedure entitled Elopement/Wandering last revised in 08/2020, documented: It is the policy of the facility to provide a safe environment for all residents. The facility will properly assess residents and plan their care to prevent accidents related to unsafe wandering behavior or elopement. If a resident is identified at risk for elopement, the following precautionary measures will be undertaken alarm bracelet, photo of the resident will be given to the front/security desk for identification, bracelets will be checked weekly for functionality and elopement book is checked every shift. Review of the facility's Summary of Investigation documented that on 08/19/2021 at about 1:00 AM, CNA observed Resident #1 was not in his/her bed. Unit search was done, the Supervisor was informed, and code E (used for elopement) was activated. The entire building was searched but Resident #1 was not found. No one heard the wander guard alarm. The Police were notified around 1:55 AM. The investigation revealed that about 12:10 AM, Resident #1 walked to the exit door and was seen and stopped by the CNA then placed back in his/her room. The Security Guard stated that the alarm went off on the Zone Annunciator located at the front desk at 12:45 AM and the alarm was shut off. The Security Guard then checked the camera of the parking lot and did not see any movement. Surveillance cameras were reviewed and noted: at 12:05 AM, CNA went in the room, at 12:09 AM, Resident #1 tried to exit stairwell C, at 12:20 AM, CNA went in the room, at 12:29 AM, the Charge Nurse went in the room, at 12:45 AM, Resident #1 was walking to the exit door, at 12:57 AM-CNA went to the room and could not find Resident #1. Resident #1 was initially admitted to the facility on [DATE] with diagnoses including [CONDITION(S)] with [CONDITION(S)], Dementia, Hypertension and Unspecified Fracture of the Left Patella with Fixation. The Minimum Data Set (MDS, a resident assessment tool) dated 08/03/2021 identified the resident with short term and long-term memory problems and severely impaired decision-making ability. Resident #1 required extensive assistance of one person with bed mobility, transfer, and toilet use, was wheeled and walking was documented as did not occur. Section E0900 of the MDS documented that wandering behavior occurred 1 to 3 days during the look back period. A Wandering/Elopement Risk assessment dated [DATE] documented that Resident #1 was at high risk for elopement with a score of 10 as evidenced by wandering, appropriate interventions initiated. Interventions checked off: personal safety alarm devices, exit and stairwell alarms, frequent monitoring, identification bracelet, wander guard, family notified, and plan of care updated. Elopement score code 0-5=no risk, at risk =6-7 points and high risk =8 or more points. A Potential for Elopement Care Plan as evidenced by Wandering Behavior related to cognitive impairment and Dementia was initiated on 07/30/2021. The interventions included: assess for wander guard placement, explain rational for wander guard use to family, keep front desk aware of resident's risk for elopement, monitor for changes in cognition, Activities of Daily Living (ADL) and behavior and Psychiatry Consult as per Medical Doctor (MD) order. A Nursing Progress Note dated 07/30/2021 at 3:43 AM documented that resident was noted getting out of lower side door, staff placed in front of nurse's station for close monitoring. Nursing Supervisor informed, will monitor closely. A Nursing Progress Note dated 07/30/2021 at 11:13 AM documented that wander guard applied to right wrist today as ordered. Resident is alert with confusion, unable to verbalize needs. Fall safety precaution maintained. All due care rendered. Will continue to monitor. A Resident Nursing Instructions from 08/01/2021 to 08/19/2021 revealed that there was no instruction for Resident #1 to be monitored. A Psychiatry Consult dated 08/02/2021 at 5:25 PM documented resident's cognition impaired. Diagnoses Adjustment Not Otherwise Specified and Dementia. Recommendations; no psych meds, medical stabilization, and supportive care. A Social Services Progress Note dated 08/02/2021 at 11:15 AM documented Comprehensive Care Plan Meeting held. Resident's family member invited but did not attend teleconference, voicemail left, awaiting follow up call. Placement appropriate secondary to medical necessity. A Nursing Progress Note dated 08/13/2021 at 3:49 AM documented that at 2:20 AM, Resident noted opening lower side exit door, staff put resident to bed and monitored frequently for safety. A Social Services Discharge Planning Note dated 08/13/2021 at 11:27 AM documented that discharge plans discussed with resident's family. Family stated that resident cannot return to previous residence. Resident is able to ambulate and is not suitable for Long Term Nursing Home (LTNH) placement, family in agreement. Assisted Living Facility discussed, and referral made. A Social Services Progress Note dated 08/16/2021 at 8:39 AM documented that resident was accepted to an Assisted Living Facility. Attempted to contact resident's family multiple times on 08/13/2021,no answer. Discharge plan ongoing. Review of the CNA/Nurse Care Assignment dated 08/18/2021 from 11:00 PM- 7:00AM documented 1 Nurse and 2 CNAs plus the covering house Registered Nurse Supervisor for 40 residents. Review of the Physical Therapy Progress Report dated 08/18/2021 documented that Resident #1 could ambulate 75 feet with contact guard assistance. A Nursing Progress Note dated 08/19/2021 at 9:01 AM documented that Resident #1 was alert and oriented x 1 with confusion. Around 12:10 AM, CNA stopped Resident #1 who was trying to leave the unit at the southwest C door. CNA escorted Resident #1 back to room and assisted him/her back to bed. Resident #1at risk for elopement and wander guard in place to right wrist in good condition. Resident has been monitored every 30 minutes. At 12:30 AM, writer made round, resident was in bed lying comfortably under the sheet. By 12:55 AM, CNA reported upon making round, Resident #1 was not seen in his/her bed or in the bathroom. Staff on the floor searched all rooms, closets and bathrooms, Resident #1 was not found . Nursing Supervisor notified immediately; Code E lobby activated. A Nursing Late Note dated 08/19/2021 at 9:35 AM, documented that the writer was called by the unit charge nurse at 1:00 AM and informed that Resident #1 was missing. Immediately started looking for resident. Security Guard was called to announce Code E, and everyone started looking for the resident on each floor , stairs, basement, lobby, and parking lot. Assigned CNA were outside the building looking for Resident #1 around the block and by car in the neighborhood, nearby bus stops and subway station checked. Assistant Director was called at 1:45 AM, DON at 1:47 AM and 911 at 1:54 AM. Police arrived at 1:54 AM, report made, and some clothes given for canine police. Family member was called and message left. Resident #1 was not found. A Nursing Progress Note dated 08/19/2021 at 2:46 PM documented that the writer received a call from Emergency Medical Technician (EMT) Fire Department who stated that someone called and responded that they saw Resident #1. Resident #1 will be sent to the Hospital. Observation of the 6th floor and C stairwell was conducted on 10/21/2021 at 1:20 PM with the Maintenance Director. Resident #1's room was on the 6th floor, 3 rooms from the C stairwell exit door. The exit stairs had a keypad coded exit door stairway. One must enter a code before exiting the stairway otherwise an alarm would sound immediately. There is no delay egress. There were 8 stairs and a landing to each floor. Resident #1 went down from the 6th floor top stair to the 1st floor west exit. The 1st floor west exit door had a keypad with 15 seconds delay egress. There was also another push panic bar exit approximately 6 feet in front of 1st floor west exit which led to the street on Avenue C. The push panic bar exit did not have wander guard alarm. The parking lot was located to the left of and just next to West exit. During an interview on 10/21/2021 at 1:30 PM, the Director of Maintenance (DM) stated that the facility checks all exits door alarms for functioning every day, but it was not documented. The DM said that Resident #1 left the facility through the 1st floor west exit door from stairwell exit C. The DM further stated that the unit's stairwell exits doors alarms do not transmit to the security desk. The DM also said that the 1st floor stairwell C exit alarm sounds at the security desk. The DM verbalized that the west push bar exit door to the street did not have an alarm. The DM also verbalized that the facility's 5 exits were equipped with wander alarm system. The security cameras did not cover the stairwell, they covered the perimeters of the building. During an interview on 10/21/2021 at 1:50 PM, the Director of Security(DS) stated that there were 2 Security Guards on duty, 1 Security Guard covered the front desk, and another Security Guard was covering the 8th floor. The DS further stated that pictures of residents at risk for elopement are kept at the Security desk. Security Guards check the wander guard book at the beginning of their shifts to be familiar and to see if there are any changes. The DS said that the facility exit doors alarms sounded at the security desk. The DS also said that cameras did not cover the units exits doors. During an interview on 10/21/2021 at 2:10 PM, Certified Nursing Assistant #1 (CNA #1) stated that he/she was assigned to Resident #1 when he/she eloped on 08/19/2021. CNA #1 further stated that he/she made rounds at the beginning of the shift and saw Resident #1 lying in bed around at 11:00 PM. CNA #1 took the report then went to pack linen. CNA #1 observed Resident #1 in bed again around 11:20 PM-11:30 PM. At 12:10 AM, CNA #1responded to the stairwell exit alarm and observed Resident #1 attempting to leave the unit. CNA #1 placed Resident #1 back to bed. CNA #1 further said that he/she checked Resident #1 about 2 times afterwards and saw Resident #1 lying in bed; CNA #1 did not remember the times. CNA #1 verbalized that they did not usually sign on a rounds/monitoring sheet. CNA #1 also said that he/she did not hear the stairwell exit door sound when Resident #1 left the unit. During an interview on 10/21/2021 at 2:20 PM, CNA #2 stated that he/she worked on the unit on the shift when Resident #1 eloped. CNA #2 said that he/she was monitoring another resident who was a fall risk. CNA #2 further said that he/she heard the alarm when Resident #1 attempted to leave the first time during the shift, but he /she did not hear the alarm when Resident #1 left through the stairwell exit door. CNA #2 verbalized that they did not sign a monitoring sheet for Resident #1 or the resident who he/she was monitoring. During an interview on 10/21/2021 at 3:30 PM, Security Guard #1(SG#1) stated that he/she worked from 11:00 PM on 08/18/2021 to 08/19/2021 at 7:00 AM. SG #1 further said that he/she heard the 1st floor West stairwell alarm on 08/19/2021 at around 12:48 AM. SG #1 further stated that he/she silenced the alarm then looked in the camera. SG #1 stated that he/she saw about 8-10 construction staff in a section of the parking lot area just next to the exit and thought that it was a construction worker who opened the exit door. SG #1 also said that he/she could not see the area in front of the West stairwell exit C. SG #1 said he/she did not check the West stairwell exit area or alert the nursing supervisor. SG #1 verbalized that he/she was in-serviced on Elopement Precautions. During an interview on 10/25/2021 at 9:17 AM, Registered Nurse Supervisor #1 ( RNS #1) stated that he she was the Nursing Supervisor when Resident #1 eloped. RNS #1 further stated that Licensed Practical Nurse #1 (LPN #1) informed him/her that Resident #1 had attempted to leave the unit prior to his/her elopement. RNS #1 stated that he/she told LPN #1 to tell a CNA to keep an eye on Resident #1. RNS #1 said that there were only 2 CNAs assigned to the unit and another fall risk resident was trying to get up. RNS #1 stated that he/she went up to the unit after he/she was informed that Resident #1 had attempted to leave. Resident #1 was already back in his/her room. RNS #1 further stated that he/she was informed that Resident #1 was missing at 12:55 AM. The staff started looking everywhere on the unit. After Resident #1 was not found, Code E was called. A total of 3 staff went outside and searched around the building and neighborhood. Calls were made to the Assistant Director, Director of Nursing, Police and Resident #1's family. During an interview on 12/08/2021 at 11:19 AM, Licensed Practical Nurse #1 (LPN #1) stated that he/she was the charge nurse of the unit when Resident #1 eloped from the facility on 08/19/2021. LPN #1 stated that Resident #1 often got out of bed and walked around on the unit during the night, staff redirected him/her to his/her room. Resident #1 was at risk for elopement and had a wander guard in place. On 08/19/2021 at 12:10 AM, Resident #1 attempted to leave the unit through the stairwell exit door. The alarm sounded and CNA #1 stopped Resident #1 from leaving the unit. LPN #1 said that he/she told CNA #1 to put on Resident #1's sleepwear and place him/her in bed. LPN #1 stated that he/she informed RNS #1 that Resident #1 attempted to leave the unit and RNS #1 told him/her that the unit staff should watch Resident #1. LPN #1 said that he/she and the 2 CNAs had an eye on Resident #1 every 30 minutes. LPN #1 verbalized that he/she last saw Resident #1 at 12:30 AM lying in bed, covered under the sheet. At around 1:00 AM, CNA #1 informed LPN #1 that Resident #1 was not in his/her room. LPN informed unit staff to search the unit for Resident #1 then called Security Guard #1 and RNS #1. LPN #1 stated that he/she did not hear the stairwell exit door alarm when Resident #1 left the unit. During an interview on 12/20/2021 at 2:39 PM, the Director of Nursing (DON) stated that Resident #1 was on a documented every half hour visual monitoring prior to his/her elopement. The DON further stated that Resident #1's monitoring sheets that were done prior to the elopement were thrown out. The facility only had proof of Resident #1's monitoring sheets that were done post elopement. All the facility's residents were monitored every half hour. The DON said that visual monitoring should have been included on Resident #1's Potential for Elopement Care Plan and Resident Nursing Instructions. The DON also said that the facility implemented everything and could not have done anything else to prevent Resident #1's elopement. The staff were already taking turns monitoring Resident #1 after he/she attempted to elope earlier in the shift when he/she eloped on 08/19/2021. The CNAs were also taking care of other residents. In-services on Elopement Prevention were done with Security Guards and the facility's staff. Security Guard #1 was terminated from employment at the facility. 415.12(h)(2)

Based on observations, record review, and interviews during an unannounced Focused Infection Control Survey (Event ID:YFSJ11) conducted 7/20/21, the facility failed to ensure each resident has a right to receive visitors of their choosing at the time of their choosing, subject to the residents' right to deny visitation when applicable, and in a manner that does not impose on the rights of other residents. Specifically, the facility has only allowed for window visits and Compassionate Care visits and no regular visitation since 3/13/2020. The findings are: The New York State Health Advisory: Revised Skilled Nursing Facility Visitation dated 7/8/21 documented visitation can be conducted through different means based on a facility's structure and residents' needs, such as in resident rooms, dedicated visitation spaces, and outdoors. Outdoor visitation is preferred whenever practicable even when the resident and visitor are fully vaccinated against COVID-19, and facilities should create accessible and safe outdoor spaces for visitation. In accordance with CDC and CMS guidelines, facilities should allow indoor visitation at all times and for all residents (regardless of vaccination status), except for a few circumstances when visitation should be limited due to a high risk of COVID-19 transmission. These scenarios include limiting indoor visitation for: Unvaccinated residents if, the nursing home's COVID-19 county positivity rate is >10% and <70% of residents in the facility are fully vaccinated; Residents with confirmed COVID-19 infection, whether vaccinated or unvaccinated until they have met the 2 criteria to discontinue Transmission Based Precautions; or residents in quarantine, whether vaccinated or unvaccinated, until they have met criteria for release from quarantine. With the appropriate safeguards, visitation can still occur when there is an outbreak, but there is evidence that the transmission of COVID-19 is contained to a single area (e.g., unit) of the facility. The Centers for Medicare & Medicaid Services (CMS) memo (Ref: QSO-20-39-NH) titled Nursing Home Visitation - COVID-19 (REVISED), dated 9/17/21, documented facilities should allow indoor visitation at all times and for all residents (regardless of vaccination status), except for a few circumstances when visitation should be limited due to a high risk of COVID-19 transmission (note: compassionate care visits should be permitted at all times). These scenarios include limiting indoor visitation for unvaccinated residents, if the nursing home's COVID-19 county positivity rate is >10% and <70% of residents in the facility are fully vaccinated; residents with confirmed COVID-19 infection, whether vaccinated or unvaccinated until they have met the 2 criteria to discontinue Transmission Based Precautions; or residents in quarantine, whether vaccinated or unvaccinated, until they have met criteria for release from quarantine. The Facility Policy and Procedure titled COVID -19 Visitation Plan, revised 7/8/2021, documented the facility would create accessible and safe outdoor spaces for visitation, such as patios in the front and on the side of the building by 7th Avenue. The facility will allow indoor visitation at all times and for all residents (regardless of vaccination status), except for the few circumstances, per the CMS guidance, when visitation should be limited due to a high risk of COVID-19 transmission (exception compassionate care visits should be permitted at all times). The facility will schedule visits for a maximum of three hours to help ensure all residents are able to receive visitors. A resident shall have one visitor at a time. For residents who share a room, visits may not be conducted in the resident's room if possible. For situations where there is a roommate and the health status of the resident prevents leaving the room, in room visitation may be conducted while adhering to the core principles of COVID-19 infection prevention. The New York State Percentage COVID-19 Positivity Rate on 7/20/21 was 1.7%, and the 7-day rolling average was 1.5%. A listing of all positive COVID-19 test results the facility received in the current outbreak was provided. The facility received positive COVID-19 test results for 3 residents swabbed on 7/12/21. Two additional positive COVID-19 results were received for 2 residents swabbed on 7/14/21 and one resident swabbed on 7/19/21. The 7th floor was placed on quarantine 7/12/21 in response to the new COVID-19 cases identified on the unit. During an interview on 7/20/21 at 5PM, the Director of Nursing (DON)/ Infection Control Preventionist (ICP) stated since visitation was suspended on 3/13/2020, the facility has not resumed visitation. The facility has continued video calls, window visits, personal caregiver visits, and compassionate care visits. The facility conducted routine weekly swabbing for all residents until 7/12/21, when the current outbreak was identified. The facility implemented twice weekly testing for residents and staff, which continues, in response to the outbreak. The last date of testing was 7/19/21, and one resident on the 7th floor tested positive for COVID-19 and was hospitalized . There are no staff on [NAME] due to COVID-19 infection. The DON/ICP stated that she is aware of the 7/8/2021 Health Advisory regarding visitation. The DON/ICP stated that although the county positivity rate is below 10%, the number of vaccinated residents in the facility is below 70%, therefore all visitation remains suspended except for compassionate care and personal caregiver visits. 415.3

Based on observation, record review, and staff interview conducted during the Recertification survey, the facility did not ensure that medication and biologicals were discarded by expiration date. Specifically, a bottle of expired eye vitamins was observed in the stock medications in the medication room. This was evident on 1 of 6 units reviewed for Medication Storage (Unit 2). The findings are: The Medication Storage and Labeling Policy dated 03/2021 documented in house medication bottles is labeled with red ink as an identifier of the expiration date. When delivered upstairs and ready to use, Licensed nurse must label the bottle with open date with black ink as the identifier. The procedures for Licensed Nurses documented that medications and biologicals are labeled in accordance with currently accepted professional principles and include the expiration date, when applicable. On 06/16/2021 at 4:55 PM, an observation of the medication room on the 2nd floor was conducted with the RN Supervisor (RN# 1) due to LPN#1 conducting medication pass on the unit. One bottle of [MEDICATION(S)] I-Cap Eye Vitamin and Mineral Supplement Age Related Eye Disease Study (AREDS) Coated tablets with an expiration date of 08/2019 was noted in the medication room cabinet. RN#1 noted that the medication was expired and needed to be discarded. Inservice training on Medication Storage and Labeling dated 08/18/2020 documented that LPN#1 attended the training. The Pharmacy Nursing Station Evaluation form for the 2nd Floor dated 06/02/2021 was reviewed and documented that there were expired medications that were located in the medication room to include insulin, [MEDICATION(S)] and , inner nasal cannula. On 06/16/2021 at 5:03 PM, an interview was conducted with the Licensed Practical Nurse (LPN #1). LPN#1 stated it is the responsibility of the LPN to check the medication room every time they work, and if they have time, they organize vitamins and liquids and check expiration dates. They stated that the item was on the shelf in the back and they were not aware the item was expired. When giving medications to residents check the expiration date and label and verify the expiration date is correct. If giving a medication after the expiration date, the medication can have a different effect and may not be good for the patient. The chemical may be dangerous to patient. Expired medication should not be given to the patient. On 06/17/2021 at 3:39 PM, an interview was conducted with RN #2. RN#2 stated that they supervise the 2nd and 3rd floor. RN#2 stated that they do not use vitamin medications a lot. RN#2 stated that the LPNs check the med room and expiration dates of medication weekly, but it is not mandatory. RN#2 stated that the RNs conduct a random monthly check at the beginning of the month. If expired medication is found, they conduct an in-service. It is important to check dates to make sure we do not give expired medications to the patient, to prevent adverse reactions or harm to the residents. LPN #1 checks the expiration dates of items in the medication cart and medication room [ROOM NUMBER] days per week. On 06/18/2021 at 9:35 AM, an interview was conducted with the Assistant Director of Nursing (ADNS). The ADNS stated that the medications should be checked every shift and every day. The medication nurse should check the medication room for expiration date because we don't want to have any expired medication. It is checked so we do not have a medication error and have to contact the medical doctor and decide how to evaluate the resident if we administer an expired medication. The facility has a system in place, and staff were in-serviced. When the nurse comes on duty, they check the refrigerator temperature, check liquid medication and storage medications. ADNS stated that they audit the medication rooms, and the supervisor does daily checks. The ADNS stated they perform random checks of the medication room every 2-3 months. On 06/18/2021 at 9:47 AM and 11:54 AM, a telephone interview was conducted with the Pharmacy Consultant Supervisor (PCS) secondary to the facility pharmacy consultant not being available. The PCS stated that they come to the facility on ce a month and check the medication room, medication cart, narcotic cabinet, and insulin refrigerator. PCS stated that the medication room is checked, and a report is provided to the facility. If expired items are found, they are taken off the shelf and brought to the nurse's office. They also inform the facility of medications about to expire so that they can order a replacement. PCS stated that on the most recent inspection, expired items were located in the medication room on the 2nd floor. PCS stated that they are provided a copy of the inspection report monthly from the assigned pharmacy consultant. On 06/18/2021 at 2:23 PM, an interview was conducted with the Director of Nursing Services (DNS) who stated the checking of medications should be done weekly and whatever we have on the chart should be checked to ensure they are not expired. Pharmacist check done monthly. We also implemented that any medication that comes in is labeled in red ink to show expiration date and black is the open date. We encourage the nurse to check meds frequently, and we insist that they check meds as often as possible. 415.18 (e) (1-4)

Based on observations, record review, and staff interviews during the recertification survey, the facility did not ensure that the resident's assessment accurately reflected his health care condition. Specifically, The most recent assessment as recorded on the Significant Change Minimum Data Set (MDS) documented that Resident #22 had a [DIAGNOSES REDACTED]. This was evident of 1 out of 35 sampled residents. The findings are: Resident # 22 was admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. Major [MEDICAL CONDITION] single episode mild, Other Chronic Pain, Acute Respirator Failure, Dependence on Respirator. A [DIAGNOSES REDACTED]. No [DIAGNOSES REDACTED]. The most recent assessment as documented on the Significant change MDS dated [DATE]; documented the resident as having an active [DIAGNOSES REDACTED]. Resident [DIAGNOSES REDACTED]. The physician's notes do not document a [DIAGNOSES REDACTED]. Initial Minimum Data Set ((MDS) dated [DATE] does not document Non-Alzheimer's Dementia as an active diagnosis. Quarterly MDS dated [DATE] does not not document Non-Alzheimer's Dementia as an active diagnosis. During a review of the Comprehensive Care Plans (CCP) that there resident has Non-Alzheimer's Dementia. The Social Services Note dated 9/18/18 documented that the resident appears to be adjusting to placement as capacity permits. Resident is alert and responsive to tactile touches and verbal command, comprehends Mandarin. Resident is moderately impaired in cognition with short term memory problems as per staff assessment secondary to dx (diagnosis) : moderate cognitive impairment. Subsequent Social Services notes dated 9/20/18, 10/9/18, 10/21/18, 11/4/18, 11/11/18, 11/26/18, 12/9/18, 12/27/18, 12/30/18, 1/6/19, 1/17/19, and 1/27/19 have no mention of resident being diagnosed with [REDACTED]. The Psychiatry Note dated 9/14/18-no known psych history- resident arrived with orders for [MEDICATION NAME] with no specific indication, he is at risk for self-injury if moves around excessively. hospital records reflect he was given [MEDICATION NAME] 100 mg q (every) 12- in facility he was prescribed [MEDICATION NAME] 50 mg q 12, no known history of depression, mania, or [MEDICAL CONDITION], - behavior is mildly restless, mild cognitive impairment, diagnosis- restlessness and agitation due to General Medical Condition. 10/12/18- Psychiatry Note- patient was re hospitalized due to worsening of physical condition, now readmitted . He continues to pull tubes and now in mitten. Gradual Dose Reduction (GDR) discussed with staff. Staff consensus is that further [MEDICATION NAME] GDR will result in worsening of serious self-endangering behavior. Diagnosis- restlessness and agitation due to general medical condition, mild cognitive impairment. The psychiatrist did not mention a [DIAGNOSES REDACTED]. 12/28/18- Psychiatry Note- no known history of depression,[MEDICAL CONDITIONS], history of cognitive decline, [MEDICATION NAME] 37.5 mg q 12. patient was sent to the hospital due to worsening condition and is now readmitted . at this point we can lower the [MEDICATION NAME] to 25 mg am and 37.5 mg hs (at hour of sleep). dx- restlessness and agitation due to general medical condition, moderate cognitive impairment vs mild dementia. The Psychiatrist did not definitively make a [DIAGNOSES REDACTED]. 1/25/19- Psychiatry Note - [MEDICATION NAME] was lowered to 25 mg am and 37.5 mg hs, staff agree with plans to lower [MEDICATION NAME] further to 25 mg am and hs moving forward, dx- restlessness and agitation due to general medical condition, moderate cognitive impairment, possible [MEDICAL CONDITION]. 3/1/19- Psychiatry Note - [MEDICATION NAME] lowered to 25 mg am and 25 mg hs. staff agree with plans to lower [MEDICATION NAME] further to 12.5 mg am and 25 mg hs moving forward. dx- restlessness and agitation due to general medical condition, moderate cognitive impairment, possible [MEDICAL CONDITION]. On 04/04/19 at 10:54 am and interview was held with Registered Nurse (RN) # 1. RN#1 stated that staff reported the resident is very active and alert. Staff reported resident is being weaned off the ventilator and is tolerating ventilator well. Staff reported that resident is able to make needs known. Staff reports the resident was agitated after he was first admitted , but now he understands what he needs and that it is good for him. Staff reported the resident is able to tell us what he wants like if he wants to be in the wheel chair. RN #1 stated that the resident does not have a [DIAGNOSES REDACTED]. On 04/05/19 at 09:57 am, the MDS coordinator was interviewed and stated that when completing MDS we interview resident/staff/family/significant others, go through hospital records, and then from chart itself and whatever is in the Electronic Medical Record (EMR). MDS assessors are the ones that actual completing the MDS, they are the ones doing the interviews and communicate with staff. If the MDS assessors are not sure about something they will ask me, and I will ask the medical doctor or medical director Dementia [DIAGNOSES REDACTED]. Sometimes the PRI has dementia and resident goes out and comes back and the dementia [DIAGNOSES REDACTED]. For this resident after review there was no dementia care plan. On 04/05/19 at 11:02 am an interview with the psychiatrist was held. The psychiatrist stated that the resident came to the facility from the hospital and had spinal surgery and had multiple medical problems and is cognitively impaired. the psychiatrist stated that he does not know if the res has Alzheimer's, due to multiple medical conditions, and that the resident is definitely cognitively impaired. The psychiatrist did not give a definitive [DIAGNOSES REDACTED]. 415.11 (b)

Based on records review and interview conducted during the recertification survey; the facility did not develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Specifically, the most recent Comprehensive Assessment of Resident #160 documented that the resident had a [DIAGNOSES REDACTED]. The finding is The facility policy Care Planning: Interdisciplinary revised 11/01/2017 document the Comprehensive Care Plan will include measurable objectives and timetables in order to meet the Resident's medical, nursing and psychosocial needs that are identified from the Initial Assessment and in conjunction with the Comprehensive Assessment. Resident #5 was originally admitted to the facility on [DATE]. The most recent comprehensive assessment was documented on the Minimum Data Set (MDS) 3.0, dated 03/05/2019. It documented the resident with short-term memory impaired cognition and a [DIAGNOSES REDACTED]. The CCP for Psychoactive medication documented the need to use [MEDICAL CONDITION] medication secondary to/related to/ as evidence by depression but does not provide specific interventions or measurable objectives, or goals to address the resident's symptoms of depression. The same can be said for the CCP for behavior. The CCP did not specifically address the resident's mood or behavior as it specifically relates to their [DIAGNOSES REDACTED]. On 04/04/19 at 12:58 PM an interview was conducted with Registered Nurse (RN #2) employed by the facility for three years. RN#2 stated on (MONTH) 11, 2019 the resident was transferred from the 7th floor to 4th floor. RN #2 stated when a resident is transferred to the unit the care plan, immunization, medication, and physician notes ([DIAGNOSES REDACTED]. The care plan is updated when there are changes such as behavior, skin and MDS assessment of the resident. RN #2 stated a care plan specific for depression is not required; the [DIAGNOSES REDACTED]. On 04/04/19 at 02:33 PM, an interview was conducted with RN#3 employed by the facility for seven years. RN #3 stated on the 7th floor, resident #160 was alert, verbally responsive, and confused at times. RN#3 also stated resident #160 would not reply when spoken to or say live me alone on some days. The behavior care plan does not include depression and most of behavior notes are related to combative behaviors stated the RN#3. RN #3 stated at this time there is no active care plan specific to depression, but depression addressed in the psychotherapy medication CCP document verbalization of feelings, recreational activities and social service as interventions. RN#3 stated more details on the signs and symptoms of depression needed to be documented in the care plan. 415.11(c)(1)

Based on observation, staff interviews, and record review during an abbreviated and partial extended survey (NY 084), the facility failed to provide necessary respiratory care and services consistent with professional standards of practice. In addition, the facility failed to provide continuous mechanical ventilation on ventilator dependent residents. This was evident for 2 out of 7 residents sampled (Resident #1 and Resident #2). Specifically, Resident #1 and Resident #2 had an Operational Verification Procedure (OVP) that was performed on their ventilators on [DATE]. Resident #1 and Resident #2 were found unresponsive and were pronounced dead at the facility within 10 minutes of each other. The investigation revealed that the mechanical ventilation was not resumed after the OVP was performed, by the Respiratory Therapist #1 (RT #1), on the residents' ventilators. Resident #1 was without ventilation for 1 hour and 20 minutes and Resident #2 was without ventilation for 2 hours and 14 minutes. This practice resulted in actual harm for 2 residents (Resident #1 and Resident #2) and the potential for serious harm to the health and safety of all ventilator dependent residents in the facility that is Immediate Jeopardy and Substandard Quality of Care. The findings are: The facility's respiratory care policy on mechanical ventilation with a subject The HT 70 Plus Operational Verification Procedure (OVP) with an issue date of (MONTH) (YEAR) documented that OVP is recommended before initial use of a ventilator, once per month and when the circuit is removed or replaced. The procedure also stated that after performing a successful circuit check (also known as OVP), the following steps must be done: 1. Activate Ventilation 2. Check for chest rise and bilateral breath sounds 3. Check for peak pressure rise and fall 4. Do an OVP completed ventilator check for safe connection confirmation Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DATE] Minimum Data Set (MDS), a resident assessment tool, documented that the resident had moderately impaired cognition - decisions poor; cues/supervision required. The care plan on impaired airway clearance was implemented on [DATE] and documented that Resident #1 was full ventilator use and tolerating the settings. A Physician order [REDACTED]. Attached to Newport HT 70 plus Ventilator Mode: APC (Assist Pressure Control) Rate: 12 Volume: 500 FiO2 (Fraction of Inspired Oxygen): 30% PEEP (Positive End Expiratory Pressure): +5 iT (Inspiratory Time): 1.1 sec I:E (Inspiratory: Expiratory Ratio): 1:2 Duration: 20 hours from 2:00 PM to 10:00 AM Spontaneous Breathing Trial (SBT) from 10:00 AM to 2:00 PM as tolerated. Document end-tidal Carbon [MEDICATION NAME] (CO2) daily and as needed; Mode: Pressure Support Ventilation (PSV), PEEP +5, FiO2 30% for 4 hours. A Medical Doctor's (MD) note dated [DATE] at 9:53 AM documented that Resident #1 was seen for weekly rounds, vitals were stable and to continue with ventilator support. A Ventilator/Treatment Flow Sheet for Resident #1 documented that on [DATE] at 10:30 AM, the resident's ventilator mode was on PSV (indicates that she was on SBT/weaning mode) and the oxygen saturation was 100%. The last entry documented, by RT #1, for Resident #1 was on [DATE] at 4:05 PM. The resident's ventilator was on Assist Control mode (A/C) and the oxygen saturation was 99%. There was no documentation that OVP was performed on [DATE]. RT #1's progress note dated [DATE] at 5:05 PM documented that Resident #1 was placed on weaning via PSV for 4 hours and it was tolerated well. RT #1's progress note dated [DATE] at 7:41 PM documented that the RT was called to Resident #1's room at around 6:30 PM. Upon arrival, Resident #1 was observed ashen gray and unresponsive. A STAT (code for emergency) was called; Cardiopulmonary Resuscitation (CPR) was initiated, and 911 was called. A MD's note dated [DATE], entry time 8:27 PM, documented that Resident #1 was seen on [DATE] (time not documented). Resident #1 has been weaning for the past few days up to 4 hours on Pressure Support mode. The resident was seen on full ventilator support, A/C mode, normal peak pressure, and with adequate oxygen saturation. The resident was hemodynamically stable and in no distress. A Registered Nurse Supervisor's (RNS) progress note dated [DATE] at 10:05 PM documented that the RNS responded to a STAT call at approximately 6:30 PM in Resident #1's room. Resident #1 was noted ash gray with no pulse, no respiration, no blood pressure, pupils were fixed and non-reactive to light. CPR was initiated; Artificial External Defibrillator (AED) applied with no shock advised. 911 responded and took over CPR. Resident #1 was pronounced dead at 7:00 PM. A facility surveillance camera dated [DATE] was viewed by the surveyor and the Assistant Director of Nursing (ADON) on [DATE] at 10:30 AM. The surveillance camera showed RT #1 entered Resident #1's room at 4:45 PM and left the room at 4:54 PM. Licensed Practical Nurse #1 (LPN #1) was observed entering Resident #1's room at 4:53 PM, 5:25 PM, 6:01 PM, left and reentered the room again at 6:06 PM and was observed running out of the room at 6:09 PM. The staff including RT #1 and RT #2 were observed going into Resident #1's room at 6:09 PM. The camera showed 911 Emergency Medical Technician (EMT) arrived at 6:26 PM. A print out of Resident #1's Ventilator Record dated [DATE] to [DATE] revealed the following: [DATE] at 4:47 PM -Ventilator was powered down [DATE] at 4:49 PM - Ventilator was powered up [DATE] at 4:49 PM - Circuit check passed [DATE] at 6:09 PM - Reset pressed [DATE] at 6:09 PM - Silence Activated [DATE] at 6:09 PM - Start Ventilation Based on the events reviewed from the ventilator record, Resident #1 was not receiving mechanical ventilation from 4:49 PM up to the time she was found unresponsive at 6:09 PM (1 hour and 20 minutes). Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DATE] MDS documented that the resident had severely impaired cognition - never/rarely made decisions. The care plan on impaired clearance dated [DATE] documented that Resident #2 was ventilator dependent and tolerating the settings. A Physician order [REDACTED]. Attached to Newport HT 70 plus Ventilator Mode: AVC (Assist Volume Control) Rate: 18 Volume: 500 FiO2: 35% PEEP: +5 iT: 0.9 sec I:E: 1:2 Duration: continuous A MD's note dated [DATE], entered at 9:41 AM, documented that Resident #2 was seen for weekly rounds, vital signs were stable with plan to continue with ventilator support. RT #1's progress note dated [DATE] at 7:39 PM documented that he was called to Resident #2's room at around 6:40 PM. CPR was in progress upon arrival. No vital signs were appreciated. EMT arrived and took over. RNS #1's progress note dated [DATE] at 10:21 PM documented that during rounds at approximately 6:40 PM, he observed Resident #2 pale looking with no pulse, no blood pressure, pupils were fixed and non-reactive to light. A STAT was called, CPR was initiated, and AED applied with no shock advised. 911 responded and took over. Resident #2 was pronounced dead at 7:15 PM. A Ventilator/Treatment Flow Sheet, dated [DATE] at 5:00 AM, for Resident #2 documented oxygen saturation 100% and heart rate 73. The last entry, by RT #1, dated [DATE] at 7:50 AM only documented the ventilator settings. The oxygen saturation and heart rate were not documented. There is no documentation to support that OVP was performed on [DATE]. The facility surveillance camera dated [DATE] for Resident #2 was viewed by the surveyor and the ADON on [DATE] at 10:30 AM. The camera revealed that RT #1 entered Resident #2's room holding a circuit tubing at 4:16 PM, he left the room but went back in at 4:19 PM and left the room at 4:24 PM. LPN #2 entered the room at 4:30 PM and left, reentered at 4:57 PM and left at 5:07 PM, reentered 5:07 PM and left at 5:09 PM. RT #3 entered the room at 4:50 PM, 5:14 PM, 5:35 PM and 6:12 PM. RN #1 went into Resident #2's room at 6:32 PM and a few seconds later RNS #1, RT #2 and RT #3 went in the room. RT #1 was observed entering Resident #2's room at 6:35 PM and 911 EMT arrived at 6:37 PM. A print out of Resident #2's Ventilator Record dated from [DATE] to [DATE] revealed the following: [DATE] at 4:16 PM - Ventilator was powered down [DATE] at 4:18 PM - Ventilator was powered up [DATE] at 4:18 PM - Circuit check passed [DATE] at 6:38 PM - Start Ventilation [DATE] at 6:38 PM - Alarm on, check circuit [DATE] at 6:38 PM - Alarm on, low pressure [DATE] at 6:38 PM - Ventilator was powered down Based on the events reviewed from the ventilator record, Resident #2 was not receiving mechanical ventilation from 4:18 PM up until the time she was found unresponsive at 6:32 PM (2 hours and 14 minutes). The Director of Respiratory Therapy (DRT) was interviewed on [DATE] at 12:10 PM and stated that he was out of the facility when he received a phone call stating that Resident #1 and Resident #2 had arrested. He stated that he went back to the facility at approximately 7:00 PM. He reviewed the stored events in the residents' ventilators and found that an OVP was performed on both ventilators. The ventilators passed the circuit check, however, the start ventilation button was not pressed. The ventilators were left in standby mode. When the ventilator is in standby mode, the resident is not receiving ventilation. RT #1 was interviewed on [DATE] at 1:07 PM and stated that on [DATE] he was conducting afternoon rounds when the nurses called his attention that Resident #1 was not responding. He stated that he started CPR with RNS #1 until EMS came and took over. He was trying to finish up with Resident #1 when he heard that Resident #2 also needed help. He responded and started ambu bagging Resident #2 until EMS came and took over. RT #1 stated that Resident #1 and Resident #2 were assigned to him. RT #1 did a circuit change on some of the residents but could not remember which residents and stated, I think I did Resident #1 and #2. RT #1 explained that after the OVP procedure is completed, the START VENTILATION button must be pressed. However, he could not remember if he pressed the START VENTILATION button for Residents #1 and #2. He stated, I did, I think so .It is hard for me to remember when you try to process everything all at once. RNS #1 was interviewed on [DATE] at 3:27 PM and stated that on [DATE] at around 6:30 PM, he responded to a STAT for Resident #1. Upon his arrival to the room, CPR was already in progress and continued until 911 arrived and took over. At around 6:,[DATE]:45 PM, he also responded to another STAT and observed Resident #2 pale, with no pulse and no blood pressure. CPR was initiated and AED was applied onto Resident #2 with no shock advised. The RNS stated that the RTs are responsible for checking the ventilator settings and that the ventilators are functioning. He received no training on the ventilators. Licensed Practical Nurse #1 (LPN #1) was interviewed on [DATE] at 3:09 PM and stated that on [DATE] when she went to Resident #1's room at around 6:00 PM to hang her tube feeding, she observed that Resident #1 was pale and unresponsive with no pulse. She immediately called STAT and CPR was initiated. The AED was applied onto Resident #1 and it said, No shock advised. She stated that she made rounds at the start of her shift, but did not check the ventilators. It is the RTs' responsibility to check the ventilators. The nurses respond to the ventilator alarm and call the RTs. She has no training on the ventilator. RT #2 was interviewed on [DATE] at 1:33 PM and stated that on [DATE] she responded to a code in Resident #1's room. The RT observed the resident was pale and not responding. She grabbed the ambu bag, disconnected the resident from the vent, and started ambu bagging. She stated that she does not recall if Resident #1's ventilator was on or off, she was just concerned for the resident. She stated that she remembers turning OFF the power button before ambu bagging because it will make a lot of noise when she disconnects the tubing from the ventilator. She does not remember touching the ventilator screen/monitor. The RT stated there is no alarm when a machine is on prolonged standby mode. There is no way to know unless an RT goes in the room and visually checks the ventilator. The RT stated that RTs are responsible in operating and managing the ventilator, nurses do not touch the machines. RT #3 was interviewed on [DATE] at 2:44 PM and stated that on [DATE] she was in the hallway when she responded to a STAT for Resident #2. She stated that she was not assigned to Resident #2. She had been going in and out of Resident #2's room because she had to use the sink to wash her hands. She stated that she did not check on Resident #2 because she is not my patient. Registered Nurse #1 (RN #1) was interviewed on [DATE] at 2:38 PM and stated that when he made rounds at the start of his shift on [DATE], Resident #2 was fine in the dayroom. Resident #2 was transferred back to her room at approximately 4:00 PM. RN #1 stated that there was a STAT for Resident #1 and that CPR was in progress when he arrived in the room. 911 arrived and took over the code, he stated that he left the room to check on the other residents assigned to him. He entered Resident #2's room at around 6:40 PM and observed the resident pale. A STAT was announced for Resident #2, CPR initiated, and 911 came and took over. RN #1 denied touching the ventilator and stated that he did not observed anyone touching the ventilator during STAT. He stated that the nurses' responsibility is to respond to the ventilator alarms; the ventilators are solely operated by the RT. He stated that when a ventilator is on standby the screen is completely off. RN #1 stated that he did not receive any in-service on ventilators. LPN #2 was interviewed on [DATE] at 11:36 AM and stated that on [DATE] she was the medication nurse on the side of the unit where Resident #2 resided. LPN #2 stated that the resident looked fine at the start of the shift. She stated that she went to Resident #2's room a few times. She was in the recliner and was placed back to bed before she started the resident's tube feeding at around 5:00 PM. She administered a scheduled 4:30 PM medication and a 6:00 PM medication to Resident #2. She remembered RN #1 instructing her to call 911 for Resident #2 and they started CPR. The LPN stated that she has no training on ventilators and that she would not have known if a ventilator was on STANDBY mode. She only responds to the ventilator alarm and then calls the RT. The vendor, who sold and services the ventilators in the facility, was interviewed on [DATE] at 12:18 PM. The vendor stated that monthly circuit check is performed on ventilators to check the integrity of the circuit. The vendor explained that to perform the circuit check (or OVP), the resident must be taken off the ventilator and another form of ventilation must be supplied to the resident (in this case, ambu bag). During OVP, the machine is turned OFF, turned back ON, and the main start up screen will show. The CIRCUIT CHECK button must be pressed (instruction will show up on the screen). If the machine passed the circuit check, the screen goes back to the main start up screen (STANDBY MODE) with 3 buttons in the top message area, START VENTILATION, CIRCUIT CHECK & ACTIVATE PRESET. The start ventilation button must be pressed to resume ventilation, and then the patient is hooked back to the ventilator. The vendor also stated there is no alarm and no flashing light when a ventilator is on STANDBY, it is just like waiting for instruction. It is the same situation when the machine is turned OFF, it will not alarm. There is no pulse oximeter built into the ventilator machine. RNS #2 was interviewed on [DATE] at 3:15 PM and stated that she is the supervisor for the ventilator unit from 7AM-3PM. RNS #2 stated that nurses respond to the ventilator alarms but they do not touch the ventilator. The nurses do not know anything about the ventilator management. The MD orders the ventilator setting and the RTs enters the setting in the ventilator. There is no way for the nurses to know if the residents are getting ventilation, and they do not know anything about STANDBY MODE. 6 RNs and 4 LPNs who work in the ventilator unit were interviewed on [DATE]. They all stated that they did not receive any in-service on ventilators and that they would not know when a ventilator is in STANDBY MODE. The Medical Director was interviewed on [DATE] at 2:14 PM and stated that the Administrator informed him on Thursday [DATE] that 2 ventilator dependent residents passed away and that there was a questionable problem with the ventilators. He was told by the DRT that the ventilators were left in standby mode and that the time of the codes were close to each other. The MD was interviewed on [DATE] at 11:40 AM and stated that he is the attending physician for Residents #1 and Resident #2. He stated that he saw the residents on Monday ([DATE]) in the morning and that they were both stable. The MD stated that his initial impression was that the residents must have suffered a massive infarction, but 2 residents passing away did not make him happy and he felt that something was wrong. He stated that when he came to the facility on Wednesday [DATE], the DRT told him that they were investigating the incidents. The MD stated that last week (could not remember which day) the DRT told him that something went wrong and that the ventilators for Resident's #1 and Resident #2 were left on standby mode. The ADON was interviewed on [DATE] at 1:28 PM and stated that she was covering for the Director of Nursing (DON) from [DATE] to [DATE] and no one told her about the situation involving Residents #1 and Resident #2. She reviewed the 24-hour report on Tuesday ([DATE]) and found out that 2 residents expired but was not aware that there was a problem with the ventilators. She found out about the problem on [DATE] when the DON came back to work. The ADON is also the in-service coordinator for the facility. She stated that licensed nurses receive competency on [MEDICAL CONDITION] care and other bedside nursing care. The nurses have no competency / training on ventilators, it is entirely for the RT's responsibility. The Administrator was interviewed on [DATE] at 11:15 AM and on [DATE] at 12:38 PM. He stated that the incident happened on Monday [DATE] but that the DRT told him about the situation on Wednesday [DATE]. He was told that 2 residents expired and that the DRT wanted to make sure that everything was done properly. The DRT checked the ventilator machines and found that the ventilators were not put back to ventilation position. The DON was interviewed on [DATE] at 2:30 PM and stated that she was out sick and came back on Thursday [DATE] when the DRT informed her about the deaths of Resident #1 and Resident #2. The DRT showed the DON a paper about the time generated from the ventilators showing that ventilation was not started after the circuit checks were completed and that was the reason they decided to report the incident to the State. The DON stated that the licensed nurses who work on the ventilator units are responsible for assessing the residents, administering medications, care planning, wound care, suctioning [MEDICAL CONDITION] if needed. The [MEDICAL CONDITION] and suctioning is the RT's responsibility. The licensed nurses also monitor the resident's respiratory status, vital signs, and oxygen saturation every shift. The licensed nurses, however, have no specific training on the specific function of the ventilator, they do not know how to operate the machine, and if the ventilator alarms they call any RT on the unit. The licensed nurses would not know if a ventilator is on standby mode, the only thing they know, if the machine alarms, call the RT. There is no way also for licensed nurses to know if the ventilator is ON or OFF. Immediate Jeopardy was removed on [DATE] prior to surveyor exit on [DATE] based on the following corrective actions taken by the facility: 1. The facility implemented a revised policy on OVP for HT-70 Plus on [DATE]. The facility added steps in the procedure such as: RT documentation that OVP was performed in the treatment record and progress notes that include: activate ventilation, chest rise and breath sounds, peak pressure rise and fall, and the outcome from ventilator check confirming safe connection between resident and ventilator. The RT shall inform the RN on the unit regarding the completed circuit change and OVP pass, and the RN shall assess the resident within ,[DATE] minutes after circuit change and document it in the progress notes. 2. For easy identification of the ventilator screen by the staff, the ventilator screen was changed to ventilation graphic (visual picture of resident's breathing). 3. An audit tool was developed to track circuit change/OVP pass compliance 4. As of [DATE], 100% of the licensed nurses and RTs were in-serviced on the revised policy on OVP and identification of ventilator screen. 96% of the Certified Nurses' Aide were also in-serviced on identification of ventilator screen. 5. Competency skill test was started for RT, licensed nurses and Certified Nursing Assistants. 415.12 (k) (6)