Every finding on record at Pathways Nursing and Rehabilitation Center

Based on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice. Specifically, (a.) an opened medication had no open and/or expiration date; (b) 3 medications were passed expiration dates; (c.) medication requiring refrigeration were stored in the medication cart unrefrigerated, and (d.) shift change narcotic count signatures were missing on several dates, for 3 out of 3 medication carts reviewed. This is evidenced by: The Facility's Policy and Procedure titled, Medication Storage, revised 1/03/2017, documented, Medications listed in Schedules II, III, IV, and V would be stored under double locked conditions. The access key to the controlled medications was not the same key that allowed access to other medications. The medication nurse on duty would maintain possession of a key to the controlled medications and does not relinquish the key until a count has been completed and thus, the transfer of responsibility for the key and controlled medications has been completed. Controlled medications would be counted every eight hours (at change of shift 7:00 AM, 3:00 PM, and 11:00 PM) and as needed with the nurses beginning and ending a tour of duty with assignment of medication administration for a particular patient grouping. The oncoming nurse handled and counts the remaining controlled medications and the outgoing nurse records the amount noted. The actual amount of the controlled medication present would be compared to the remaining amount Indicated on the Controlled Substance Record and the amount remaining would be recorded on the Controlled Medication Change of Shift Audit form. Both nurses Involved in the count would sign the Controlled Medication Change of Shift Audit form verifying the integrity of the Information represented. The Facility's Policy and Procedure titled, Insulin Administration and Safety, revised July 2015, documented, Storage in of insulin Vials and FlexPen: The individual manufacturer's storage recommendations and expiration dates must be followed. These usually suggest that o Insulin vials and FlexPen pen must never be frozen. o Direct sunlight or warming (in hot climates) damages insulin. o Unused insulin vials and FlexPen should be stored in a refrigerator. o After opening, an insulin vial and FlexPen should be discarded per manufacturer recommendation. MIX insulin-Novolog 70/30=14 days; Rapid acting- Novolog R =28 days and Long acting- Levemir/ Lantus= 42 days. The Facility's Policy and Procedure titled, Medication Administration, revised 3/19/2018 documented, pre-mixed medications from pharmacy with a label 'Refrigerate' should be kept in the refrigerator at all times. Never give a medication that has expired. During an observation on 1/02/2025 at 10:36 AM on the Traumatic Brain Injury Unit, the Shift Change Narcotic Count for Cart B was noted to have missing signatures on the following dates: 12/23/2024 7-3 PM and 3-11 PM shifts; 12/25/2024 7-3 and 3-11 PM shifts; 12/27/2024 3-11 PM shift; 1/1/25 3-11 PM shift. The Ventilator Unit, Cart B was noted to have no signatures for 1/2/2025 7-3 PM shift. There were no discrepancies in the medications. During an observation on 1/02/2025 at 10:40 AM on the Traumatic Brain Injury Unit, Medication Cart B contained 1 bottle of artificial tears with an expiration date of 12/08/2024. At the time of observation, Registered Nurse #1 stated they were unaware the medication had expired 30 days after opening, and they were not aware of medication that had shortened expiration dates after opening. During an observation on 1/02/2025 at 11:00 AM on the Traumatic Brain Injury Unit, Medication Cart A, contained an opened bottle of Omeprazole liquid medication labeled 'keep refrigerated.' At the time of observation, Registered Nurse #2 stated this was an oversight and immediately placed medication in medication room refrigerator. During an observation on 1/02/2025 at 11:30 AM on the Ventilator Unit, Medication Cart B contained 1 bottle of Systane eye drops with an expiration date of 11/30/2024; 1 bottle of Alphagan 0.1% eye drops with an expiration date of 12/30/2024, and 1 Lantus insulin pen with no open and expiration date. At the time of observation, Licensed Practical Nurse #1 stated expired medications should be discarded and not used. During an interview on 1/02/2025 at 10:54 AM, Nurse Educator #1 stated there was a grid of medications with shortened expiration dates posted in the medication room; All nursing staff received training upon hire on the administration of medication including checking expiration dates; During orientation each nurse was observed and signed off on proper shift change narcotic count; During shift change narcotics were counted and signed by two nurses, the outgoing and oncoming nurse. During an interview on 1/2/2025 at 10:56AM, Director of Nursing #1 stated all clinical staff received Inservice training upon hire and annually on medication shortened expiration dates after opening. In addition, each nurse was observed and signed off on proper shift change narcotic count. During shift change narcotics were counted and signed by two nurses, the outgoing and oncoming nurse. This included nurses who we worked double consecutive shifts. Director of Nursing #1 stated they were not aware there were missing signatures in the narcotic signoff sheets; It was the responsibility of the unit manager to monitor narcotic signoff sheets daily. 10 New York Codes, Rules, and Regulations 415.18(d)

Based on observation, record review, and interviews during the recertification survey, the facility did not ensure the provision of sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident throughout the facility. Specifically, the facility's minimum staffing level of Certified Nurse Aides was not consistently met every day on 3 of 3 Nursing units from 12/07/2024 to 1/08/2025. This is evidenced by: Upon entrance to the facility on [DATE], there were 106 residents residing on 3 units. The Policy and Procedure titled, Nursing Services and Sufficient Staff, revised 5/2023, documented it was the facility's policy to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility's census, acuity and diagnoses of the resident population would be considered based on the facility assessment. The facility would supply services by sufficient numbers of staff on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans except when waived, licensed nurses and other personnel, including but not limited to nurse aides. 34630 The Facility assessment dated [DATE], documented the average daily census was 109. The number of residents dependent on assistance with activities of daily living documented: 95 residents for both bathing and dressing 90 residents for transfer 69 residents for eating 102 residents for toileting 99 residents who were in a chair most of the time were dependent for mobility The facility assessment documented a Certified Nurse Aide Staffing Plan (the number of Certified Nurse Aides for each unit and shift) for 7 days as follows for the Traumatic Brain Injury unit: -- 4 for the 7:00 AM to 3:00 PM day shift, -- 4 for the 3:00 PM to 11:00 PM evening shift, and -- 2 for the 11:00 PM to 7:00 AM night shift. The facility assessment documented a Certified Nurse Aide Staffing Plan (the number of Certified Nurse Aides for each unit and shift) for 7 days as follows for the Sub-Acute/Ventilator unit: -- 4 for 7:00 AM to 3:00 PM day shift, -- 4 for the 3:00 PM to 11:00 PM evening shift, and -- 2 for the 11:00 PM to 7:00 AM night shift. The facility assessment documented a Certified Nurse Aide Staffing Plan (the number of Certified Nurse Aides for each unit and shift) for 7 days as follows for the Pediatrics unit: -- 3 for the 7:00 AM to 3:00 PM day shift, -- 3 for the 3:00 PM to 11:00 PM evening shift, and -- 1 for the 11:00 PM to 7:00 AM night shift. A review of the Facility Scheduling Worksheets (daily staffing sheets) dated from 12/07/2024 to 1/08/2025 documented the following units were short Certified Nurse Aides: Saturday, 12/07/2024: -- The Traumatic Brain Injury unit had a census of 39 and was short 1 Certified Nurse Aide on the evening shift. -- The Sub Acute/Vent unit had a census of 33 and was short 1 Certified Nurse Aide on the day shift, 2 on the evening shift, and 1 on the night shift until 5:15 AM. Sunday, 12/08/2024: -- The Traumatic Brain Injury unit had a census of 39 and was short 2 Certified Nurse Aides on the day shift, 2 on the evening shift, and was short 1 on the night shift until 5:15 AM. -- The Sub Acute/Vent had a census of 33 and was short 2 Certified Nurse Aides on the day shift, 2 on the evening shift, and 1 on the night shift. Wednesday, 12/11/2024: -- The Traumatic Brain Injury unit had a census of 39 and was short 1 Certified Nurse Aide on the evening shift. -- The Sub Acute/Vent unit had a census of 33 and was short 1 Certified Nurse Aide on the day shift, 1 at the start of the evening shift at 3:00 PM and was short 2 as of 3:50 PM. Saturday, 12/14/2024: -- The Traumatic Brain Injury) unit had a census of 39 and was short 2 Certified Nurse Aides on the day shift and 1 on the evening shift. -- The Sub Acute/Vent unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. -- The Pediatrics unit had a census of 36 and was short 1 Certified Nurse Aide on the evening shift. Sunday, 12/15/2024: -- The Traumatic Brain Injury unit had a census of 39 and was short 1 Certified Nurse Aide on the day shift, 1 on the evening shift, and 1 on the night shift until 5:30 AM. -- The Sub Acute/Vent unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift, and 1 on the evening shift. -- The Pediatrics unit had a census of 36 and was short 1 Certified Nurse Aide on the evening shift. Monday, 12/16/2024: -- The Traumatic Brain Injury unit had a census of 39 and was short 1 Certified Nurse Aide on the evening shift. -- The Sub Acute/Vent unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift and 2 on the evening shift. Tuesday, 12/17/2024: -- The Traumatic Brain Injury unit had a census of 39 and was short 2 Certified Nurse Aides on the evening shift. -- The Sub Acute/Vent unit had a census of 33 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. Wednesday, 12/18/2024: -- The Traumatic Brain Injury unit had a census of 39 and was short 1 Certified Nurse Aide on the evening shift. -- The Sub Acute/Vent had a census of 34 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. Thursday, 12/19/2024: -- The Traumatic Brain Injury unit had a census of 39 and was short 1 Certified Nurse Aide on the evening shift. -- The Sub Acute/Vent unit had a census of 34 and was short 1 Certified Nurse Aide on the evening shift and 1 on the night shift. -- The Pediatrics unit had a census of 35 and was short 1 Certified Nurse Aide on the day shift. Friday, 12/20/2024: -- The Traumatic Brain Injury unit had a census of 38 and was short 1 Certified Nurse Aide on the evening shift. -- The Sub Acute/Vent unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. -- The Pediatrics unit had a census of 35 and was short 1 Certified Nurse Aide on the day shift. Saturday, 12/21/2024: -- The Traumatic Brain Injury unit had a census of 38 and was short 1 on the day shift and 1 on the night shift. -- The Sub Acute/Vent unit had a census of 34 and was short 1 Certified Nurse Aide on the day, evening, and night shifts. Sunday 12/22/2024: -- The Traumatic Brain Injury unit had a census of 37 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. -- The Sub Acute/Vent unit had a census of 34 and was short 2 Certified Nurse Aides on the day shift and 2 on the evening shift. -- The Pediatrics unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. Monday 12/23/2024: -- The Traumatic Brain Injury unit had a census of 37 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. -- The Sub Acute/Vent unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. Tuesday, 12/24/2024: -- The Traumatic Brain Injury unit had a census of 37 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. -- The Sub Acute/Vent unit had a census of 34 and was short 1 Certified Nurse Aide on the evening shift. -- The Pediatrics unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. Wednesday, 12/25/2024: -- The Traumatic Brain Injury unit had a census of 37 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. -- The Sub Acute/Vent unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift, 1 on the evening shift, and was short 1 on the night shift, as of 12:30 AM. -- The Pediatrics unit had a census of 34 and was short 1 Certified Nurse Aide on the evening shift. Saturday, 12/28/2024: -- The Traumatic Brain Injury unit had a census of 38 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. -- The Sub Acute/Vent unit had a census of 34 and was short 2 Certified Nurse Aides on the day shift and 2 on the evening shift. -- The Pediatrics unit had a census of 35 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. Sunday, 12/29/2024: -- The Traumatic Brain Injury unit had a census of 37 and was short 3 Certified Nurse Aides at the start of the day shift at 7:00 AM and as of 10:00 AM was short 2 Certified Nurse Aides. At the start of the evening shift at 3:00 PM, was short 2 Certified Nurse Aides and at 8:00 PM was short 3 Certified Nurse Aides. -- The Sub Acute/Vent unit had a census of 34 and was short 2 Certified Nurse Aides on the day shift as of 7:18 AM. At the start of the evening shift at 3:00 PM, the unit was short 2 Certified Nurse Aides, and as of 8:00 PM, was short 3 Certified Nurse Aides. -- The Pediatrics unit had a census of 35 and was short 1 Certified Nurse Aide on the day shift. On the evening shift at 3:00 PM, was short 1, and at 5:00 PM was short 2. Monday, 12/30/2024: -- The Traumatic Brain Injury unit had a census of 37 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. -- The Sub Acute/Vent unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift and 2 on the evening shift. -- The Pediatrics unit had a census of 35 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. Tuesday, 12/31/2024: -- The Traumatic Brain Injury unit had a census of 37and was short 2 Certified Nurse Aides on the evening shift. -- The Sub Acute/Vent unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift and 2 on the evening shift. -- The Pediatrics unit had a census of 35 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. Wednesday, 1/01/2025: -- The Traumatic Brain Injury unit had a census of 36 and was short 2 Certified Nurse Aides on the day shift and 1 on the evening shift. -- The Sub Acute/Vent unit had a census of 34 and was short 2 Certified Nurse Aides on the day shift and 1 on the evening shift. -- The Pediatric unit had a census of 35 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. Thursday, 1/02/2025: -- The Traumatic Brain Injury unit had a census of 35 was short 1 Certified Nurse aide on the evening shift. -- The Sub Acute/Vent unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. -- The Pediatrics unit had a census of 35 and was short 1 Certified Nurse Aide on the day shift. Friday, 1/03/2025: -- The Traumatic Brain Injury unit had a census of 35 and was short 1 Certified Nurse Aide on the evening shift. -- The Sub Acute/Vent unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. The Pediatrics unit had a census of 35 and was short 1 Certified Nurse Aide on the evening shift. Saturday, 1/04/2025: -- The Traumatic Brain Injury unit had a census of 35 and was short 1 Certified Nurse Aide on the evening shift. On the night shift, was short 1 until 5:00 AM. -- The Sub Acute/Vent unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. -- The Pediatrics unit had a census of 34 and was short 1 Certified Nurse Aide on the evening shift. Sunday, 1/05/2025: -- The Traumatic Brain Injury unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. -- The Sub Acute/Vent unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. -- The Pediatrics unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. Monday, 1/06/2025: -- The Traumatic Brain Injury unit had a census of 35 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. -- The Sub Acute/Vent unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. -- The Pediatrics unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. Tuesday, 1/07/2025: -- The Traumatic Brain Injury unit had a census of 35 and was short 1 Certified Nurse Aide on the evening shift. -- The Sub Acute/Vent unit had a census of 34 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. -- The Pediatrics unit had a census of 33 and was short 1 Certified Nurse Aide on the day shift and 1 on the evening shift. Wednesday, 1/08/2025: -- The Traumatic Brain Injury unit had a census of 36 and was short 1 Certified Nurse Aide on the evening shift. -- The Sub Acute/Vent unit had a census of 34 and was short 1 Certified Nurse Aide on the evening shift. -- The Pediatrics unit had a census of 33 and was short 1 Certified Nurse Aide on the day shift. Census data for the Traumatic Brain Injury, Sub Acute/Ventilator, and Pediatrics units for December 2024 and January 2025 provided by the facility documented the following: CENSUS DECEMBER 2024 Day-Month, Traumatic Brain Injury Unit Census, Sub-Acute/Ventilator Unit Census, Pediatrics Unit Census, Total Census 1-December 39 33 36 108 2-December 39 33 36 108 3-December 39 33 36 108 4-December 39 33 36 108 5-December 39 33 35 107 6-December 39 34 35 108 7-December 39 33 35 107 8-December 39 33 35 107 9-December 39 33 35 107 10-December 39 33 35 107 11-December 39 33 35 107 12-December 39 33 35 107 13-December 39 34 36 109 14-December 39 34 36 109 15-December 39 34 36 109 16-December 39 34 36 109 17-December 39 33 35 107 18-December 39 34 35 108 19-December 39 34 35 108 20-December 38 34 35 107 21-December 38 34 35 107 22-December 37 34 34 105 23-December 37 34 34 105 24-December 37 34 34 105 25-December 37 34 34 105 26-December 37 34 35 105 27-December 38 34 35 107 28-December 38 34 35 107 29-December 37 34 35 106 30-December 37 34 35 106 31-December 37 34 35 106 CENSUS JANUARY 2025 Day-Month, Traumatic Brain Injury Unit Census, Sub-Acute/Ventilator Unit Census, Pediatrics Unit Census, Total Census 1-January 36 34 35 105 2-January 35 34 35 104 3-January 35 34 35 104 4-January 35 34 34 103 5-January 34 34 34 102 6-January 35 34 34 103 7-January 35 34 33 102 8-January 36 34 33 103 During an interview on 12/30/2024 at 2:55 PM, Resident #64 stated they stayed in bed all when there was not enough staffing because they required the assistance of 2 staff and a mechanical lift for transfers out of bed. During an interview on 12/30/2024 at 12:07 PM, Family Member #1 stated there were times when the facility was short staffed. During an interview on 12/30/2024 at 2:57 PM, Resident #39 stated the facility was 'severely' understaffed on a regular basis and was short staffed on all shifts. They stated that last night, 12/29/2024, they had to wait 5 or 6 hours during the evening shift to get changed when their incontinence brief was wet. The resident stated there had been recent turnover with staff. During an interview on 12/30/2024 at 3:59 PM, Resident #52 stated there was a staffing problem. They stated the 3:00 PM to 11:00 PM shift was the worst and stated there was usually 1 Certified Nurse Aide on the unit. Resident #52 stated they could not get their shower on the 3:00 PM to 11:00 PM shift because the aide stated they could not handle the shower without another staff member to assist. They stated the evening shift did follow the care plan for brushing their teeth and changing them because they were short staffed. The resident stated they usually had to wait 30 minutes to one hour for care. During an interview on 12/31/2024 at 10:21 AM, Resident #260 stated that every time they needed to go to the bathroom, they were told to wait. During an interview on 12/31/2024 at 11:24 AM, Family Member #2 stated they were concerned there were not enough staff to correctly turn and position the resident. They stated there was often only 1 to 2 Certified Nurse Aides on the unit. During an interview on 1/08/2025 at 10:12 AM, Staffing Coordinator #1 stated they were also a Certified Nurse Aide and helped in many areas of the facility. They stated they looked at the facility census when they assessed the staffing needs and stated they had to 'balance' staff; They gave the units what they required and was aware of the number of nursing staff required for each unit. They stated the facility had been very good about staffing, but the gastrointestinal illness effected staffing on the (Pediatrics) unit. Traveler staff came and then they went back home to their home states. Stated staffing was bad this past week. Stated supervisors call them about weekend staffing. Staffing Coordinator #1 stated they would come in on Sunday to work. Stated they worked closely with supervisors, especially with staffing. Surveyor asked specifically about staffing on 12/29/2024. They stated that on the Sub Acute/Vent unit, a Certified Nurse Aide left at 7:18 AM due to a personal issue and another aide that was scheduled from an agency cancelled, leaving 2 aides on unit for the shift. They stated the Agency would just cancel and would not give a reason. They stated for 3-11 shift, there were 2 Certified Nurse Aides but 1 left at 8:00 PM, leaving 1 aide on the unit. On the Traumatic Brain Injury unit during the 3-11 PM shift, there were 2 aides and then 1 left at 8:00 PM to accompany a resident to the hospital. Stated the facility utilized Agency staff and had a sheet of agencies/staff/phone number they provide to the supervisors. The facility had 5 contracted agencies but only 3 were providing nursing staff. The facility requires 3 days of training for agency staff. Staffing Coordinator #1 was called when by staff when they were not coming in or staff would call the off-shift supervisor. Stated December staffing was 'hit or miss' due to flu or flu-like symptoms. Stated the facility did float staff to other units. During a subsequent interview on 1/08/2025 at 12:46 PM, Resident #39 stated there was a lot of staff in the building today. They stated when the unit was short staffed, they had to wait for care. They stated The Certified Nurse Aides would come into the room after they (the resident) puts their call light and then is told by them to give them a minute but then they do not come back for 2 hours. They stated it was a problem during the weekend more than the week when sometimes they only had 1 person (aide) on the unit who had 18-20 people to provide care to. During an interview on 1/10/2025 at 10:27 AM, Administrator #1 stated there was turnover from out of state staffing in December. Stated several staff left with no notice: 4 in early December, and then 2 in the week of 12/30/2024. Stated the out-of-state Certified Nurse Aide staff were not contracted and were facility employees. Stated that during the sudden staff shortage in December, the facility brought in agency staff for the short term. Stated the facility had new hires as of 1/7/2025 and were orienting 7 new Certified Nurse Aides. The biggest issue was Criminal History Record Check which took 'months.' Stated the facility did not bring in staff without clearance due to the vulnerable population. The facility currently offered a sign on bonus, had increased the base rate of pay, and offered a shift differential. Stated there was continuous overtime pay. Stated that although the facility had stressed to new hires that it was a 'different' facility, staff often state they were not aware of the heavy patient care load and then resign. 10 New York Code Rules and Regulations 415.13(a)(1)(i-iii)

Based on record review and interview during the recertification survey, the facility did not ensure each resident was treated with respect and dignity and care in a manner and in an environment that promotes maintenance or enhancement of their quality of life for 2 (Resident #s 39 and 65) of 106 residents reviewed. This is evidenced by: The Policy and Procedure titled, Resident Rights and Dignity, revised 11/2018, documented it was the facility's policy to ensure that all residents' rights were ensured and respected. In addition, the facility would maintain strict adherence to state and federal guidelines with regards to granting residents' rights, maintaining resident dignity, and ensuring a pleasant and home-like environment for residents and their families. Resident #39: Resident #39 was admitted to the facility with diagnoses of acute and chronic respiratory failure with hypoxia (low levels of oxygen in blood), tracheostomy (surgical procedure that creates an opening in the trachea (windpipe) through the front of the neck, and injury of the spinal cord (at the neck level). The Minimum Data Set (an assessment tool) dated 10/23/2024, documented the resident was cognitively intact. The resident was able to make themselves understood and was able to understand others. The Care Plan fo Activities of Daily Living documented the following: Dressing, Grooming, Feeding, Bathing, Toileting, Personal Hygiene, revised 10/24/2024, with a goal that the resident would be clean, dry, and groomed daily. Care plan interventions documented to check and change incontinent briefs every 2-4 hours and as needed. During an interview on 12/30/2024 at 2:57 PM, Resident #39 stated that the night before, 12/29/2024, they had to wait 5 or 6 hours during the evening shift to get changed when their brief was wet. During a subsequent interview on 1/08/2025 at 12:46 PM, Resident #39 stated they were offended by staff who were always angry and would scold them. Resident #39 stated they had asked a Certified Nurse Aide to put their medicated powder on them and was told it was in an angry tone it was not their job; it was the nurse's job. Resident #39 stated, 'The Certified Nurse Aides make it look like I am being taken care of when I am not.' Resident #39 stated that it 'seemed to be a policy here.' They further stated they would activate their call light, for the Certified Nurse Aide to come in and turn it off, and would not help them. Resident #39 stated Certified Nurse Aides 'leave them wet half the night.' During an interview on 1/7/2025 at 11:45 AM, Licensed Practical Nurse #2 stated Resident #39 was dependent on 1 staff for their personal care needs. Stated they were not aware the resident had been left in a wet brief for 5-6 hours on 12/29/2024. Stated Certified Nurse Aides should be checking the resident's brief as care planned. Stated Certified Nurse Aides should be answering the resident's call light in a timely manner and assisting the resident at that time. 48615 Resident #65: Resident #65 was admitted to the facility with diagnoses of respiratory (lung) failure, coronary artery disease (heart disease that occurs when the arteries that supply blood to the heart narrow), and anxiety. The Minimum Data Set, dated dated dated [DATE], documented the resident was cognitively intact. The resident was able to make themselves understood and was able to understand others. The assessment documented impairment to upper extremities on both sides and impairment to lower extremity on one side. The resident required partial/moderate assistance with oral hygiene, toileting hygiene, shower/bathing, and upper body dressing. The resident required substantial/maximal assistance with lower body dressing and personal hygiene. The resident was frequently incontinent of bowel and bladder. During an interview on 1/08/2025 at 1:41 PM, Resident #65 stated they had problems with some of the Certified Nurse Aides. Stated their regular aide was good, but some of the aides were very rude and short with them. Stated they were often left in a wet bed for hours. Resident #65 stated they wait all night to get assistance. Stated they would put their call light on, and the aide would come into the room and turn the light off. Stated they would leave the room and never come back. Stated they had to ask for assistance with activities of daily living such as washing up and toileting. Stated the aide would tell them to do it yourself. Stated they could not do it alone all the time secondary to having the tracheostomy and shortness of breath. Stated the aides were very abrupt and then leave the room. Resident #65 stated they had spoken to the nurse manager and there has been no resolution. Stated that one aide told them it was the nurse manager's problem. Resident #65 could not identify the Certified Nurse Aides but said some of them still worked in the facility and some have left. Stated they thought they were Certified Nurse Aides who were from a travelling agency. During an interview on 1/08/2025 at 1:48 PM, Registered Nurse #2 stated there was a turnover of staff, specifically Certified Nurse Aides. Stated Certified Nurse Aides would stay for a few months and then leave. Stated it was mostly the travel Certified Nurse Aides that would leave. Stated they had not received any complaints from residents. Stated Resident #65 preferred certain staff. Stated that in the past, Resident #65 had a problem with a Certified Nurse Aide, stating they were rude. They stated they talked to the aide at that time and provided them with an onsite in-service. Stated it was a female Certified Nurse Aide and they did not notify Administrator #1 or Director of Nursing #1. During an interview on 1/08/2025 at 1:53 PM, Director of Nursing #1 stated they did not recall a staff member reporting a Certified Nurse Aide that was being inappropriate. Stated they had addressed an issue in the past with another resident who had a preferred Certified Nurse Aide because they felt they had to argue with Certified Nurse Aide staff. 10 New York Code Rules and Regulations 415.5(a)

Based on record review and interviews during the recertification survey, the facility did not ensure that each resident was screened for a mental disorder or intellectual disability prior to admission for 2 (Resident # ' s 30 and 64) of 24 residents reviewed. Specifically, the Preadmission Screening and Resident Review (PASARR, New York State Department of Health form 695) was incomplete for Residents #30 and 64. This is evidenced by: The facility Policy titled, Assessment Prior to Admission, last revised September 2011 documented recipient was to be admitted without an assessment prior to admission of the need for the intended level of care using New York State mandated forms. The screen must be completed and signed by a qualified professional. Resident #30 Resident #30 was admitted to the facility with diagnoses of anoxic brain damage (brain damage caused by lack of oxygen), anxiety disorder, and chronic respiratory (lung) failure. The Minimum Data Set (an assessment tool) dated 12/05/2024 documented that the resident was in a persistent vegetative state. The Preadmission Screening and Resident Review dated 10/30/2024 for Resident #30 was incomplete, with questions 23 through 26 (level 1 review for mental illness, mental retardation, and developmental disability) unanswered. 48615 Resident #64 Resident #64 was admitted to the facility with diagnoses of major depressive disorder, generalized anxiety disorder, and psychotic disorder with delusions (disorder characterized by disconnection from reality which results in strange behavior). The minimum Data Set (an assessment tool) dated 10/24/2024 documented that the resident could understand, be understood, and was cognitively intact. The Preadmission Screening and Resident Review dated 07/12/2021 for Resident #64 was incomplete, with questions 31, 32 (danger to self or others), and 33 (level 2 referrals) unanswered. During an interview on 01/03/2025 at 12:21 PM, Admissions Staff #1 stated the screen was completed at the hospital and reviewed by Admission staff for completion, dates and signature. During an interview on 01/03/2025 12:30 PM, Director of Nursing #1 stated the Screen forms should have been reviewed by the Admissions department and sent back to the hospital if it they were incomplete. 10 New York Code of Rules and Regulations 415.11(3)

Based on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure ongoing provision of programs to support each resident and their choices of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being for 1 (Resident #10) of 3 residents reviewed. Specifically, Resident #10 did not consistently attend meaningful, accommodating activities to maintain their highest practicable quality of life. This is evidenced by: The facility's Policy and Procedure titled, Activities, effective 9/30/2023, documented, the purpose was to provide structured and engaging activities that promoted the physical, mental, and emotional well-being of all participants, ensuring compliance with New York State Department of Health and Centers for Medicare & Medicaid Services regulations. Resident #10 was admitted to the facility with diagnoses of anoxic brain injury (caused by a complete lack of oxygen to the brain, which results in the death of brain cells), chronic respiratory failure ( shortness of breath and or difficulty breathing that develops over time), and asthma (inflammation and muscle tightening around the airways, which makes it harder to breathe). The Minimum Data Set (an assessment tool) dated 11/2024, documented the Brief Interview for Mental Status was not completed, and that the resident could understand and be understood by others. The Comprehensive Care Plan dated 10/2024, documented Resident #10 needed 1-to-1 structured multi-sensory activities to stimulate cognitive functioning through religious visits, conversation, tactile therapy, music therapy, and light hand massage. They were unable to develop meaningful routine daily, staff must anticipate all activity needs and interventions. Interventions: Turn on animated cartoons daily. Weekly 1-to-1 visit to promote sensory, cognitive, and social stimulation. During observations on 12/30/2024 at 1130 AM, 12/31/2024 at 10:00 AM, 1/02/2025 at 2:40 PM, 1/03/2025 at 1:00 PM, and 1/06/2025 at 9:45 AM, Resident #10 was observed in their room, in bed alone with the television on. During an interview on 1/07/2025 at 11:11 AM, Director of Activities #1 stated residents who did not attend group therapy had 1-to-1 activities once per week. They stated there were multiple staff members in and out of resident room daily such as medication nurse, respiratory therapists, certified nurse aides that were considered part of daily activity. A barber service visits the facility twice per month to give haircuts and shave. Director of Activities #1 stated they had 5 Activities Staff members for their department. In order to provide more frequent 1-to-1 activity sessions, the Activities Department would need an additional 10 staff members. Resident #10's December 2024 Activity Log for 1-to-1 sessions was blank with the exception of 12/28/2024 and 12/31/2024. During an interview on 1/07/2025 at 12:07 PM, Director of Activities #1 stated Resident #10 did not tolerate sitting in wheelchair. Director of Activities #1 also stated for ventilator-dependent residents to attend group therapy, they must be able to tolerate out of bed to chair, and respiratory therapy and or family member must be present during activity. During an interview on 1/07/2025 at 12:09 PM, Licensed Practical Nurse #2 stated Resident #10 did not attend group activities. They stated not every resident got up and out of bed daily. It depended on staffing, and if an aide had them frequently, sometimes the aide would get them up. Licensed Practical Nurse #2 stated some residents had daily routines where they got up daily and some did not. Licensed Practical Nurse #2 stated that it was also related to staffing for the day. They stated Resident #10 had not gotten out of bed in a week and did not attend group activities. During an interview on 1/07/2025 at 12:32 PM, Director of Respiratory Therapy #1 stated all residents at this facility could attend group activities; Ventilator dependent residents who attended activities would use the same ventilator that they used while in their room; When leaving the room, the ventilator would be disconnected from the outlet and then function on its battery; The ventilator also had a portable monitor that went along with it. Director of Respiratory Therapy #1 further stated residents who were ventilator dependent did not have any restriction for getting out of bed or leaving their rooms. Director of Respiratory Therapy #1 stated they were never informed of Resident #10 having respiratory difficulty when out of bed. During an interview on 1/07/2025 at 12:45 PM, Director of Nursing #1 stated some residents did not get out of bed daily because they could not tolerate it clinically. For those cases, residents would receive 1-to-1 therapy and or activities. Residents who were ventilator dependent had no restrictions for getting out of bed or engaging in activities. During an interview on 1/07/2025 at 3:17 PM, Administrator #1 stated the facility conducted group activities daily and 1-to-1 individual activity as frequently as possible; The Activities Department was recently changed with a new director; Staffing was increased to meet demands for staff to patient ratio. Administrator #1 stated they were currently working on new ideas to enhance all activities. 10 New York Codes, Rules, and Regulations 415.5(f)(1)h

Based on record review and interviews conducted during an abbreviated survey (Case # NY00269229), the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for one (1) (Resident #1) of five (5) sampled. Specifically, for Resident #1, the facility did not ensure that injuries of unknown origin (bruising on the resident's forehead and swelling to their left eyelid) observed on 12/22/2020 were reported to the State Survey Agency in accordance with State law. The injuries of unknown origin were reported to the State agency on 12/28/2020; six days after the injuries were observed. This is evidenced by: Resident #1 Resident #1 was admitted to the facility with diagnoses of anoxic brain damage, acute and chronic respiratory failure with hypoxia (below normal level of oxygen in the blood) and dementia with behavioral disturbance. The Minimum Data Set (MDS-an assessment tool) dated 10/19/2020, documented the resident could be understood and could usually understand others and severe cognitive impairment. The Policy and Procedure (P&P) titled, Resident Abuse, Neglect, Mistreatment , last revised 10/27/2021, read in pertinent part under subsection titled Reporting/Response, The facility will report any incident and/or violation where abuse, neglect or mistreatment is suspected to the New York State Department of Health. All allegations of abuse must be immediately reported to the administrator and no later than two (2) hours to other officials including to the state survey agency after the allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury. Review of the facility's Investigation Summary dated 12/26/2020 documented, The investigation has revealed that there is no cause to believe any alleged resident abuse, mistreatment or neglect has occurred. The summary documented that the incident was not reported to the New York State Department of Health. The summary was signed by the Director of Nursing (DON) on 12/26/2020, signed by the Administrator on 12/27/2020 and signed by the Medical Director on 12/30/2020. Review of the facility's Investigative Summary dated 12/28/2020 documented on 12/22/2020, Resident #1 was observed to have bruising on their forehead and swelling to their left eyelid. The investigation concluded, at this time and until more information is obtained, a conclusion of abuse, neglect or mistreatment cannot be made nor ruled out. It is for that reason that this event will be reported an incident of unknown origin to the New York State Department of Health. Review of the Incident Report from the state reporting system dated 12/28/2020 documented the incident occurred on 12/23/2020 at 11:30 AM and was reported to the state survey agency on 12/28/2020 at 3:49 PM. The report inaccurately documented that the incident occurred on 12/23/2020 rather than 12/22/2020 when the injury was first observed. The report was made six days after the injury was observed. During an interview on 9/8/2023 at 1:11 PM, the Nursing Home Administrator (NHA) said they acted as the abuse coordinator for the facility and were responsible for reporting qualifying reportable incidents to the state survey agency. They said they worked at the facility during the time Resident #1's injuries were investigated; however, they were not the administrator/abuse coordinator at that time and therefore would not have been responsible for reporting the incident. They said injuries of an unknown source were treated in the same manner as suspected abuse and were reported and investigated to rule out that abuse occurred. They said allegations of abuse and injuries of unknown source should be reported to the state survey agency within a two-hour time frame from time they are initially reported. They said the facility then has five days after the initial report was made to investigate the incident and report the findings. During an interview on 9/8/2023 at 1:39 PM, the DON said an injury of unknown source should be reported right away. They said the facility should report the incident and initiate an investigation to determine what may have caused the injury and to rule out that abuse occurred. They said the facility investigated Resident #1's injury that occurred on 12/22/2020 since they were unable to report what had occurred to cause their injury due to cognitive impairment and there were no observations or indicators that the resident had fallen. During an interview on 9/12/2023 at 12:14 PM, the former Nursing Home Administrator (FNHA) said it was typically within a two-hour window that an incident would be reported. They said, generally if it is an injury of an unknown source, a report would be made that day. They could not recall many details about the incident or why a report was made six days after the injury was observed. 10 NYCRR 415.4(b)(2)

Based on observation, record review and interviews during the recertification survey on 04/13/2022 through 04/19/2022 and abbreviated survey (Case #NY 615), the facility did not maintain medical records in accordance with accepted professional standards and practices that are accurately documented and complete for 3 (Resident #'s 2, 32, and 89) of 21 residents reviewed. Specifically, the facility did not ensure daily Certified Nurse Aide (CNA) documentation of Activities of Daily Living (ADLs) care was complete and accurate. This was evidenced by: The Policy and Procedure titled Documentation and dated 05/2019 documented, the clinical team shall document all relevant data and information pertaining to the provision of care and services to the residents in the medical record. Documentation is relevant as evidence of clinical practice. Resident #2: Resident #2 was admitted to the facility with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-an assessment tool) dated 04/05/2022, documented the resident had no cognitive impairment, could make self understood and could understood others. The Certified Nurse Aide (CNA) Assignment Summary documented the resident required extensive assistance of one person for bed mobility, dressing, and transfer. Documented the resident required total assistance of one person for locomotion, personal hygiene, and toilet use. The CNA Accountability for ADL Care dated 04/01/2022 thru 04/17/2022, did not include documentation of care provided on the following shifts and dates: -11:00 PM to 7:00 AM shift: 4/01/2022 through 4/07/2022 and 4/10/2022 through 4/12/2022, 4/15/2022 and 4/16/2022 -7:00 AM to 3:00 PM shift: 4/06/2022, 4/08/2022 through 4/16/2022, -3:00 PM to 11:00 PM shift: 4/02/2022 through 4/16/2022, Resident #32: Resident #32 was admitted to the facility with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-an assessment tool) dated 1/19/2022 documented, the resident had moderate cognitive impairment and could usually make self understood and usually understood others. The Certified Nurse Aide (CNA) Assignment Summary documented the resident required total assistance of one person for bed mobility, dressing, locomotion, personal hygiene, and toilet use. The CNA Accountability for ADL Care dated 01/15/2022 thru 01/31/2022, did not include documentation of care provided on the following shifts and dates: -11:00 PM to 7:00 AM shift: 1/15/2022, 1/16/2022, 1/17/2022, 1/20/2022 through 01/31/2022. -7:00 AM to 3:00 PM shift: 1/15/2022, through 1/20/2022, 1/22/2022, 1/23/2022, through 1/31/2022. -3:00 PM to 11:00 PM shift: 1/15/2022, 1/16/2022, 1/17/2022, 1/19/2022, 1/24/2022, 1/26/2022, 1/27/2022, 1/29/2022, 1/30/2022. Resident #89: Resident #89 was admitted to the facility with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-an assessment tool) dated 03/23/2022 documented, the resident had severe cognitive impairment and could sometimes make self understood and sometimes understood others. The Certified Nurse Aide (CNA) Assignment Summary documented the resident required total assistance of one person for bed mobility, dressing, locomotion, personal hygiene, and toilet use. The CNA Accountability for ADL Care dated 4/01/2022 thru 4/14/2022, did not include documentation of care provided on the following shifts and dates: -11:00 PM to 7:00 AM shift: 4/01/2022, through 4/07/2022, 4/10/2022 through 4/12/2022. -7:00 AM to 3:00 PM shift: 4/01/2022 through 4/14/2022. -3:00 PM to 11:00 PM shift: 4/02/2022 through 4/14/2022. Interviews: During an interview on 4/15/2022 at 10:00 AM, CNA #3 stated they document the resident care in the computer every shift. Sometimes they are so busy that they do not get to finish all the documentation. During an interview on 4/18/2022 at 01:43 PM, Registered Nurse Manager #2 (RNM #2) stated, ideally, the Certified Nurse Aides (CNA) should have documented on each resident once they were done with care. The Nurse Managers and Supervisors were responsible to make sure the documentation was done. RNM #2 stated, the lack of CNA documentation was a surprise to them. During an interview on 4/18/2022 at 02:05 PM, Licensed Practical Nurse Manager #1 stated, the CNAs were supposed to document when all care was done on a resident. The Nurse Managers and Unit Nurses were supposed to oversee that the CNAs were completing their documentation. We knew there was an issue with CNA documentation, the Director of Nursing (DON) had talked to us about it. The Administrative Nurses from downstairs come up to help with care when needed as well as the therapists and they completed the CNA documentation for what they did. During an interview on 4/18/2022 at 2:42 PM the MDS Coordinator (MDS) stated the CNAs try to document when they can. The facility was aware of the problem with CNAs documentation. The MDS would help on the units when needed and would document the care provided, and would also help to document the intakes and bowel movements. During an interview on 4/19/22 at 10:02 AM, the Director of Nursing (DON) stated, they had spoken with the Nurse Managers about the CNA documentation not getting done and it was getting better. The residents were being cared for and that was the priority. The DON was working with the people from the computer company to come up with an easier way for the CNAs to document. We have all staff in the building trained to do certain things and help on the Units anytime they are needed. 10 NYCRR 415.22

Based on record review and interviews during an abbreviated survey (Case #NY 204), the facility did not ensure each resident was free from abuse for 1 (Resident #1) of 3 residents reviewed. Specifically, for Resident #1, who was care planned as at risk for abuse and neglect due to a developmental delay, the facility did not ensure the resident was free from physical abuse by a Physical Therapy Aide. This resulted in psychosocial harm as defined by the reasonable person concept referenced in the Centers for Medicare and Medicaid Services Psychosocial Outcome Severity Guide. This was evidenced by: The Policy and Procedure (P&P) titled Resident Abuse, Neglect, Mistreatment dated January 2019, documented all residents were to be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment, and care for personal needs. Residents were not to be subjected to abuse by anyone, including but not limited to facility staff. Physical abuse was defined as the non-accidental use of force that resulted in bodily injury, pain or impairment; including but not limited to being slapped, burned, cut, bruised or improperly physically restrained. Resident #1 was readmitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - an assessment tool) dated 4/20/2021, documented the resident's cognitive skills for daily decision making were severely impaired. The Comprehensive Care Plan (CCP) for Alteration in Cognitive Function last revised on 6/22/2021, documented the resident had cognitive impairment due to developmental disability, and was non-verbal. The CCP for Sensory Deficit-Visual Deficit last revised on 6/22/2021, documented a visual deficit related to a history of retinal detachment and bilateral [CONDITION(S)]. An Incident Investigation Report, dated 6/22/2021 at 10:42 AM, written by the Administrator, documented a possible occurrence of abuse in the Pediatric Day Room on 6/17/2021 during the mid to late morning. It was alleged that Physical Therapy Assistant (PTA) #1 shoved and threw a cup at Resident #1. The Administrator saw on video an event that occurred on camera and immediately requested PTA #1 to come to the office, however, PTA #1 had left the facility with a headache. PTA #1 was suspended pending investigation. Upon further review of the video footage the Administrator documented PTA #1 was observed on numerous occasions on that shift, being abusive toward Resident #1. The incident was reported to the New York State Department of Health (NYSDOH) and the local police department. PTA #1 was to be terminated as a result of the investigation. Video footage of the pediatric dayroom on 6/17/2021 was provided to the NYSDOH in a total of six video files. Incident times are identified in minutes and seconds (for example 02:34) from the start of the identified video, and do not represent the time of day. The videos showed the following: A video labeled 6.17 8.15 - 8.45 am showed: - At 18:44 PTA #1 stood in front of the resident and put their hands on Resident #1's shoulders and shoved the resident toward the floor. Resident #1 fell to the floor and then came to a sitting position. A video labeled 6.17 8.15 - 8.45 am pt 2 showed: - At 02:05 PTA #1 picked up Resident #1's cup, went to the resident who was crawling on the floor, and shoved them. The resident came off the floor, fell backwards and landed on their elbows. PTA #1 then threw the cup in the direction of Resident #1. Resident #1 sat up and leaned forward to reach for their cup. PTA #1 grabbed Resident #1 and shoved them. The resident fell over backwards onto the floor. PTA #1 picked up the cup, grabbed and shoved the resident and the resident fell on to their back. - At 04:05 PTA #1 handed Resident #1 their cup and Resident #1 started to crawl on the floor with the cup in their right hand. PTA #1 approached the resident and forcefully put their left hand on the resident's face/chin and shoved them into a sitting position. - At 25:19 PTA #1 walked to the back of the room, picked up a beanbag chair and dropped it on the floor. With both hands PTA #1 took ahold of Resident #1 by the head/face and dragged the resident approximately 3 feet to the beanbag chair. PTA #1 then leaned over the resident, placed both hands on the resident's upper back and shoved the resident face-down onto the beanbag chair. A video labeled 6.17 10.42 - 10.52 am showed: - At 04:29 PTA #1 took Resident #1 by their shoulders and shoved them to the floor. Resident #1 fell on to their side and rolled over onto their back. PTA #1 picked up a plastic cup and threw it in the direction of Resident #1, not hitting the resident. - At 7:33 PTA #1 pushed Resident #1 to the floor. PTA #1 kicked the resident's legs twice and pointed to the resident who then raised their left arm. PTA #1 then grabbed the resident's left wrist and held it for several seconds. A video labeled 6.17 11.15 - 11.45 am showed at 04:17 Resident #1 was crawling on the floor. PTA #1 kicked Resident #1 in the chest causing the resident to sit upright in the beanbag chair. A Medical Progress Note dated 6/23/2021 at 7:28 AM, written by physician (MD) #1, documented they were notified of an incident that occurred on 6/17/2021, involving inappropriate rough handling of Resident #1. The Administrator reviewed the videos, notified MD #1, the NYSDOH, and police. MD #1's examination of the resident revealed that there was no apparent injury to the resident. During an interview on 11/17/2021 at 2:25 PM, the Human Resources Director (HRD) stated they were talking to LPN #3 in the hallway, and they were both looking in the window to the dayroom on the day of the incident. The HRD said out of the corner of their eye they saw a cup fly and saw Resident #1 on the floor. The HRD looked at LPN #3 and gasped because they thought PTA #1 had pushed Resident #1. LPN #3 continued talking as if there was no problem, which made HRD wonder if the resident really had been pushed. After a sleepless night, the HRD reported to the Corporate Compliance Officer on 6/18/2021 that they thought they witnessed PTA #1 push a resident in the dayroom on 6/17/2021. The HRD stated they had watched some of the video footage and said it was shocking and appeared that PTA #1 slapped Resident #1 in the head, pushed them to the ground, kicked them, and threw their cup across the room. During an interview on 11/17/2021 at 1:05 PM, the Child Life Specialist (CLS) stated Resident #1 could make sound effects, but not words. Resident #1 did not have behaviors that frustrated staff and kept to themself. Resident #1 was cognitively impaired and would not internalize what had been done to them. The CLS had reviewed some of the video footage and said they saw Resident #1 sitting at a table, banging a cup on it. PTA #1 went over to Resident #1, threw the cup across the room, and pushed Resident #1 down. During an interview on 11/26/2021 at 10:14 AM, Social Worker (SW #1) stated they watched some of the video footage and said there was no excuse for PTA #1's behavior and at the very least, the behavior was degrading. It did not appear as though Resident #1 was physically harmed but SW #1 wondered how the resident felt emotionally. During an interview on 8/6/2021 at 1:40 PM, Registered Nurse Manager (RNM) #1 stated Resident #1 never spoke, was strong and could be aggressive, especially with staff they were unfamiliar with. PTA #1 was familiar with the residents but was not happy being assigned to the dayroom, and had verbalized that they were a PT, and were not supposed to be taking care of kids. RNM #1 stated Resident #1 would get close to staff because the resident wanted to see them up close because of the [CONDITION(S)] in both eyes. During an interview on 8/6/2021 at 4:43 PM, the Director of Nursing (DON) stated PTA #1 had been monitoring the dayroom for almost a year and had never asked for help with the kids. During an interview on 8/6/2021 at 11:40 AM, the Administrator stated that, during review of the video footage, they saw PTA #1 push Resident #1 to the floor, push them by the back of the head into a beanbag on the floor, and kick the resident twice. There were multiple pushes to the floor, and it seemed there was one time when PTA #1 might have grabbed Resident #1 by the back of the hair. The Administrator stated it seemed as though PTA #1 was targeting Resident #1. There were other kids in the room whose actions could be more frustrating, but Resident #1 did not appear to have provoked that kind of behavior from PTA #1. The Administrator also stated Resident #1 was non-verbal and only made noises. During an interview on 11/26/2021 at 12:40 PM, Resident #1's family member (REP #1) stated Resident #1 was developmentally delayed and could not defend themselves. Resident #1 was not able to talk but if they could, they would have told the accused to stop, or something like that. Resident #1 would have told staff to call the police and would have told REP #1 what had happened. Resident #1 would not have felt good at all during the incident. 10 NYCRR 415.4(b)(1)(i)

Based on observation, record review and interviews during an abbreviated survey (Case # NY 987), the facility did not ensure the development and implementation of a comprehensive care plan (CCP) that included measurable objectives and timeframes for 1 (Resident #4) of 3 residents reviewed. Specifically, the facility did not develop and implement a care plan with measurable objectives and timeframes for Resident #4 laying on top of the heating units in the dayroom, and for removing their socks and shoes and ambulating with bare feet. This was evidenced by: The Policy and Procedure (P&P) titled Comprehensive Care Plan last revised on 8/2015, documented alterations, additions and/or deletions/evaluations on the CCP would be made by the responsible interdisciplinary team member(s) on an ongoing basis, ensuring the capture of transient conditions and events. Goals and objectives were to be specific, measurable, and within a stated time frame. Interventions were to be specific, and the responsible discipline was to be indicated on the CCP. Resident #4 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - an assessment tool) dated 3/8/2021, documented the resident's cognitive skills for daily decision making were severely impaired. The resident rarely/never made themself understood and rarely/never understood others. Finding #1: The facility did not develop and implement a care plan for Resident #4 laying on top of the heating units in the dayroom. The CCP for Behavioral Symptoms, last revised on 8/13/2021, documented the resident required ongoing redirection, monitoring, and structured activities to alter behavior problem. Staff were to provide close supervision when the resident was awake. The CCP did not include a care plan with measurable objectives and times for Resident #4's behavior of laying on top of the heating units in the dayroom. Hospital documentation of Emergency Department (ED) visit on 3/31/2021, documented Resident #4 was examined and photographed by the Registered Nurse Forensic Examiner (RNFE). The photographs included pictures of the face, abdomen, legs and arms. The RNFE documented the right arm had an area of dry skin/?healed burn with scattered small circular purple bruises. A Safety Modification Note by the Maintenance Director (MDIR) documented that on 6/10/2021 a verbal request was made to install a slanted cover on the Pediatrics dayroom heating/cooling unit to prevent climbing. During an interview on 9/13/2021 at 2:38 PM, Registered Nurse Manager (RNM #1) reviewed the Forensic Examiner's report and photographs of the resident from the ED visit dated 3/31/2021. RNM #1 stated they had seen the areas of marbled skin during the skin assessment that was done prior to the resident being transferred to the ED, and that they had not the seen the discolored areas before that day. RNM #1 said it was something new and thought it was caused from the resident laying on the heating units in the dayroom. Resident #4 could fit their whole body on top of the heating unit and would lay on it with their arms and legs on it. The resident loved the heat and it calmed them when they were on it. When Resident #4 was removed from the heater the resident would cry. RNM #1 stated the CCP did not include the resident's behavior of laying on top of the heating units. During an interview on 9/17/2021 at 10:31 AM, the Certified Nurse Aide (CNA #4) stated they had supervised Resident #4 in the dayroom and had seen the resident on the heating units. CNA #4 said the resident loved the heat and would sit on the unit and put their hand on it. During an interview on 9/17/2021 at 10:42 AM, CNA #5 stated they had seen Resident #4 climb on the heating units. Resident #4 liked the heat and would sit and lay on the heating unit. CNA #5 encouraged the resident to get off the heating unit, but the resident would get upset. They would try to distract the resident and sometimes it would work and other times it would not and then resident would climb back onto it. CNA #5 said the heating units were covered because the resident wanted to lay on it all day. During an interview on 9/17/2021 at 11:34 AM, the Maintenance Director (MDIR) stated the heating units in the dayroom had slotted tops and were used for heating and cooling. There had been a discussion in morning report about one of the residents climbing on the heating/cooling units and they were asked to put a cover on it to prevent the climbing. The MDIR also stated the units did not get hot enough to cause a burn. During an interview on 9/17/2021 at 12:00 PM, the physician (MD #1) stated they were aware that Resident #4 would lay on the heater, and they assumed the heaters did not get hot enough to cause [CONDITION(S)]. MD #1 stated they were more concerned that the resident could fall off the heating units. During an interview on 9/17/2021 at 1:20 PM, the Director of Nursing (DON) stated they were not aware Resident #4 sometimes laid on top of the heating unit, but knew that whenever the heat was on, the resident liked the warmth. The covering of the heater was done because the resident climbed onto the heater, and that laying on the heater may have been a resident preference or a safety risk. The DON stated RNM #1 should have told them about the resident laying on the heating unit when it was first identified. A supervisor had reported the resident was standing on the heater poking up at a ceiling tile. They talked about it in morning report, where they always discussed risk management after report was given. They discussed the risk to the resident and decided to cover the heating unit to prevent the residents from climbing and possibly falling. During an interview on 9/23/2021 at 1:24 PM, the RNFE stated they performed a child maltreatment examination on 3/31/2021, at the request of the resident's representative. The RNFE stated they documented dry skin/?healed burn related to the right arm because that was what the resident's representative had told them the area was. They measured the area on the arm and documented the areas were scattered small circular bruises. Finding #2: The facility did not develop and implement a care plan for the resident removing their socks and shoes and ambulating with bare feet. The CCP for at Risk for Skin Breakdown, last revised on 4/16/2021, documented the resident was at risk related to mobility, behavioral symptoms, and bladder and bowel incontinence. Interventions effective 2/12/2016, included the following protective/preventive foot care: Medical/Nursing staff were to keep the resident's feet clean and dry, apply lotion as needed, and inspect the feet (especially between toes and heels daily). The resident was to wear proper fitting shoes and was to have a Podiatry consult as needed. The CNA was to observe skin condition daily during care and report any skin abnormalities to the nurse. The CCP did not include a care plan with measurable objectives and times for Resident #4's preference/behavior of removing their shoes and socks and ambulating with bare feet. During an observation on 8/31/2021 at 1:00 PM, with RNM #1 present, Resident #4 was sleeping face down on a bean bag in the dayroom. The resident's feet were bare and had areas of dry skin on the soles. RNM #1 stated the resident refused to keep their socks and/or shoes on. An Emergency Department (ED) note dated 3/31/2021, documented Resident #4 was examined by the RNFE and the resident's feet were photographed. The Photography Log documented the bottom of the left foot had several deep cracks in dry skin with dirt in the cracks. The left big toe had a 1 cm crack and was dirty. The bottom of the right foot big toe and mid-foot had cracked dry, dirt-filled skin. During an interview on 9/15/2021 at 11:27 AM, CNA #3 stated they worked the evening shift and bathed, changed, and fed Resident #4. CNA #3 said they put lotion on the resident's arms, legs, chest, and back after they were bathed, but would not put lotion on the bottom of the resident's feet because it would rub off if they put socks on the resident. When they put socks and shoes on the resident, once the resident was in the dayroom, the resident would take them off. During an interview on 9/15/2021 at 11:42 AM, the Licensed Practical Nurse (LPN #1) stated they put lotion on Resident #4 arms, legs, and feet, but not much on the soles and heels because the resident would take their socks off and LPN #1 did not want the resident to slide. During an interview on 9/15/2021 at 12:35 PM, LPN #2 stated they knew the bottom of the resident's feet were dry and callused. It was impossible to keep anything on the resident's feet, and the resident would walk around with no shoes and socks on. Sometimes other residents would take Resident #4's shoes and sock off Resident #4. During an interview on 9/15/2021 at 1:03 PM, the Registered Nurse (RN #3) stated Resident #4 had dry, cracked skin on the bottom of their feet. The resident would run around in the dayroom and they avoided putting too much lotion on the resident's feet, so the resident would not fall. Staff would put socks and shoes on the resident, but the resident would remove them. During an interview on 9/13/2021 at 2:38 PM, RNM #1 reviewed the Forensic Examiner's photographs dated 3/31/2021 of Resident #4 and stated there was a fissure on the resident's left great toe that was a bit old and said they had missed it, and that they were not aware it was there. RNM #1 stated they were more concerned with Resident #4's upper body and not as much concerned with the bottom of the foot. They usually put moisturizing lotion on the top of the foot and not much, and not often, on the sole because the resident would ambulate with bare feet and they were concerned about the resident's safety. RNM #1 said they never met with the interdisciplinary team or the MD to discuss Resident #4's behavior of removing their socks and shoes, and the behavior had not been documented on the CCP. During an interview on 9/13/2021 at 2:23 PM, the Director of Nursing (DON) reviewed the Forensic Examiner's photographs of Resident #4 dated 3/31/2021 and stated the resident had dry skin with cracks on the bottom of their feet when they first came into the facility. Resident #4's feet have looked worse, and the time of year played a role in the resident's skin issues. It was hard to moisturize the resident's feet because the resident would run around with bare feet. During an interview on 9/13/2021 at 1:09 PM, MD #1 reviewed the Forensic Examiner's report and photographs of the resident dated 3/31/2021. MD #1 stated there were calluses and [CONDITION(S)] (increased thickening of the skins outer layer), and there were cracks within the callus formation on the bottom of the resident's feet. MD #1 stated they had not been made aware that it was difficult to keep shoes on the resident. 10 NYCRR 415.11(c)(1)

Based on record review and interviews during an abbreviated survey (Case #NY 987), the facility did not ensure the physician (MD) wrote, signed and dated progress notes at each visit for 2 (Resident #'s 4 and 1) of 3 residents reviewed. Specifically, for Resident #4, the facility did not ensure the MD wrote progress notes for visits dated 3/26/2021, 8/11/2021, 8/13/2021, 8/16/2021, and 8/18/2021. For Resident #1, the facility did not ensure the MD wrote a progress note for a visit dated 7/19/2021. This was evidenced by: The Policy and Procedure (P&P) titled Physician Visits to Residents last revised 4/2014, documented that whenever the physician/physician assistant/nurse practitioner was called to see a resident for a problem at times other than the routine visits, they were to document the reason the for the visits, the findings, and the evaluations on a dated and signed progress note. Resident #4: Resident #4 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - an assessment tool) dated 3/8/2021, documented the resident's cognitive skills for daily decision making were severely impaired. The resident rarely/never made themself understood and rarely/never understood others. The Nursing Progress Note dated 3/26/2021 at 3:51 PM by Registered Nurse Manager (RNM) #1, documented Resident #4 had an excoriation (erosion or destruction of the skin that appears as a scratch or abrasion) and swelling on the left upper eyelid. The resident was seen and examined by MD #1 and ordered a vitamin ointment every shift for 5 days and acetaminophen 400 mg every 6 hours for 3 days for pain. The medical record did not include a progress note dated 3/26/2021 from MD #1. The Nursing Progress Note dated 8/11/2021 at 11:12 AM by RNM #1, documented they received a call from the school around that the resident had vomited a small amount and had nausea. The resident came back to the facility around 11:00 AM. The resident was seen and examined by MD #1 who ordered not to send the resident to school the next day and to re-evaluate on 8/13/2021. The medical record did not include a progress note dated 8/11/2021 from MD #1. The Nursing Progress Note dated 8/13/2021 at 1:44 PM by RNM #1, documented the resident was seen and examined by MD #1 who ordered not to send the resident to school on the following Monday. The resident was to be re-assessed by the MD. The medical record did not include a progress note dated 8/13/2021 from MD #1. The Nursing Progress Note dated 8/16/2021 at 4:07 PM by RNM #1, documented the resident was seen and examined by MD #1 and ordered to go back to school the next day. The medical record did not include a progress note dated 8/16/2021 from MD #1. The Nursing Progress Note dated 8/18/2021 at 7:14 PM by the Registered Nurse (RN #3), documented that around 6:30 AM, the resident vomited a moderate amount of food. The MD was notified, and the Dietitian was informed. The Nursing Progress Note dated 8/18/2021 at 2:54 PM by RNM #1, documented Resident #4 was seen and examined by MD #1, with no new orders. The medical record did not include a progress note dated 8/18/2021 from MD #1. Resident #1: Resident #1 had been readmitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE], documented the resident's cognitive skills for daily decision making were severely impaired. The Nursing Progress Note dated 7/19/2021 at 2:15 PM, documented Resident #1 was restless during lunch time and was placed in the ventral (the front of the body) position on the bean bag. After a few seconds, the resident started wandering around and a had a few blank stares for 10 seconds. Further assessment was done, and the resident was noted to be bothered by something. The resident then laid himself on the floor and had generalized tremor-like activity with generalized body stiffness for 10 seconds. The resident was being monitored as per MD #1's order. The Nursing Progress Note dated 7/19/2021 at 10:59 PM by RNM #1 documented Resident #1 was seen and examined by MD #1, with no new orders. The medical record did not include a progress note dated 7/19/2021 from MD #1. Interviews: During an interview on 9/22/2021 at 11:49 AM, RNM #1 stated if they documented the resident was seen and examined by MD #1, then MD #1 definitely saw and examined the resident on that day. RNM #1 said MD #1 did not write a progress note at every visit, and that MD #1 usually wrote a monthly note and would summarize the visits in that note. During an interview on 9/17/2021 at 12:00 PM, MD #1 stated they did not see Resident #4 the day they went to the hospital, 3/31/2021, and that the date of the examination did not always reflect the actual date of the visit. MD #1 stated the visits were usually prior to the date the note was documented, and that the notes were expected in the charts by the end of the month, and they reflected significant events during that month and prior months. During an interview on 9/21/2021 at 11:17 AM, the Administrator stated that, if they needed to know when the physician saw a resident, they would rely on Nursing staff to tell them and also on the charting of the physician's exam. The Administrator stated they expected their doctors to chart on the resident within 24 hours of seeing the resident. During an interview on 9/21/2021 at 12:30 PM, the Medical Director (MD #2) stated MD #1 was talking about monthly visits when they said the notes were expected in the chart by the end of the month. Writing a cumulative note at the end of the month was not the way it was supposed to be done. A note needed to be documented with each acute visit and scheduled monthly visits, at the time of the visit and needed to include a plan for what to do for the resident. MD #2 said they would not know a problem with the resident existed unless a note was written. 10 NYCRR 415.15(b)(2)(iii)

Based on record review and interview during an abbreviated survey (Case # NY 987), the facility did not ensure medical records were maintained on each resident that was complete and accurately documented for 2 (Resident #'s 4 and 1) of 3 residents reviewed. Specifically, for Resident #4 the facility did not ensure complete and accurate documentation of the condition of resident's skin and the resident's medications on the physician's monthly progress note dated 3/31/2021. Additionally, documentation of Resident #4's feet on 4/2/2021 was not complete and accurate. For Resident #1, the facility did not ensure complete and accurate documentation of the physician's monthly progress note dated 7/31/2021. This was evidenced by: The Policy and Procedure (P&P) titled Documentation, last revised on 5/2019, documented the clinical team should document all relevant data and information pertaining to the provision of care and services to the residents in the medical record. Any and all forms of documentation by a clinician should be recorded according to accepted professional standards of practice. The documentation was relevant as evidence of clinical practice. Documentation in the medical record was the basis of communication between health professionals; it informed other health care clinicians of the treatment and care provided, care planned, and the outcomes of that care. Resident #4: Resident #4 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - an assessment tool) dated 3/8/2021, documented the resident's cognitive skills for daily decision making were severely impaired. The resident rarely/never made themself understood and rarely/never understood others. The Comprehensive Care Plan (CCP) for at Risk for Skin Breakdown, last revised on 4/16/2021, documented the resident was at risk for skin breakdown. Interventions effective 2/12/2016, included the following protective/preventive foot care: Medical/Nursing staff were to keep the resident's feet clean and dry, apply lotion as needed, and inspect the feet (especially between toes and heels daily). The resident was to wear proper fitting shoes and was to have a Podiatry consult as needed. The Certified Nurse Aide (CNA) was to observe skin condition daily during care and report any skin abnormalities to the nurse. Finding #1: The facility did not ensure complete and accurate documentation of the condition of Resident #4's skin on the physician's monthly visit note dated 3/31/2021. The Pediatric Monthly Progress Note dated and signed on 3/31/2021 at 8:49 PM by the physician (MD #1), documented 3/31/21 Noted to have abrasion over left eye with periorbital swelling (swelling around the eye) which resolved over course of about 24 hours. There was no documentation about the condition of the resident's skin. Hospital documentation of an Emergency Department (ED) visit on 3/31/2021, documented Resident #4 was examined and photographed by the Registered Nurse Forensic Examiner (RNFE). The photographs included pictures of the face, abdomen, legs and arms. The RNFE documented the following findings related to the photographs on the Photography Log: The left eyelid was swollen and had a 1 x 1.5 cm pink abrasion and there was purple bruising in the left inner eyelid and below the eyelid. The abdomen from left had marbled dark pigment on the left front area. The right inner thigh had a 7 x 13 cm area of marbled skin that was non-raised and had dark pigments. The right lateral arm had a 7 cm linear area of dry skin/?healed burn with scattered small circular purple bruises. During an interview on 9/17/2021 at 12:00 PM, MD #1 stated they did not see Resident #4 on 3/31/2021, and that the date of the examination did not always reflect the actual date of the visit. MD #1 stated the visits were usually prior to the date the note was documented and that the notes were expected to be in the resident's record by the end of the month. MD #1 stated the resident record reflected significant events during that month and prior months. Finding #2: The facility did not ensure the physician's monthly progress note dated 3/31/2021, included complete and accurate documentation of Resident #4's current medications. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The following medication renewals were not documented in the progress note: [MEDICATION(S)] (for diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 9/23/2021 at 11:45 AM, MD #1 reviewed the monthly progress note dated 3/31/2021 and stated Resident #4's medications were not documented completely and accurately in that note due to an oversight on their part. MD #1 said they had misconceptions about the requirements for monthly notes. During an interview on 9/23/2021 at 10:51 AM, the Medical Director (MD #2) stated that on 9/22/2021 they identified that MD #1's medication renewals did not coincide with the monthly visit progress note. MD #2 said medications took a lot of time to review, it had to be thorough, and was to be reflected in the progress note. Finding #3: The facility did not ensure complete and accurate documentation of the condition of Resident #4's feet on 4/2/2021. A hospital record of an ED visit on 3/31/2021, documented Resident #4 was examined by the RNFE and the resident's feet were photographed. The Photography Log documented the bottom of the left foot had several deep cracks in dry skin with dirt in the cracks. The left big toe had a 1 cm crack and was dirty. The bottom of the right foot big toe and mid-foot had cracked dry, dirt-filled skin. The Nursing - admission nursing assessment dated [DATE] by the Registered Nurse Manager (RNM #1), documented areas identified as #1 (top of right foot) and #2 (top of left foot) had dry, scaly skin. There was no documentation about the bottom of the resident's feet. During an interview on 9/13/2021 at 2:38 PM, RNM #1 said they did not document about the bottom of Resident #4's feet on 4/2/2021, because they did not look at the bottom of the resident's feet. During an interview on 9/17/2021 at 1:20 PM, DON stated they would have expected RNM #1 to look at the bottom of the resident's feet on 4/2/2021, and document what they saw. Finding #4: The facility did not ensure complete and accurate documentation of the physician's monthly progress note for Resident #1 dated 7/31/2021. Resident #1: Resident #1 was readmitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - an assessment tool) dated 4/20/2021, documented the resident's cognitive skills for daily decision making were severely impaired. The CCP for at Risk for Falls/Injury, last revised on 6/22/2021, documented the resident was at risk for falls/injury secondary to [CONDITION(S)] disorder. On the unsigned Pediatric Monthly Assessment Note dated 7/31/2021 by MD #1, the Assessment and Plan section of the note did not include documentation of an assessment of the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 9/23/2021 at 11:45 AM, MD #1 stated they had misconceptions about the requirements for monthly notes and was not aware the monthly assessment note was incomplete and did not have a signature. 10 NYCRR 415.22(a)(1-4)

Based on record review and interview during the recertification survey, the facility did not ensure the development and implementation of comprehensive person-centered care plans for each resident that included measurable objectives and timeframes to meet each resident's medical, nursing, and mental and psychosocial needs for 6 (Resident #12, 23, 26, 30, 86, and #91) of 22 residents reviewed for comprehensive care plans (CCPs). Specifically, the facility did not ensure CCPs were individualized and included person-centered interventions for Resident #12's mood state and cognitive function; for Resident #'s 26 and #30's mood state; for Resident #91's communication, behavior, and mood state; for Resident #86's behavior and mood state; and for Resident #23, the facility did not ensure the CCP included Range of Motion (ROM) care needs. This is evidenced by: The Policy and Procedure titled Comprehensive Care Plan last revised 9/2015 documented a comprehensive, accurate, standardized and reproducible assessment and plan of care for the resident's individualized problems would be formulated by the Interdisciplinary Team. The policy documented the CCP would have goals and objectives that were specific, measurable, and within a stated timeframe and interventions would be specific. Resident #12: The resident was admitted to the facility with the [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - an assessment tool) dated 11/25/19, documented the resident had severely impaired cognition, could sometimes understand others and could make self understood. The CCP for Mood State, last revised 3/14/19, documented to monitor mood state or feelings as manifested by resident showing signs of sadness, reduced social interaction and to administer medications as prescribed, encourage decision making, encourage family involvement and visits, and encourage verbalization of feelings. The CCP did not include individualized and person-centered interventions. The CCP for Cognitive Function, last revised 3/15/19, documented an alteration in cognitive function due to [MEDICAL CONDITIONS] and history of dementia. The CCP interventions were to explain procedures prior to performing them, introduce self upon approaching resident, observe for signs of decline in cognitive, notify MD as needed, and obtain psychiatric consult as needed. The CCP did not include individualized and person-centered interventions. During an interview on 12/09/19 at 10:58 AM, Registered Nurse (RN) #2 stated the mood state care plans were personalized to the resident if needed and if not, interventions were chosen from a care plan library. RN #2 stated the care plans should include person centered approaches. The Social Work Department was responsible for initiating the mood state care plans, but the care plans were also reviewed by the Interdisciplinary Care Team to ensure care plans were resident specific. RN #2 stated Resident #12's mood state and cognitive function care plans were considered personalized. and the facility did not have a dementia specific care plan. During an interview on 12/09/19 at 2:56 PM, the Director of Social Work (DSW) stated a mood state care plan was initiated for every resident upon admission and if the resident was not having a mood issue, the care plan would not necessarily be tailored to the individual resident. Resident #26: The resident was admitted to the facility with the [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], documented the resident was cognitively intact, could usually understand others and could usually make self understood. The CCP for Mood State, last revised 12/28/18, documented to monitor mood state or feelings as manifested by resident showing signs of sadness, reduced social interaction and to encourage participation in leisure activities, encourage family involvement, and administer medications as prescribed. The CCP did not include individualized and person-centered interventions. During an interview on 12/09/19 at 10:58 AM, RN #2 stated the mood state care plans were personalized to the resident if needed and if not, interventions were chosen from a care plan library. RN #2 stated the care plans should include person centered approaches. During an interview on 12/09/19 at 2:56 PM, DSW stated Resident #26's mood state care plan could probably be more specific to him and there should definitely be something on the care plan for the staff to try in terms of non-pharmacological interventions. The DSW stated a mood state care plan was initiated for every resident upon admission and if the resident was not having a mood issue, the care plan would not necessarily be tailored to the individual resident. Resident #91: The resident was admitted to the facility with the [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], documented the resident had severely impaired cognition and was rarely able to make himself understood or understand others. The CCP for Communication-Language barrier, last revised 10/25/19, documented the resident speaks in native language. Communication skills are not functional for ADL's in native language. Resident is not able to use a communication board. The interventions included, meet and anticipate needs; encourage use of communication board; obtain interpreter as needed. The CCP did not include individualized and person-centered interventions to include the native language. The CCP for Mood State, last revised 10/25/19, documented monitor mood state or feelings as manifested by resident showing signs of sadness, reduced social interaction. The interventions included; support self-esteem through positive feedback, encourage participation in leisure and self-care activities, encourage family involvement and visit and administer medications. The CCP did not include individualized and person-centered interventions. The CCP for Behavior Symptom, last revised 10/29/19, documented potential for resident to exhibit inappropriate behavioral problem as evidenced by-resident pulling [MEDICAL CONDITION]'s. The interventions included; identify pattern of behavior, documented in the progress notes the intensity, duration or frequency of behavior, notify MD immediately for changes in behavior; assess participation in ADLs, Social service evaluation and follow-up; redirect negative behaviors; orient to daily routines as needed; refer to Psychiatrist for further consultation related to behavior and administer medications as ordered by physician. During an interview on 12/10/19 at 8:45 AM, Licensed Practical Nurse Manager (LPNUM) #3 stated the interdisciplinary team met every morning and talked about resident behaviors related to diagnosis, incident reports, falls and any new issue that had come up. They added interventions to the care plans at the meeting. LPNUM #3 stated the care plan for Resident # 91 could be more resident centered and will do much better with the care plans going forward. During an interview on 12/10/19 at 9:07 AM, the MDS Coordinator stated she did not attend the care plan meetings. She did some editing and reviewing of care plans and she stated at times the care plans were not resident centered. During an interview on 12/10/19 at 9:15 AM, the Director of Nursing (DON) stated she did attend some of the care plan meetings. The facility was working on the pediatric care plans and improving the interventions. She stated the interventions need to be more resident centered. 10NYRR415.11(c)(1)

Based on observation, record review and interviews during the recertification survey, the facility did not ensure residents with limited range of motion (ROM) received appropriate treatment and services to increase ROM and/or to prevent further decrease in ROM for 2 (Resident #'s 41 & #76) of 3 residents reviewed. Specifically, for Resident #'s 41 and #76, the facility did not ensure the residents were provided with ROM with morning care. This was evidenced by: The Policy and Procedure (P&P) titled Range of Motion (undated) documented ROM should be performed at least two times per day; Once with AM care and once with PM care. Do each exercise/stretch 3-5 times or move the joint to the end range and hold for 10-15 seconds. Resident #41: The resident was admitted to the facility with the [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], documented the resident had no discernible consciousness, and had limited ROM to all four extremities. During an observation of AM care on 12/5/19 at 9:00 AM, CNA #7 washed and dried resident's face, torso and extremities while using minimal movement of his extremities. The resident was not provided with ROM. The CNA Care Card (instructions related to a resident's level of care required) did not include instructions for ROM. During an interview on 12/5/19 at 1:00 PM, the Rehabilitation Director stated that Resident #41 received Rehabilitation Maintenance ROM by a Rehab aide 2-3 times per week. The CNAs are supposed to provide ROM with care for every resident, regardless of any therapy program the resident received. During an interview on 12/9/19 at 10:16 AM, CNA #5 stated she had been working at the facility for years. She gets her residents care instructions from the kiosk (CNA Care Card) prior to starting care. If there was no documentation on the kiosk to do the ROM, then it is not done. Resident #76: The resident was admitted to the facility with the [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], documented the resident had severe cognitive impairment and was usually able to be understood by others and was rarely/never able to understand others. It documented the resident had limited ROM to all four extremities. During an observation of AM care on 12/9/19 at 9:51 AM, Certified Nurse Aide (CNA) #6 provided morning care to Resident #76. While washing the upper body, each arm was lifted three times, by holding the wrist and raising the arm to allow for washing, drying and application of deodorant. Each leg was lifted once for the washing and drying. There was no ROM done on the elbow, wrist, fingers or legs. The CNA Care Card did not include instructions for ROM. During an interview on 12/9/19 at 10:54 AM, CNA #6 stated that rehab staff does some of the residents for ROM 2-3 times per week. If the therapy aide does ROM, then CNAs do not have to do it. I just did ROM when I was washing Resident #76, I lifted her arms and legs up with her bath. During an interview on 12/9/19 at 11:00 AM the Licensed Practical Nurse Manager (LPNM) stated every resident was supposed to get ROM done with bathing and care. The LPNM and other nurses monitor the residents and care but not specifically to see if ROM was being done. She was not aware that ROM was not being done. During an interview on 12/9/19 at 11:33 AM, the Registered Nurse (RN) Educator stated the Rehab Department has their own maintenance ROM program for certain residents but the CNAs are still required to do ROM on every resident no matter their rehab program. The CNAs are supposed to be doing ROM on every resident during care paying particular care to the contractures and ranging as far as the resident can tolerate, and ranging the hips, knees, ankles and the shoulder, elbows and hands. ROM is reviewed with all CNAs on orientation and they learn it in their CNA certification class, they should be doing it correctly. She recently realized the CNAs were not doing the correct ROM or ROM at all and they needed new instruction. Before the survey started, she was planning on developing a new ROM in-service. During an interview on 12/5/19 at 1:00 PM, the Director of Nursing stated that all residents should receive ROM every day with care regardless of their rehab program. ROM is not documented on the CNA Care Card because it is part of the AM and PM care. When the CNA signs that the resident care was done that included ROM. 10NYCRR415.12(E)(2)

Based on observations, record review, and interviews during a recertification survey the facility did not ensure based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, for one (Resident #24) of one reviewed for activities. Specifically, facility did not ensure that the resident received ongoing and appropriate activities based on the resident's abilities. This is evidenced by: Resident #24: The resident was admitted with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-an assessment tool) dated 2019, assessed the resident as being in a persistent vegetative state. A Therapeutic Recreation and Arts assessment dated [DATE], documented preferred recreation consisted of movies, listening to music, radio reading and television. The resident showed little to no signs of response to activity stimuli and would mainly benefit from sensory stimulation 3-4 times a week. During observations; 12/04/19 at 10:30 AM, the resident was in a crib in the room. There was no music, television (TV), or lights on in the room. 12/05/19 at 9:30 & 10:35 AM, and 1:03 PM, the resident was in a crib in the room with the lights off. The was on and stationed on a news program broadcasting impeachment hearing. A Comprehensive Care Plan for Activities dated 10/2/12, documented the resident needed structured multi-sensory activities to stimulate cognitive functioning through religious visits, conversation, music, tactile therapy and light hand massages. Interventions documented to turn on the TV daily and encourage/provide one to one multi-sensory activities. The last assessment note dated 9/24/19 documented the resident received visits 3-4 times weekly for soft reading and light music. Progress note dated from 11/1/19 - 12/12/5/19, did not include documentation that the resident had any illness or respiratory issues during that time frame. Daily Activity Program Attendance Records (documentation of each resident that received activity for that day), dated from 11/2/19 - 21/5/19 did not include documentation that Resident #7 was provided with any activities for those days. Monthly Activity Attendance Records dated from 11/1/19 - 12/5/19, documented 8-15 minute units of music, sensory, and 1-1 social visits for each of the days and 10-15 minute units in each of the days for TV/movies. During an interview on 12/06/19 09:13 AM, the Activities Director (AD) stated the resident only got 1:1 visits as he/she did not have the ability to respond. They documented the resident had TV and movies because she expected CNAs or nurses to put the TV on and it should be on animation an or soft music. It was not appropriate to have no lights or music or to have new programs on. As long as the resident was awake staff were to have the lights on and appropriate music or TV on. She has staff visits on the evening shift. Sensory would be TV music or light hand massage depending on the resident. They do 15-minute increments. Daily activity attendance sheets do not have the resident in any activity. She is getting monthly attendance record info based on the assumption that all disciplines are participating in the act of providing activities. She does walk throughs on the units and yesterday she did not notice the TV station. There was an Activity Aide (AA) on the unit doing one to one visits but she was not sure if the resident received one. Is aware of a lack of activities and has been brought up with administration. Activity staff are not able to get medically compromised residents up (vents/airways). During an interview on 12/09/19 at 01:30 PM, the Director of Nursing (DON) stated that her expectation was that the resident had recreational activities in his/her room and that TV and music should be appropriate for the child. During an interview on 12/09/19 at 02:57 PM, AA #8 stated she worked full time days and was responsible for one to one activities for the whole building when she was there. She came to the Pediatric unit from 2:30 PM - 4:30 PM daily. They do the best they can and if the residents name was not on the daily Activity Program Attendance Record, then he/she was not seen. 10NYCRR 415.5(f)(1)

Based on observations, record review, and interviews during a recertification survey the facility did not ensure that its medication error rates are not 5 percent or greater. Specifically, during a medication pass observation, the facility did not ensure that the medication rate was at or below 5%. This is evidenced by: A facility policy titled Metered Dose inhalers (MDI) and dry powder inhalers (DPI) last revised 2/15/18, documented that nursing staff will administer medications via MDI or DPI to maintain airway patency and improve respiratory function. When using a MDI, allow at least one minute for resident to rest between inhalations and for a DPI to allow at least one minute between inhalations and to repeat process until the total number of inhalations ordered is administered. Medical Doctor (MD) order dated 11/28/19, documented the following: - [MEDICATION NAME] 160 micrograms (mcg) -4.5 mcg/actuation HFA aerosol inhaler (MDI); 2 puffs BID - [MEDICATION NAME] with Handihaler 18 mcg and inhalation capsules (DPI); 1 capsule by inhalation route once daily two inhalations. During a medication pass observation on 12/09/19 10:16 AM, the nurse placed the [MEDICATION NAME] and the [MEDICATION NAME] in front of the resident. The resident took 2 inhales of the [MEDICATION NAME] without a rest between inhales. The resident asked the nurse if she should do the [MEDICATION NAME], the nurse responded yes, and the resident did two consecutive inhales of the [MEDICATION NAME] without taking a rest between inhales. Package insert information for [MEDICATION NAME] documented if you are using other inhalers at the same time, wait at least one minute between the use of each medication. Package insert information for [MEDICATION NAME] documented if prescribed dose is 2 puffs, wait at least one minute between puffs and if using other inhalers at the same time, wait one minute between the use of each medication. During an interview on 12/09/19 at 11:16 AM, Registered Nurse (RN) #4 stated there should have been intervals between inhales of her medication. During an interview on 12/09/19 at 1:23 PM, the Director of Nursing (DON) stated there should have been a minute between different inhalers and between each puff of the same inhaled medication. 10NYCRR 415.12(m)(2)

Based on observations, record review, and interviews during a recertification survey the facility did not ensure that it established and maintained an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #96) of three residents observed for dressing changes. Specifically, for Resident #96, the facility did not ensure infection control measures were maintained during a dressing change. This is evidenced by: Resident #96: The resident was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - an assessment tool) dated 11/14/19 documented the resident had severely impaired cognition, could understand others and could make self understood. The Policy and Procedure titled Dressing Change Policy and Procedure last revised 3/2018, documented it was the policy of the facility to cleanse all wounds in order to clear exudates, bacterial contamination and debris from the wound bed. This process was done since optimal healing cannot proceed until the inflammation-producing substances were removed from the wound surface. The Comprehensive Care Plan for Skin Integrity, last updated 9/26/19, documented the presence of moisture associated [MEDICAL CONDITION] (MASD) on 7/18/18 to the resident's coccyx that progressed to an unstageable pressure injury, and then to stage 4 pressure ulcer. A Physician order [REDACTED]. gauze (use roll gauze) followed by a silicone dressing to the stage 4 pressure ulcer of the sacral region. During a dressing change observation on 12/09/19 at 11:00 AM, the nurse cleansed the inside of the resident's wound with Dakin's (a bleach solution used in wound care) soaked gauze and then with same gauze cleansed the peri wound (tissue surrounding skin) area. The nurse discarded the gauze and repeated this process two more times. During an interview on 12/09/19 at 11:16 AM, Registered Nurse (RN) #4 stated she cleaned the cleanest part of the wound first; clean inside the wound and then the outside but stated a different gauze should have been used. During an interview on 12/09/19 at 1:38 PM, the Infection Control Preventionist (ICP) stated the wound and peri wound area should have been cleansed with separate gauze and that cleansing the wound then the peri wound with the same gauze was a break in infection control. 10NYCRR 415.19(a)(1-3)

Based on observation and staff interview during the recertification survey, the facility did not dispose of garbage and refuse properly. Specifically, the trash dumpster lids and doors had holes, making them non-pest resistant. This is evidenced as follows. The trash dumpster area was inspected on 11/27/18 at 3:15 PM. The first of two dumpsters had a 2-inch by 4-inch hole on the left-side door, and a 2-inch by 6-inch hole on the right-side door. The second of two dumpsters had 2 plastic lids on the top of the dumpster. At the bottom of the lids there was a gap 4 inches wide by 2 feet high. At no point did the two doors meet or close completely. During an interview on 11/27/18 at 4:15 PM, the Food Service Director stated that she was not aware of the condition of the dumpsters. No one had let her know that there was a problem with the doors or lids. She was not aware of regulations regarding dumpster conditions. 10 NYCRR 415.14(h)

Based on observation, record review and interview during the recertification survey, the facility did not maintain an infection control program to prevent the development and transmission of disease and infection determined for 3 of 4 dressing changes for two (2) (Resident #'s 33 and 37) of five (5) residents reviewed. Specifically; for Resident #33, the facility did not ensure standard precautions were maintained during a dressing change to the resident's stage 4 decubitus ulcer to the back of the resident's head and stage 4 decubitus ulcer to the resident's sacral area, for Resident # 37, the facility did not ensure standard precautions were maintained during a dressing change to the resident's left and right stage 3 decubitis ulcers on the residents left and right buttocks area. This is evidenced by: Resident #33: This resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was severely impaired for cognition and was unable to make needs known. The Policy and Procedure for Dressing Change with a revision date of 1/6/16, documented the policy is to perform wound dressing changes using clean technique with packaged wound dressings and materials. These will be used in conjunction with good hand washing technique. The procedure documented to wash hands, wipe down the over bed table, clear the waste bag and prepare equipment. Wash hands. Open all equipment and place onto clean field of table. Apply clean gloves to remove soiled dressing. Discard dressing into plastic bag. Remove gloves and wash hands. Put on clean gloves. Cleanse wound as ordered. Washed hands. Apply clean gloves. Apply new dressing. Remove gloves and discard into plastic bag. Dispose of plastic bag in appropriate receptacle. Wash hands. A physician's orders [REDACTED]. Cover with a silicone dressing. A physician's orders [REDACTED]. Pack with dry gauze and cover with a silicone dressing. During an observation on 11/29/18 at 10:56 AM, Registered Nurse (RN) #2 was observed tearing open gauze packages and pulling out the gauze. She then placed the pieces of gauze onto the barrier. She did not remove her gloves, wash her hands and donn a new pair of gloves after touching the outside of the dressing packages. The torn portion of one of the packages fell on to a piece of gauze and touched the barrier. RN #2 did not remove the barrier or the contaminated piece of gauze. With the same gloved hands she was then observed opening the cotton tipped applicator package by holding it with the same gloved hands and taking the applicator out of the package. RN #2 was observed opening the package of colleginate and placing the package on the barrier. She was observed placing the dressing materials and dressing packages on the same barrier. She was then observed providing a dressing change to the back of the resident's head. She held the package of wound gel, squeezed out the gel and applied it to the wound. She did not remove her gloves, wash her hands and donn a new pair of gloves after touching the outside of the package of wound gel. She then opened the protective dressing by holding the outside of the package and placed it on the wound. She did not remove her gloves, wash her hands and donn new gloves after touching the outside of the protective dressing package and before touching the dressing. She then washed her hands and changed her gloves. During an observation on 11/29/18 at approximately 11:15 AM, RN #2 was observed providing a dressing change to the resident's sacrum. She cleansed the wound with normal saline, washed hands and changed gloves. She applied the calcium alleginate to the wound bed. She opened the silicone dressing package by holding it with the same gloved hands and applied it to the wound. She did not wash her hands and change gloves after touching the dressing package and before touching the dressing material. During an interview on 11/2918 at 11:30 AM, RN #2 stated she did not realize she was touching the outside of the dressing packages and touching the dressing materials without first washing her hands and changing her gloves. She stated she was very nervous because the resident's family member was present during the dressing change. She acknowledged she had repeatedly contaminated the dressing materials in this manner. During an interview on 11/29/18 at 11:44 AM, the Licensed Practical Nurse (LPN) Nurse Manager (NM) #1 agreed the RN should have washed her hands and changed her gloves after touching the outside of the dressing packages and before touching the dressing. She stated the RN should have opened the dressing packages and should have dropped the dressing materials onto the barrier without touching them. She also stated the RN should not have placed dressing materials and packages containing dressings on the same barrier. During an interview on 11/30/18 at 8:44 AM, the RN Infection Control Nurse/Nurse Educator stated the nurses who do wound care are constantly being monitored by the wound care nurse. The nurses have been inserviced not to touch the outside of the dressing packages before first washing their hands and changing gloves before touching dressing supplies. There is ongoing assessment of the nurses' wound care skills as the nurses are observed doing wound care. RN #2 was re-inserviced. Resident #37: This resident was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE], documented the resident was severely impaired for cognition and was unable to make needs known. A physician's orders [REDACTED]. Cover with a foam dressing. A physician's orders [REDACTED]. Cover with a foam dressing. During an observation on 11/29/18 at 8:59 AM, RN #2 was observed to tear open gauze packages, pull out the gauze and place the pieces of gauze onto the barrier. She did not remove her gloves, wash her hands and don a new pair of gloves after touching the outside of the dressing packages. She removed the old dressing on the left buttocks, cleansed the wound with a 4 x 4 gauze wet with normal saline, discarded the wet soiled gauze, packed the wound with alginate dressing and covered it with a foam dressing. No hand sanitizing or glove change was performed between tasks. She then washed her hands, donned new gloves, moved the bedside table to the other side of the bed touching the underside of the bedside table, proceeded to remove the old dressing from the right buttocks wound, reglove, cleansed the wound with a wet 4 x 4 gauze, discarded the soiled gauze, packed the wound with alginate dressing and applied the foam dressing. No hand sanitizing was performed between glove change. During an interview on 11/29/18 at 9:40 AM, LPN NM stated RN #2 should have washed her hands and changed her gloves after moving the bedside table and between tasks. The accepted method would be to set up a barrier, wash hands, glove, open dressing material dropping them on the barrier. After cleaning the wound with normal saline, the RN #2 should have washed her hands and donned clean gloves before packing the wound and prior to covering the wound with the foam dressing. During an interview on 11/29/18 at 12:09 PM, RN #2 stated she didn't realize she had touched the underside of the table with her gloved hands before beginning the dressing change. She stated she should have washed her hands and changed her glove in between cleaning of the wound. During an interview on 11/29/18 at 4:05 PM, the Director of Nursing (DON) stated she reviewed the dressing changes with RN #2. She should have washed her hands between tasks and regloving. She had been nervous but said dressing changes have to be done correctly each and every time to prevent contamination and infections to the resident's wound. RN #2 would be reducated. 10NYCRR415.19(b)(4)

Based on record review and interview during the recertification survey, the facility did not ensure a policy was developed for the monthly medication regimen review (MRR) that included time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. This is evidenced by: Review of the facility's undated policy titled: Drug Regimen Review- Monthly Policy and Procedure on 11/28/18, revealed that the policy did not include timeframes for when written documentation of all recommendations and prescriber response should be done in step 2 of the policy. The policy did not include; a time frame for when recommendations should be placed in the medical record or documented in the paper chart for each resident, a time frame for when the Physician would review the Pharmacist's recommendations, a time frame for when the Physician would document decisions and rationale regarding the recommendations or steps the pharmacist would take when he or she identifies an irregularity that requires urgent action to protect the resident. During interview on 11/30/18 at 1:42 PM, the Director of Nursing (DON) stated that the policy provided was the only one the facility had. Upon review of the policy the DON was not able to identify the missing timeframes from each step. During interview on 11/30/18 at 1:49 PM, the Administrator reviewed the current Medication Review Policy and stated timeframes were clearly missing from the policy. He stated 2 out of 4 steps were missing timeframes. 10NYCRR415.18(c)(2)

Based on observation, record review, and interview during a recertification survey the facility did not maintain an environment free from accident hazards as possible on one (1) (Pediatric Unit) of 3 units. Specifically: The facility did not ensure that toxic chemicals were not accessible to residents on the Pediatric Unit; and did not ensure that shower gurneys were properly drained, free from standing water, and not accessible to residents on the Pediatric Unit. This was evidenced by: Safety Data Sheet (SDS) Sienna Neutral Disinfectant - Hazards Identification - contains the word danger, may be corrosive to the eyes, causes skin burns, and may be harmful if swallowed. SDS - Fusion Silver (stainless steel cleaner) Hazards Identification - GHS classification #1. Skin 2 A, #2. Eyes 2 A Warning: May cause eye or skin irritation, redness or swelling. Store in cool place in original container. Keep container tightly closed away from food and drink. Finding #1: The facility did not ensure that toxic chemicals were not accessible to residents on the Pediatric Unit. Observations: During an observation on 3/9/17 at 8:15 am, an opened 32 oz bottle of Santec fusion silver ( a stainless steel polish),with a level 2 A skin and level 2 A eye hazard classification was observed on the counter in an unlocked small resident kitchenette by the nursing station. There were no staff observed near the kitchenette. During an interview on 3/9/17 at 8:20 am, the unit secretary stated there is usually a lock on the kitchenette area, and did not know why it had been left unlocked. She stated the key was left on the wall outside the room. She further stated the stainless steel cleaner should not have been left on the counter. She secured the top on the bottle of Santec and stated she was going to remove it from the room. During an interview on 3/9/17 at 1:15 pm, the housekeeper stated she was not sure who had left the stainless cleaner in the kitchenette. She also stated that is never to be left in there because sometimes that door is locked and sometimes it's not. During an interview on 3/9/17 at 1:30 pm, the maintenance supervisor stated no cleaners should be left in any unlocked areas where a resident could possibly gain access to them. On 3/9/17 at 8:30 am, a 64 oz spray bottle of Sienna Neutral Disinfectant cleaner was observed on the shelf in an unlocked shower suite. The hazard warning on the spray bottle contained the word danger, may be corrosive to the eyes, causes skin burns, and may be harmful if swallowed. Interviews: During an interview on 3:/9/17 at 1:20 pm, the activity director stated staff need to be mindful of safety with residents at all times especially with hazardous chemicals. She also stated pediatric residents are very quick and all chemicals are to be locked at all times to prevent accidents. She stated they are very resourceful when it comes to figuring out how to get in and out of places they are not suppose to be in. She also stated prevention is the best defense. During an interview on 3/9/17 at 1:30 pm, the maintenance supervisor stated no cleaners should be left in any unlocked areas where a resident could possibly gain access to them. He further stated the cleaning solution in the spray bottle is to clean the pads on the shower gurney's, but should be locked back in a cabinet when the staff is done using it. He stated it should not be left on a shelf in an unlocked room. Finding #2: The facility did not ensure that shower gurneys were properly drained, free from standing water, and not accessible to residents on the Pediatric Unit. Observations: On 3/9/17 at 8:35 am, in an unlocked shower suite two shower gurney's were observed to have standing water in the bottom overflow pan. (The MJM model 910 shower gurney has a black hard overflow pan underneath the frame to catch standing water while showering a resident. The hose connected to the pan drains off water preventing collection of water in the pan.) The canvas collection pan on shower gurney #1 was filled with standing water that was approximately 6 inches in depth and approximately 12 inches in width. Gurney #1 was unlocked and accessible to a child. Gurney #2 was unlocked and the black collection pan was filled with standing water that was also accessible to a child. On 3/9/17 at 9:30 am, children were observed ambulating around the unit. One child was observed consistently attempting to enter the shower suite. On 3/9/17 at 11:30 am, in an unlocked shower suite, two shower gurney's bottom overflow pans contained standing water. On 3/9/17 at 3:30 pm, in an unlocked shower suite, two shower gurney's bottom overflow pans contained standing water. One child observed by the nurses desk, made several attempts to go into the shower suite. On 3/10/17 at 9:30 am, in an unlocked shower suite, two shower gurney's overflow pans under the lower frame of the units contained standing water. Shower gurney #1 was not locked and had different levels of water stain marks around the canvas water collection pan. The drain hose attached to the unit did not appear to be in working order to allow water to drain from the overflow pan. Gurney #2 contained less standing water than the previous day, remained unlocked and the drain pan contained standing water. On 3/10/17 at 3:30 pm, two unlocked shower gurney's in an unlocked shower suite had standing water in the bottom of the overflow pans under the lower frame of the units. The headrests of the shower gurney's were in a position that a child could access. On 3/15/17 at 1:30 pm, two unlocked shower gurney's in an unlocked shower suite had standing water in the bottom of the overflow pans under the lower frame of the units. Both shower gurney's were accessible to a child. Shower gurney #1's canvas pan contained 8 inches of standing water. Multiple pediatric residents were observed walking in the hall on the unit. One cognitively disabled male resident, was observed repeatedly attempting to access the shower suit. There were no nursing staff observed in the area. When the resident opened the shower door, a secretary redirected the resident preventing him from entering the shower suite. The resident made multiple attempts to enter the shower suite between 1:30 pm and 2:30 pm. Interviews: During an interview on 3/10/17 at 4:00 pm, the Registered Nurse Unit Manager (RNUM) stated that the unit is cleaned daily by housekeeping and any chemicals used should be put away immediately. The RNUM stated that all of the staff is responsible to clean up any thing that could possibly be dangerous to the residents. The RNUM stated that no standing water should be left in the overflow pans under the shower gurneys and that no chemicals should be left accessible to residents. She stated she believes there was a defect in the design of the shower gurney that causes water to collect in the pans, and when the Certified Nursing Assistants (CNA's) bathe a resident they should make sure that the water has drained out of the pan. She stated there is a hose that the water flows out of that sometimes doesn't work so the gurney need to be tipped. She also stated she didn't know why this wasn't done, and that she would reeducate staff on this. She stated she does have mobile pediatric residents and could see this as a potential hazard, because the shower suite does not lock. The RNUM further stated she had never asked maintenance to look at the shower gurney. During an interview on 3/13/17 at 10:00 am, the CNA #1 on the pediatric unit stated that some of the residents are as fast as lightening and can get in the shower room before you can blink your eyes. She stated there is always standing water in the bottom of the shower gurney's. She also stated someone always forgets to empty that pan. She said I've come in on days and had to do it after the water has been in there all night. During an interview on 3/15/17 at 2:00 pm, the RNUM stated she hadn't noticed there was water in the bottom of the shower gurney pan. She stated she had told the staff, but that she hadn't checked on it herself, as she did the day before. She stated all the residents had been on the unit, because of the snow day and she had been very busy. She stated she realized it was a hazard and would again reeducate the staff on maintain the equipment properly. 10NYCRR415.12(h)(1)

Based on record review and staff interviews during a complaint investigation (Case #NY 310) and a post survey revisit, it was determined that the facility did not ensure that each resident was free from mistreatment, and neglect. Specifically, for 1 of 1 employees reviewed the facility did not develop a plan to reeducate and monitor a Registered Nurse's (RN) performance after this nurse received multiple disciplinary notices on 7/15/10. This RN continued to make errors, which included not writing physicians orders when they were obtained , not writing accurate orders, and not transcribing orders accurately. This resulted in Resident #1 being admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. Finding #1 During a complaint investigation for Resident #1, the RN's employee file was requested. It documented that on 7/15/10, a Disciplinary Report was generated due to repeated medication errors for the past month. The specific errors this RN was responsible for occurred between the time period of 6/24/10 to 7/15/10. These errors were documented as: 1. Three consecutive doses of a hormone replacement cream were not administered on 6/17/10, 6/21/10, and 6/27/10. 2. A treatment to a wound area was written on the Treatment Administration Record (TAR), on 6/15/10 without a written physician's orders [REDACTED]. 3. A physician's orders [REDACTED]. The order was not discontinued from the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. 4. A physician's orders [REDACTED]. The order was incorrectly transcribed to the MAR indicated [REDACTED]. The resident received 8 incorrect doses of the medication. 5. On 7/8/10 the physician ordered [MEDICATION NAME] (an oral medication used to treat diabetes), 2.5 mg daily. The medication incident report documented that the resident's blood sugar at 4:30 pm on 7/9/10 was 290, and that from 7/8/10-7/10/10 the antidiabetic medication was not started. 6. On 7/14/10 at 9:00 pm, FSBS were not performed on two residents as ordered. The previously noted Disciplinary Report dated 7/15/10 for the RN documented that this was a final warning. The recommendations were that, the nurse would transcribe all physician orders [REDACTED]. There was no documented plan to reeducate the nurse or to monitor the performance of this nurse. On 8/17/10 on two occasions and 8/19/10, additional Disciplinary Reports were generated for this RN for unsatisfactory work performance. Additional medication and performance errors were found which included: 1. An order was written on 7/11/10 to obtain an urine specimen for urinalysis and culture and sensitivity. The the urine specimen was not obtained and caused a delay in treatment. 2. Antibiotic medication was ordered and received on 7/21/10, but was not transcribed to be started until 7/22/10. The report documented this was considered a delay in treatment. 3. On 8/19/10 there was lack of documentation on the TAR to ensure a red dot (used to identify Advance Directive Status) was present on resident's name bracelets. The report recommendation was to review the TAR for missing signatures at the end of shift. There was no plan initiated to monitor this RN's performance on any of these Disciplinary Reports. Finding # 2 Resident #1 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During a complaint investigation conducted on 10/15/10 -10/22/10, multiple medication errors involving RN #1 were found for Resident #1. The errors identified included: 1. The hospital discharge plan/instructions dated 7/15/10, documented [MEDICATION NAME], (HCTZ, used to reduce extra body fluid and retention) 25 milligrams (mg) daily, with the next scheduled dose to be given in the morning on 7/16/10 and for [MEDICATION NAME] (a blood thinning medication), 1 mg to be given at 6:00 pm on 7/15/10. The instructions also included documentation for the facility to arrange an appointment with the orthopedic surgeon in 7-10 days. The telephone admission orders [REDACTED]. 2. Additional admission physician orders [REDACTED]. The INR test result of 7/16/10 was documented as 1.6 (therapeutic target level is 2.5). RN #1 was the charge nurse on duty 7/15/10 and was responsible to complete the residents admission. There was no documented evidence that the physician had been notified by RN #1 of the laboratory results on 7/16/10. There was a physician's orders [REDACTED]. 3. On 7/19/10, physician orders [REDACTED]. The [MEDICATION NAME] order at this time was 4 mg, one time a day. The MAR indicated [REDACTED]. There was no documented evidence of a written physician's orders [REDACTED]. 4. An undated, orthopedic consultation report, from the follow-up orthopedic appointment, on 7/28/10, documented that the resident could weight bear as tolerated, [MEDICATION NAME] therapy was to be discontinued on 8/1/10 and to start Keflex (an antibiotic) 500 mg every six hours for 10 days. The MAR indicated [REDACTED]. There was no corresponding physician's orders [REDACTED]. A different nurse wrote the order for the Keflex on 7/29/10 at 4:06 am, after 1 dose had already been given. No order was obtained to discontinue the [MEDICATION NAME] and the resident continued to receive it until 8/10/10. The documentation from the hospital emergency room (ER) dated 8/11/10, documented the resident was admitted to the hospital with [REDACTED]. The last CBC obtained prior to this ER visit was on 7/16/10, and documented the Hemoglobin at 12.4 and the Hematocrit at 35.8 . On 8/12/10 at 11:45pm the residents' INR was 7.5 and the H&H were 8.3 and 24.2. The nurse's note from the hospital dated 8/13/10 at 5:46 am, documented the resident passed 450 millimeters (ml) of frank red blood from the rectum. The hospital documentation included that the resident was treated with multiple blood [MEDICAL CONDITION]. In an interview on 10/20/10 at 2:15 pm, with LPN #2 who administered the 4.5 mg dose of [MEDICATION NAME] on 7/21/10 and 7/22/10, LPN #2 stated that the charge nurse reviews the INR results, then notifies the physician. After the physician has been notified the charge nurse will document on the MAR, in the box area below the signature box the dosage of [MEDICATION NAME] to be given. The charge nurse would be responsible to obtain and document the order in the resident chart. LPN #2 stated that typically, she would not go to the chart to verify the order. LPN #2 stated that RN #1 made a lot of mistakes. The surveyor asked LPN #2, if the RN Manager and nursing supervisors were made aware of RN #1's performance. LPN #2 stated they were, but she was not aware of what was done about the situation. In an interview on 10/19/10 at approximately 9:30 am, with LPN #1 who administered the Keflex at 2:00 am on 7/29/10, LPN #1 stated that he was told verbally at change of shift report that the resident was starting Keflex, for an infection in the left hip incision. When he went to administer the Keflex, the medication had not been received from the pharmacy. LPN #1 stated he then went to the resident's chart for the physician's orders [REDACTED]. He notified the supervisor, who stated the resident was to receive Keflex. He stated he was instructed to write an order for [REDACTED]. In an interview on 10/18/10 at 10:50 am, the family member who accompanied the resident to the Orthopedic appointment on 7/28/10, stated that the physician told her the resident would no longer need the [MEDICATION NAME] and it would be stopped on 8/1/10. The family member stated that on 8/11/10, she was notified by the facility that the resident was being sent to the hospital, because he had a high fever and rectal bleeding. When the resident was seen in the emergency room , it was discovered that the [MEDICATION NAME] was never stopped. She stated that the resident was admitted to the hospital with [REDACTED]. In an interview the Registered Nurse Manager (RNM) on 10/18/10 at 11:20 am, stated that she was not aware of the specifics regarding the [MEDICATION NAME]. She stated, that in the past several weeks new policies regarding consultations have been put in place. She stated that the charge nurse on duty, who received the consultation report, would be the nurse responsible for calling the Primary Care Physician (PCP) to confirm and obtain orders recommended by the consulting physician. In an interview on 10/21/10 at 11:00 am, with the Assistant Director of Nursing (ADON) and the acting Administrator, it was stated that RN #1 was not monitored on an individual basis. The Acting Administrator stated that he could not single this nurse out. He was asked what measures were taken to correct or prevent further errors made by RN #1 and he stated that inservice education was provided to all nursing staff and not just this nurse. He stated there was no individual education or inservice provided to RN #1. The surveyor asked why the facility knowing the errors that were being made by this nurse, would allow this nurse to continue to perform as a charge nurse? He stated, "what was I to do, have her sit at a desk and answer phones like a secretary?" The ADON stated that the RN #1 was placed on the 7:00 am -3:00 pm shift, to be monitored by the RNM. Facility documentation, floor assignment sheets, 7/15/10 physicians orders and 24 hour report sheet documented that RN #1 was on duty between the hours of 3:00 pm and 11:00 pm shift from 7/15/10 through 8/20/10.. The Administrator again stated, that all nursing staff had been inserviced as the result of previous citations in this area. 10NYCRR 415.4(b)

Based on record review and staff interviews during a complaint investigation (Case #NY 310) and a post survey revisit, it was determined that the facility did not ensure that each resident was free from mistreatment, and neglect. Specifically, for 1 of 1 employees reviewed the facility did not develop a plan to reeducate and monitor a Registered Nurse's (RN) performance after this nurse received multiple disciplinary notices on 7/15/10. This RN continued to make errors, which included not writing physicians orders when they were obtained , not writing accurate orders, and not transcribing orders accurately. This resulted in Resident #1 being admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. Finding #1 During a complaint investigation for Resident #1, the RN's employee file was requested. It documented that on 7/15/10, a Disciplinary Report was generated due to repeated medication errors for the past month. The specific errors this RN was responsible for occurred between the time period of 6/24/10 to 7/15/10. These errors were documented as: 1. Three consecutive doses of a hormone replacement cream were not administered on 6/17/10, 6/21/10, and 6/27/10. 2. A treatment to a wound area was written on the Treatment Administration Record (TAR), on 6/15/10 without a written physician's orders [REDACTED]. 3. A physician's orders [REDACTED]. The order was not discontinued from the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. 4. A physician's orders [REDACTED]. The order was incorrectly transcribed to the MAR indicated [REDACTED]. The resident received 8 incorrect doses of the medication. 5. On 7/8/10 the physician ordered [MEDICATION NAME] (an oral medication used to treat diabetes), 2.5 mg daily. The medication incident report documented that the resident's blood sugar at 4:30 pm on 7/9/10 was 290, and that from 7/8/10-7/10/10 the antidiabetic medication was not started. 6. On 7/14/10 at 9:00 pm, FSBS were not performed on two residents as ordered. The previously noted Disciplinary Report dated 7/15/10 for the RN documented that this was a final warning. The recommendations were that, the nurse would transcribe all physician orders [REDACTED]. There was no documented plan to reeducate the nurse or to monitor the performance of this nurse. On 8/17/10 on two occasions and 8/19/10, additional Disciplinary Reports were generated for this RN for unsatisfactory work performance. Additional medication and performance errors were found which included: 1. An order was written on 7/11/10 to obtain an urine specimen for urinalysis and culture and sensitivity. The the urine specimen was not obtained and caused a delay in treatment. 2. Antibiotic medication was ordered and received on 7/21/10, but was not transcribed to be started until 7/22/10. The report documented this was considered a delay in treatment. 3. On 8/19/10 there was lack of documentation on the TAR to ensure a red dot (used to identify Advance Directive Status) was present on resident's name bracelets. The report recommendation was to review the TAR for missing signatures at the end of shift. There was no plan initiated to monitor this RN's performance on any of these Disciplinary Reports. Finding # 2 Resident #1 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During a complaint investigation conducted on 10/15/10 -10/22/10, multiple medication errors involving RN #1 were found for Resident #1. The errors identified included: 1. The hospital discharge plan/instructions dated 7/15/10, documented [MEDICATION NAME], (HCTZ, used to reduce extra body fluid and retention) 25 milligrams (mg) daily, with the next scheduled dose to be given in the morning on 7/16/10 and for [MEDICATION NAME] (a blood thinning medication), 1 mg to be given at 6:00 pm on 7/15/10. The instructions also included documentation for the facility to arrange an appointment with the orthopedic surgeon in 7-10 days. The telephone admission orders [REDACTED]. 2. Additional admission physician orders [REDACTED]. The INR test result of 7/16/10 was documented as 1.6 (therapeutic target level is 2.5). RN #1 was the charge nurse on duty 7/15/10 and was responsible to complete the residents admission. There was no documented evidence that the physician had been notified by RN #1 of the laboratory results on 7/16/10. There was a physician's orders [REDACTED]. 3. On 7/19/10, physician orders [REDACTED]. The [MEDICATION NAME] order at this time was 4 mg, one time a day. The MAR indicated [REDACTED]. There was no documented evidence of a written physician's orders [REDACTED]. 4. An undated, orthopedic consultation report, from the follow-up orthopedic appointment, on 7/28/10, documented that the resident could weight bear as tolerated, [MEDICATION NAME] therapy was to be discontinued on 8/1/10 and to start Keflex (an antibiotic) 500 mg every six hours for 10 days. The MAR indicated [REDACTED]. There was no corresponding physician's orders [REDACTED]. A different nurse wrote the order for the Keflex on 7/29/10 at 4:06 am, after 1 dose had already been given. No order was obtained to discontinue the [MEDICATION NAME] and the resident continued to receive it until 8/10/10. The documentation from the hospital emergency room (ER) dated 8/11/10, documented the resident was admitted to the hospital with [REDACTED]. The last CBC obtained prior to this ER visit was on 7/16/10, and documented the Hemoglobin at 12.4 and the Hematocrit at 35.8 . On 8/12/10 at 11:45pm the residents' INR was 7.5 and the H&H were 8.3 and 24.2. The nurse's note from the hospital dated 8/13/10 at 5:46 am, documented the resident passed 450 millimeters (ml) of frank red blood from the rectum. The hospital documentation included that the resident was treated with multiple blood [MEDICAL CONDITION]. In an interview on 10/20/10 at 2:15 pm, with LPN #2 who administered the 4.5 mg dose of [MEDICATION NAME] on 7/21/10 and 7/22/10, LPN #2 stated that the charge nurse reviews the INR results, then notifies the physician. After the physician has been notified the charge nurse will document on the MAR, in the box area below the signature box the dosage of [MEDICATION NAME] to be given. The charge nurse would be responsible to obtain and document the order in the resident chart. LPN #2 stated that typically, she would not go to the chart to verify the order. LPN #2 stated that RN #1 made a lot of mistakes. The surveyor asked LPN #2, if the RN Manager and nursing supervisors were made aware of RN #1's performance. LPN #2 stated they were, but she was not aware of what was done about the situation. In an interview on 10/19/10 at approximately 9:30 am, with LPN #1 who administered the Keflex at 2:00 am on 7/29/10, LPN #1 stated that he was told verbally at change of shift report that the resident was starting Keflex, for an infection in the left hip incision. When he went to administer the Keflex, the medication had not been received from the pharmacy. LPN #1 stated he then went to the resident's chart for the physician's orders [REDACTED]. He notified the supervisor, who stated the resident was to receive Keflex. He stated he was instructed to write an order for [REDACTED]. In an interview on 10/18/10 at 10:50 am, the family member who accompanied the resident to the Orthopedic appointment on 7/28/10, stated that the physician told her the resident would no longer need the [MEDICATION NAME] and it would be stopped on 8/1/10. The family member stated that on 8/11/10, she was notified by the facility that the resident was being sent to the hospital, because he had a high fever and rectal bleeding. When the resident was seen in the emergency room , it was discovered that the [MEDICATION NAME] was never stopped. She stated that the resident was admitted to the hospital with [REDACTED]. In an interview the Registered Nurse Manager (RNM) on 10/18/10 at 11:20 am, stated that she was not aware of the specifics regarding the [MEDICATION NAME]. She stated, that in the past several weeks new policies regarding consultations have been put in place. She stated that the charge nurse on duty, who received the consultation report, would be the nurse responsible for calling the Primary Care Physician (PCP) to confirm and obtain orders recommended by the consulting physician. In an interview on 10/21/10 at 11:00 am, with the Assistant Director of Nursing (ADON) and the acting Administrator, it was stated that RN #1 was not monitored on an individual basis. The Acting Administrator stated that he could not single this nurse out. He was asked what measures were taken to correct or prevent further errors made by RN #1 and he stated that inservice education was provided to all nursing staff and not just this nurse. He stated there was no individual education or inservice provided to RN #1. The surveyor asked why the facility knowing the errors that were being made by this nurse, would allow this nurse to continue to perform as a charge nurse? He stated, "what was I to do, have her sit at a desk and answer phones like a secretary?" The ADON stated that the RN #1 was placed on the 7:00 am -3:00 pm shift, to be monitored by the RNM. Facility documentation, floor assignment sheets, 7/15/10 physicians orders and 24 hour report sheet documented that RN #1 was on duty between the hours of 3:00 pm and 11:00 pm shift from 7/15/10 through 8/20/10.. The Administrator again stated, that all nursing staff had been inserviced as the result of previous citations in this area. 10 NYCRR 415.4(b)

Based on staff interviews and medical record review the facility did not ensure that each resident received and was provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 1 (Resident #1) of 7 residents reviewed during complaint investigation (Case #NY 310) and a post survey revisit. Specifically, the facility did not ensure that the staff addressed the orthopedic consultants recommendations to discontinue [MEDICATION NAME], did not ensure that the residents' surgical incision was assessed or treated timely, did not ensure a followup appointment with the orthopedic surgeon, and the physician was not notified in a timely manner of a a residents' change in condition. Additionally, the facility did not ensure that medications were administered as ordered. This resulted in actual harm that was not immediate jeopardy. This was evidenced by: Resident #1 The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The facility policy, undated, documented that all medications will be transcribed accurately by a licensed nurse to the residents medication/treatment administration record and verified by three nurses. Finding #1 The hospital discharge plan/instructions dated 7/15/10, included [MEDICATION NAME], (HCTZ),( used to reduce extra body fluid and retention ) 25 milligrams (mg) daily, with the next scheduled dose to be given in the morning on 7/16/10 and for [MEDICATION NAME] (a blood thinning medication), 1 mg to be given at 6:00 pm on 7/15/10. The instructions also included documentation for the facility to arrange an appointment with the orthopedic surgeon in 7-10 days. The telephone admission orders [REDACTED]. an order for [REDACTED]. On 7/15/10 at 10:50 pm, an interim physician's order documented to check left hip incision daily and apply dry protective dressing after cleanse with normal saline. The Treatment Administration Record (TAR) dated 7/15/10- 7/31/10, documented that the treatment to the left hip was performed on 7/16/10 and not again until 7/24/10. There is a large "X" handwritten over the squares where the treatment is written. The treatment is rewritten and signed as performed on 7/24/10. The Physician's Progress note dated 7/16/10, titled Admission Note, documented that the resident had a left femur fracture with surgical repair on 7/10/10. The note documented that the plan for the resident was to include; Tylenol (pain medication) for pain management, to follow-up with the orthopedic surgeon for removal of the surgical staples on post operative day 14, to continue with HCTZ for high blood pressure, and [MEDICATION NAME] for [MEDICAL CONDITION] (preventive treatment for [REDACTED]. An interim physician's order dated 7/16/10 at 3:57 pm, documented an order for [REDACTED]. The Medication Administration Record (MAR) dated 7/15/10-8/10/10, documented the HCTZ was administered at 9:00 am on 7/17/10. The nurse's note dated 7/18/10, documented that the resident complained of discomfort due to increased [MEDICAL CONDITION] (fluid retention) of both lower legs and questioned, whether he should take [MEDICATION NAME] (a diuretic), as he did at home. The note documented the presence of swelling and fluid retention in both lower legs and feet. The physician was made aware of the fluid retention and the resident's concern. A new order was obtained for the use of compression stockings. The nutrition progress note dated 7/23/10, documented that the resident had an 8.8 pound weight increase since 7/16/10. This was initialed as having been reviewed by the physician on 7/23/10. The Physician's Progress note dated 7/23/10, documented to "continue [MEDICATION NAME]" for lower extremity [MEDICAL CONDITION]. There was no documented evidence of a physician's order for [MEDICATION NAME]. The nurse's note dated 7/26/10 at 8:00 pm, documented that the staples on the left hip were intact and a scant amount of yellow drainage was noted from the incision site. The same note documented that the resident continued with [MEDICAL CONDITION] in the lower extremities. There was no documented evidence the physician was notified of the drainage or the [MEDICAL CONDITION] at this time. An undated consultation report, from the follow-up orthopedic appointment, on 7/28/10, documented for the resident to be weight bearing as tolerated, the [MEDICATION NAME] therapy to be discontinued on 8/1/10, and to start Keflex 500 mg every six hours for 10 days. The facility 24 hour report dated 7/28/10 for the 7:00 am-3:00 pm shift, documented the resident returned from the orthopedic appointment and the resident was to start Keflex for infection of the incision. The 24 hour report did not include the recommendation to discontinue the [MEDICATION NAME], as written on the orthopedic consult report. The interim physician's order dated 7/29/10 at 4:06 am, documented an order for [REDACTED]. The physican signed the order on 8/7/10. The MAR dated 7/27/10- 8/26/10 documented an order for [REDACTED]. The MAR documented that the Keflex 500 mg was first administered at 2:00 am on 7/29/10. The nurse's note dated 7/30/10, documented the the upper area of the incision site to be red, warm and hard to touch. A scant amount of tan drainage was noted from the upper area of the incision. The resident complained of soreness to the area. The facility was unable to produce documented evidence that the primary care physician (PCP) was notified of the recommendation to discontinue the [MEDICATION NAME] and start Keflex therapy at that time. In an interview on 10/18/10 at 10:50 am, the resident's family member stated that a few days after the resident was admitted to the facility, it was noticed that the resident developed a large amount of swelling of his feet, legs and hands. The family member recalled reporting the swelling to a nurse as well as inquiring about the medications the resident was receiving. The family member told the nurse that the resident had been taking both [MEDICATION NAME] and HCTZ at home. The nurse informed the family member that the resident was not receiving [MEDICATION NAME] (a medication used to reduce extra body fluid). The family member met with the PCP, who stated she, (the physician) didn't want to change any medications because she would be going on vacation. The family member requested to meet with the physician who would be covering for the PCP, but this physician never came to see her. In an interview on 10/18/10 at 10:50 am, the resident's family member further stated, that on or about 7/24/10, she noticed a big brown stain on the resident's bed pad. She stated the resident had been laying on his left side and the stain was located in the same spot as the incision on his hip. She stated that she reported it to a nurse, who inspected the stained linen. The nurse stated, "I'll take care of it". The family member stated that the next day, she spoke to the Registered Nurse Manager (RNM) regarding the drainage from the incision and asked when the follow-up appointment with the orthopedic surgeon was scheduled. The RNM stated that she had not heard anything about the drainage and did not know about a follow-up appointment. The family member stated that she herself called the surgeon's office and scheduled an appointment. The family member accompanied the resident to the orthopedic appointment on 7/28/10. She stated that the physician told her and the resident that [MEDICATION NAME] would no longer be needed and it would be stopped on 8/1/10. The orthopedic physician also informed her and the resident that he was ordering the antibiotic Keflex for the infection in the incision site. In an interview with the Registered Nurse Manager (RNM) on 10/18/10 at 11:20 am, the RNM stated that she was not aware of any of the specific issues documented in this report. She stated, that it was brought to her attention that consultation recommendations were not always being addressed. This was identified during facility audits. She stated that the charge nurse on duty, who received the consultation report would be the nurse responsible for calling the PCP to confirm and obtain orders recommended by the consulting physician. She stated that she was aware of some of the issues. She stated she was aware of the nurses poor performanceincluding medication errors. The RNM stated that a care conference meeting was held for the resident on 8/2/10, with the family and resident, and thought that all issues and concerns were addressed. She stated she was not aware that the resident was having drainage from the incision site, prior to his orthopedic appointment. She stated that she would have expected any signs of infection would be documented and reported to the physician. The RNM further stated, that she was aware that the resident's family scheduled the follow-up appointment with the orthopedic. She did not realize the hospital discharge instructions dated 7/15/10, included to arrange for a follow-up visit in 7-10 days post admission. In an interview on 10/18/10 at 1:00 pm, with the orthopedic physician's Registered Nurse (RN), the RN stated that the physician was not available for interview. She stated, if the physician ordered an antibiotic for the "patient" that she would expect for the patient to start the medication that same day, as soon as possible. In a telephone interview on 10/18/10 at 1:10 pm with the PCP, she stated she could not recall specific events regarding this resident. She stated in general she would expect any medication to be given as ordered by a physician. She stated any delay in the administration of a medication could contribute to complications. In an interview on 10/19/10 at approximately 9:30 am, with the LPN#1 who administered the Keflex at 2:00 am on 7/29/10, the LPN#1 stated that he was told verbally at change of shift report that the resident was starting Keflex for an infection in the left hip incision. When he went to administer the Keflex, the medication had not been received from the pharmacy. The LPN stated he then went to the resident's chart for the physician's order, so he could order the medication from the pharmacy. He was unable to find an order. He notified the supervisor, who stated the resident was to receive Keflex. He stated he was instructed to write an order for [REDACTED]. Finding #2 The Comprehensive Care Plan (CCP) dated 7/15/10, documented the resident was receiving anticoagulation/antiplatelet therapy secondary to a [MEDICAL CONDITION]. The CCP included that the resident was at risk for bleeding/hemorrhage related to anticoagulant therapy. The interventions included; to observe, record and report, bruises, fever, rash, [MEDICAL CONDITION], and signs and symptoms of internal bleeding to include tarry stools, blood in the urine, abnormally fast heart rate, low blood pressure, change in mental status, and weakness. Additionally documented was to observe, record, and monitor abnormal lab values and to administer medication, as ordered by the physician. An interim physician's order dated 7/15/10 at 9:04 pm, documented an order for [REDACTED]. The MAR dated 7/15/10-8/14/10 documented that [MEDICATION NAME] 2.5 mg was administered on 7/15/10. The physician's orders, dated 7/15/10, included orders for the medication [MEDICATION NAME] 40 mg daily ( an acid reducer), and [MEDICATION NAME] 650 mg every 4 hours as needed ( Tylenol). Documentation from the Nursing 2009 Drug Handbook, documented that these medications in combination with the use of [MEDICATION NAME] would place the resident at an increased risk for bleeding. The same reference documented that the peak level for [MEDICATION NAME] was 4 hours with a duration of 2-5 days and a half life of 20-60 hours. The MAR dated 7/16/10- 8/14/10, documented a type printed order for [MEDICATION NAME] Sodium, ([MEDICATION NAME],) one tablet by mouth one time a day. A hand written notation under the order, documented per MD order. The order did not include the dosage to be administered. The same MAR documented [MEDICATION NAME] 2.5 mg was administered on 7/16/10 at 9:00 pm. The laboratory report dated 7/16/10 timed 8:54 am documented an INR of 1.6. There was no evidence that the physician was notified on 7/16/10 with these results. The physician's telephone order dated 7/17/10 at 11:47 pm, documented an order for [REDACTED]. The lab report dated 7/19/10 documented an INR of 1.8. The physician's interm telephone order dated 7/19/10, documented an order for [REDACTED]. The lab report dated 7/21/10, was not available in the resident's medical records. The facility was able to obtain a lab report for 7/21/10, which documented an INR of 1.8. There was no documentation that the physician was notified of this results. The MAR dated 7/21/10 and 7/22/10, documented [MEDICATION NAME] 4.5 mg was administered. There were no physician's order documented for this doseage change. A laboratory report dated 7/23/10 documented an INR was drawn with results of 1.6. There was no physician's order documented for this laboratory test. The physician's interim telephone order dated 7/23/10, documented an order for [REDACTED]. The laboratory report dated 7/26/10 documented an INR of 1.9. The physician's interim order dated 7/26/10, documented an order for [REDACTED]. The facility 24 hour report dated 7/28/10 for the 7:00 am-3:00 pm shift, documented the resident returned from an orthopedic appointment. An undated consultation report from 7/28/10 report from the follow-up orthopedic appointment, recommended for the resident to be weight bearing as tolerated and discontinue the [MEDICATION NAME] therapy on 8/1/10. There was no evidence that the residents primary physician was made aware of this recommendation. The typed printed order for "[MEDICATION NAME] Sodium, ([MEDICATION NAME]) documented on the MAR, dated 7/16/10- 8/14/10,on the right hand side of this order, included a hand written notation, Discontinue 8/1/10. The document did not include a date to identify when this notation was made. There were no physician's order documented in the medical record to discontinue the [MEDICATION NAME]. The lab report dated 8/2/10, documented an INR of 2.1. The physician's interim telephone order dated 8/2/10, documented to continue [MEDICATION NAME] 5 mg and obtain an INR on 8/9/10. (A lab report for the INR dated 8/9/10 was not available for this report.) The MAR dated 8/2/10-8/10/10 documented that the resident continued to receive [MEDICATION NAME] 5 mg. The documentation from the hospital emergency room (ER) dated 8/11/10, documented the resident was admitted to the hospital. The blood work obtained in theER on [DATE] documented a [MEDICATION NAME] (PT) of 25.9 (normal range 9.6-10.7), an INR of 2.8, a Hemoglobin of 10.2 (normal range 13.5-17.0), and Hematocrit of 29.9 (normal range 41.0-53.0). The last CBC obtained prior to this ER visit was on 7/16/10, and documented the Hemoglobin at 12.4 and the Hematocrit at 35.8 . The nurse's note from the hospital dated 8/13/10 at 5:46 am, documented the resident passed 450 millimeters (ml) of frank red blood from the rectum. The hospital documentation included that the resident was treated with multiple blood [MEDICAL CONDITION]. In an interview on 10/20/10 at 2:15 pm, with the LPN#2 who administered the 4.5 mg dose of [MEDICATION NAME] on 7/21/10 and 7/22/10, the LPN#2 stated that the charge nurse reviews the INR results, then notifies the physician. After the physician has been notified the charge nurse will document on the MAR, in the box area below the signature box the dosage of [MEDICATION NAME] to be given. The charge nurse would be responsible to obtain and document the order in the resident chart. The LPN stated that typically, she would not go to the chart to verify the order, although when this particular nurse ( RN#1) is in charge she should. When the surveyor asked why is that? The LPN stated, because this nurse was very sloppy and careless, it was not a new thing for her to not write orders after receiving them. This nurse makes a lot of mistakes. The surveyor asked the LPN, if the RNM and nursing supervisors were made aware of this nurse's practice, the LPN stated they were, but was not aware of what was done about the situation. In an interview on 10/18/10 at 10:50 am, the family member who accompanied the resident to the Orthopedic appointment on 7/28/10, stated that the physician told her the resident would no longer need the [MEDICATION NAME] and it would be stopped on 8/1/10. The family member stated that on 8/11/10, she was notified by the facility that the resident was being sent to the hospital, because he had a high fever and rectal bleeding. When the resident was seen in the emergency room , it was discovered that the [MEDICATION NAME] was never stopped. She stated that the resident was admitted to the hospital with [REDACTED]. In an interview the Registered Nurse Manager (RNM) on 10/18/10 at 11:20 am, stated that she was not aware of the specifics regarding the [MEDICATION NAME]. She stated, that in the past several weeks new policies regarding consultations have been put in place. She stated that the charge nurse on duty, who received the consultation report, would be the nurse responsible for calling the PCP to confirm and obtain orders recommended by the consulting physician. In an interview on 10/18/10 at 1:00 pm the orthopedic physician's RN stated that the physician was not available for interview. The RN stated that the resident was seen on 7/28/10 and that the [MEDICATION NAME] was to be discontinued on 8/1/10. The RN stated that the physician prescribed [MEDICATION NAME] therapy for a period of three weeks following surgery as a preventive measure for blood clots. The RN stated that the physician would only continue anticoagulant treatment in the event that the resident had been taking the medication prior to the surgery or if the resident had developed a blood clot. The RN stated that the physician documented that the [MEDICATION NAME] was to stop on 8/1/10. In an interview on 10/18/10 at 1:10 pm the PCP stated that she could not recall being notified of the recommendation to discontinue the [MEDICATION NAME]. The PCP stated that she would have followed the recommendations of the surgeon and not have ordered the [MEDICATION NAME] to be continued. She stated the only reason she would continue the [MEDICATION NAME] was in the event the resident had a medical [DIAGNOSES REDACTED]. The PCP stated she could not recall if she reviewed the written consultation report from the orthopedic visit but stated her ususal practice was to initial and date reports. The orthopedic consultation report was not initialed or dated by the PCP. Finding #3 The Hospital Discharge Summary dated 7/15/10 documented the resident to have a past medical history of [REDACTED]. The CCP dated 7/15/10, documented the resident at risk for respiratory distress secondary to chronic [MEDICAL CONDITION]. The interventions documented were to observe, record and report, signs and symptoms of difficulty breathing, increased respirations, congestion, shortness of breath, [MEDICAL CONDITION] (low oxygen level ), signs of infection, or elevated temperature. The CCP further documented to, listen to breath sounds to assess for wheezing or diminished breath sounds, and to monitor vital signs as needed. The physician admission orders [REDACTED]. The physician's orders dated 7/25/10, documented an order for [REDACTED]. Wean as tolerated. The progress note dated 8/3/10 at 2:00 pm, documented by the Occupational Therapist (OT) during the treatment session that the resident's oxygen saturation (SPO2) was checked and remained at 90 %. The SPO2 level "post rest and 45 minutes of treatment", the SPO2 level dropped to 88 %, with O2 on at 2L. The treatment was stopped and the resident's O2 level returned to 92%. There was no documentation made by the 7:00 am-3:00 pm and 11:00 pm-7:00 am shifts regarding the respiratory status of Resident #1. The note did not include that the nursing staff or physician were notified. The nursing note dated 8/5/10 at 5:15 pm, documented that the resident was on O2 at 3L, the resident was sleeping deeply and SPO2 level was at 89 %. The O2 was increased to 4L. The resident was instructed to deep breathe and the SPO2 recovered to 92 % and maintained O2 back to 3 L. There was no documentations made by the 7:00 am -3:00 pm and 11:00 pm - 7:00 am shifts regarding the respiratory status of the resident. There was no documented evidence that the physician was notified. The nurse's note dated 8/6/10 at 6:30 pm, documented the resident's SpO2 level at 99%, and the resident appeared short of breath (SOB) upon exertion with desaturation and the resident recovered quickly with rest. There was no documentation made by the 7:00 am -3:00 pm and 11:00 pm - 7:00 am shifts of the respiratory status of the resident. The nurse's note dated 8/9/10 at 9:00 pm, documented that the resident was without respiratory distress. The nurse's note dated 8/10/10 at 2:00 pm, documented the resident was short of breath on exertion when moving in bed, speaking, or eating. The resident's SPO2 was documented as 90% on 3L of O2. There was no documented evidence that the physician was notified. The nurse's note dated 8/11/10 at 12:15 am, documented the resident's temperature at 101.5. The SPO2 at 80% on 3L of O2. The resident's heart rate (HR) was 111 beats per minute. The residents' lung sounds were decreased in the lower bases and the resident was using accessory muscles to breath. A small amount to moderate amount of rectal bleeding was noted. The Respiratory Therapist (RT) was summoned, by the RN supervisor, to assess the resident. The RT increased the oxygen to 10 L via non rebreather mask. The resident continued with respiratory distress, a HR of 100, a respiratory rate (RR) of 30, oxygen level averaging 80% with O2 at 10 L. The physician was notified at 1:10 am and ordered to transfer the resident to the emergency room . The hospital History and Physical documentation dated 8/11/10, documented that the resident was admitted to the Intensive Care Unit with [MEDICAL CONDITION] present on admission, acute urinary tract infection present upon admission, acute pneumonia, acute [MEDICAL CONDITION] and [MEDICAL CONDITION]. In an interview on 10/18/10 at 1:10 pm with the physician, she stated she could not recall the details of this particular resident, but stated if she had seen the resident on an interim visit she would have written a progress note. The last physicians' progress note documented in the medical record was dated 7/23/10. In an interview on 10/20/10 at 2:35 pm with the RN supervisor, she stated that on 8/11/10, the Certified Nursing Assistant (CNA), summoned for her to come to the resident's room. The CNA reported the resident had blood from his rectum. The RN stated she noted a small amount to maybe a moderate amount of darkish, brownish, blood on the bed pad. The RN could not signify an amount for small or moderate amounts. The RN stated she was more focused on his respiratory distress and status and did not think the blood was of a significance to this resident. She stated the physician was notified and the resident was transferred to the emergency room . 10NYCRR 415.12

Based on medical record review and staff interview, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above for 1 ( Resident #1) of 7 residents reviewed during a complaint investigation, (Case #NY 310) and a post survey revisit. Specifically, the facility did not ensure that [MEDICATION NAME] (an anticoagulant and blood thinner) was discontinued on 8/1/10 as recommended by the orthopedic surgeon (doctor who specializes in bone disorders) and the resident received an additional nine doses of [MEDICATION NAME]. Subsequently, the resident experienced a [MEDICAL CONDITION] and required hospital admission to Intensive Care Unit ( ICU) and blood [MEDICAL CONDITION]. This resulted in actual harm that is not immediate jeopardy. This was evidenced by the following: Resident #1 The facility did not ensure that [MEDICATION NAME] was discontinued as recommended by the consulting physician. The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The Hospital Discharge Summary dated 7/15/10, documented that on 7/10/10 the resident was taken to the operating room for surgical repair of a left [MEDICAL CONDITION]. The post surgical interventions were documented for [MEDICAL CONDITIONS] [MEDICATION NAME] to include; daily [MEDICATION NAME], (no specific dose was documented in this report), with an International Normalized Ratio ( INR) (used to monitor clotting time) of approximately 2.5, (normal range of INR 0.9-1.2, therapeutic range of 2-3 with a target range of 2.5 for prevention of [MEDICAL CONDITION]). Physical activity was documented as; out of bed and weight bearing as tolerated. The document included instructions for the resident to be seen by the orthopedic surgeon in 7-10 days following discharge from the hospital. The hospital medication discharge instructions, dated 7/15/10, documented for [MEDICATION NAME] 1 milligram (mg) to be given at 6:00 pm on 7/15/10. The Comprehensive Care Plan (CCP), dated 7/15/10, documented the resident was receiving anticoagulation/antiplatelet therapy secondary to fracture. The CCP included the resident to be at risk for bleeding/hemorrhage related to anticoagulant therapy. The interventions included to observe, record and report, bruises, fever, rash, [MEDICAL CONDITION], and signs and symptoms of internal bleeding to include tarry stools, blood in the urine, abnormally fast heart rate, low blood pressure, change in mental status, and weakness. The interventions also documented to observe, record, and monitor abnormal lab values and to administer medication as ordered by the physician. The physician's orders [REDACTED]. Documentation from the Nursing 2009 Drug Handbook, documents that these medications in combination with the use of [MEDICATION NAME] would place the resident at an increased risk for bleeding. The same reference, documented that the peak level for [MEDICATION NAME] was 4 hours with a duration of 2-5 days and a half life of 20-60 hours. The History and Physical dated 7/16/10, documented that daily [MEDICATION NAME] was being used [MEDICATION NAME] (to prevent the formation of blood clots), due to a recent hip surgery. There were no other medical [DIAGNOSES REDACTED]. An undated document titled, Report of Consultation, from the follow-up orthopedic appointment on 7/28/10, documented that the [MEDICATION NAME] therapy was to be discontinued on 8/1/10 and Keflex (antibiotic) 500 mg every six hours was to start. The facility 24 hour report dated 7/28/10 for the 7:00 am- 3:00 pm shift, documented the resident returned from the orthopedic appointment and the resident was to start Keflex for infection of the incision. The 24 hour report did not include documentation to discontinue the [MEDICATION NAME], as written on the orthopedic consult report. There was no evidence a physician's orders [REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was no documented evidence that the [MEDICATION NAME] had been discontinued or that the primary care physician (PCP) was made aware of the recommendation to discontinue the [MEDICATION NAME]. The nurse's note dated 8/11/10 at 12:15 am, documented that the resident had an elevated temperature, difficulty breathing with low oxygenation saturation levels and a "small to moderate amount of rectal bleeding." The physician was notified and at 1:10 am the resident was transferred to the emergency room for an evaluation. In an interview on 10/18/10 at 10:50 am, the family member who accompanied the resident to the Orthopedic appointment on 7/28/10, stated that the physician told her "the resident would no longer need the [MEDICATION NAME] and it would be stopped on 8/1/10." The family member stated that on 8/11/10, when the resident was seen in the emergency room , it was discovered that the [MEDICATION NAME] was never discontinued. In an interview on 10/18/10 at 1:00 pm the orthopedic physician's Registered Nurse (RN), confirmed that the resident was seen on 7/28/10 and that the [MEDICATION NAME] was to be discontinued on 8/1/10. The RN stated that the physician prescribed [MEDICATION NAME] therapy for a period of three weeks following surgery as a preventive measure for blood clots. The RN stated that the physician would only continue anticoagulant treatment in the event that the resident had been taking the medication prior to the surgery, or if the resident had developed a blood clot. In an interview on 10/18/10 at 1:10 pm, the PCP stated that she could not recall being notified of the recommendation to discontinue the [MEDICATION NAME]. The PCP stated that she would not have ordered the [MEDICATION NAME] to be continued, unless the resident had a medical [DIAGNOSES REDACTED]. The PCP stated she could not recall if she reviewed the written consultation report from the orthopedic visit. The PCP stated her usual practice was to initial and date consultations and laboratory work. Theere were no initials on the consultation report. In an interview on 10/20/10 at 10:25 am, with the RN#1in charge on the resident's unit, she stated she would have called the PCP to confirm the recommendation of the orthopedic surgeon, but could not state if she placed the call or received an order to discontinue the [MEDICATION NAME]. The documentation from the hospital ER dated 8/11/10, documented the resident was admitted to the hospital. The blood work obtained in the ER on 8/11/10 documented a [MEDICATION NAME] (PT) of 25.9 (normal range 9.6-10.7), an INR of 2.8, a Hemoglobin of 10.2 (normal range 13.5-17.0), and Hematocrit of 29.9 ( normal range 41.0-53.0). The last CBC obtained prior to this ER visit, while in the facility, on 7/16/10 documented the Hemoglobin at 12.4 and the Hematocrit at 35.8 . The hospital History and Physical dated 8/11/10, documented that the resident had recent hip surgery and was on anticoagulation therapy. The note included that the [MEDICATION NAME] would be held and the resident would be monitored carefully. The hospital laboratory report dated 8/12/10 at 11: 45 pm, documented a PT of 74.6, and an INR of 7.5, Hemoglobin of 8.3, and Hematocrit of 24.2. The nurse's note from the hospital dated 8/13/10 at 5:46 am, while the resident was in the Intensive Care Unit, documented the resident passed 450 millimeters (ml) of frank red blood from the rectum. The hospital documentation included that the resident was treated with blood [MEDICAL CONDITION]. 10NYCRR415.12( l )( 1 )

Based on medical record review and staff interview, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above for 1 ( Resident #1) of 7 residents reviewed during a complaint investigation, (Case #NY 310) and a post survey revisit. Specifically, the facility did not ensure that [MEDICATION NAME] (an anticoagulant and blood thinner) was discontinued on 8/1/10 as recommended by the orthopedic surgeon (doctor who specializes in bone disorders) and the resident received an additional nine doses of [MEDICATION NAME]. Subsequently, the resident experienced a [MEDICAL CONDITION] and required hospital admission to Intensive Care Unit ( ICU) and blood [MEDICAL CONDITION]. This resulted in actual harm that is not immediate jeopardy. This was evidenced by the following: Resident #1 The facility did not ensure that [MEDICATION NAME] was discontinued as recommended by the consulting physician. The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The Hospital Discharge Summary dated 7/15/10, documented that on 7/10/10 the resident was taken to the operating room for surgical repair of a left [MEDICAL CONDITION]. The post surgical interventions were documented for [MEDICAL CONDITIONS] [MEDICATION NAME] to include; daily [MEDICATION NAME], (no specific dose was documented in this report), with an International Normalized Ratio ( INR) (used to monitor clotting time) of approximately 2.5, (normal range of INR 0.9-1.2, therapeutic range of 2-3 with a target range of 2.5 for prevention of [MEDICAL CONDITION]). Physical activity was documented as; out of bed and weight bearing as tolerated. The document included instructions for the resident to be seen by the orthopedic surgeon in 7-10 days following discharge from the hospital. The hospital medication discharge instructions, dated 7/15/10, documented for [MEDICATION NAME] 1 milligram (mg) to be given at 6:00 pm on 7/15/10. The Comprehensive Care Plan (CCP), dated 7/15/10, documented the resident was receiving anticoagulation/antiplatelet therapy secondary to fracture. The CCP included the resident to be at risk for bleeding/hemorrhage related to anticoagulant therapy. The interventions included to observe, record and report, bruises, fever, rash, [MEDICAL CONDITION], and signs and symptoms of internal bleeding to include tarry stools, blood in the urine, abnormally fast heart rate, low blood pressure, change in mental status, and weakness. The interventions also documented to observe, record, and monitor abnormal lab values and to administer medication as ordered by the physician. The physician's orders [REDACTED]. Documentation from the Nursing 2009 Drug Handbook, documents that these medications in combination with the use of [MEDICATION NAME] would place the resident at an increased risk for bleeding. The same reference, documented that the peak level for [MEDICATION NAME] was 4 hours with a duration of 2-5 days and a half life of 20-60 hours. The History and Physical dated 7/16/10, documented that daily [MEDICATION NAME] was being used [MEDICATION NAME] (to prevent the formation of blood clots), due to a recent hip surgery. There were no other medical [DIAGNOSES REDACTED]. An undated document titled, Report of Consultation, from the follow-up orthopedic appointment on 7/28/10, documented that the [MEDICATION NAME] therapy was to be discontinued on 8/1/10 and Keflex (antibiotic) 500 mg every six hours was to start. The facility 24 hour report dated 7/28/10 for the 7:00 am- 3:00 pm shift, documented the resident returned from the orthopedic appointment and the resident was to start Keflex for infection of the incision. The 24 hour report did not include documentation to discontinue the [MEDICATION NAME], as written on the orthopedic consult report. There was no evidence a physician's orders [REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was no documented evidence that the [MEDICATION NAME] had been discontinued or that the primary care physician (PCP) was made aware of the recommendation to discontinue the [MEDICATION NAME]. The nurse's note dated 8/11/10 at 12:15 am, documented that the resident had an elevated temperature, difficulty breathing with low oxygenation saturation levels and a "small to moderate amount of rectal bleeding." The physician was notified and at 1:10 am the resident was transferred to the emergency room for an evaluation. In an interview on 10/18/10 at 10:50 am, the family member who accompanied the resident to the Orthopedic appointment on 7/28/10, stated that the physician told her "the resident would no longer need the [MEDICATION NAME] and it would be stopped on 8/1/10." The family member stated that on 8/11/10, when the resident was seen in the emergency room , it was discovered that the [MEDICATION NAME] was never discontinued. In an interview on 10/18/10 at 1:00 pm the orthopedic physician's Registered Nurse (RN), confirmed that the resident was seen on 7/28/10 and that the [MEDICATION NAME] was to be discontinued on 8/1/10. The RN stated that the physician prescribed [MEDICATION NAME] therapy for a period of three weeks following surgery as a preventive measure for blood clots. The RN stated that the physician would only continue anticoagulant treatment in the event that the resident had been taking the medication prior to the surgery, or if the resident had developed a blood clot. In an interview on 10/18/10 at 1:10 pm, the PCP stated that she could not recall being notified of the recommendation to discontinue the [MEDICATION NAME]. The PCP stated that she would not have ordered the [MEDICATION NAME] to be continued, unless the resident had a medical [DIAGNOSES REDACTED]. The PCP stated she could not recall if she reviewed the written consultation report from the orthopedic visit. The PCP stated her usual practice was to initial and date consultations and laboratory work. Theere were no initials on the consultation report. In an interview on 10/20/10 at 10:25 am, with the RN#1in charge on the resident's unit, she stated she would have called the PCP to confirm the recommendation of the orthopedic surgeon, but could not state if she placed the call or received an order to discontinue the [MEDICATION NAME]. The documentation from the hospital ER dated 8/11/10, documented the resident was admitted to the hospital. The blood work obtained in the ER on 8/11/10 documented a [MEDICATION NAME] (PT) of 25.9 (normal range 9.6-10.7), an INR of 2.8, a Hemoglobin of 10.2 (normal range 13.5-17.0), and Hematocrit of 29.9 ( normal range 41.0-53.0). The last CBC obtained prior to this ER visit, while in the facility, on 7/16/10 documented the Hemoglobin at 12.4 and the Hematocrit at 35.8 . The hospital History and Physical dated 8/11/10, documented that the resident had recent hip surgery and was on anticoagulation therapy. The note included that the [MEDICATION NAME] would be held and the resident would be monitored carefully. The hospital laboratory report dated 8/12/10 at 11: 45 pm, documented a PT of 74.6, and an INR of 7.5, Hemoglobin of 8.3, and Hematocrit of 24.2. The nurse's note from the hospital dated 8/13/10 at 5:46 am, while the resident was in the Intensive Care Unit, documented the resident passed 450 millimeters (ml) of frank red blood from the rectum. The hospital documentation included that the resident was treated with blood [MEDICAL CONDITION]. 10 NYCRR415.12( l )( 1 )

Based on staff interviews and medical record review the facility did not ensure that each resident received and was provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 1 (Resident #1) of 7 residents reviewed during complaint investigation (Case #NY 310) and a post survey revisit. Specifically, the facility did not ensure that the staff addressed the orthopedic consultants recommendations to discontinue [MEDICATION NAME], did not ensure that the residents' surgical incision was assessed or treated timely, did not ensure a followup appointment with the orthopedic surgeon, and the physician was not notified in a timely manner of a a residents' change in condition. Additionally, the facility did not ensure that medications were administered as ordered. This resulted in actual harm that was not immediate jeopardy. This was evidenced by: Resident #1 The resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The facility policy, undated, documented that all medications will be transcribed accurately by a licensed nurse to the residents medication/treatment administration record and verified by three nurses. Finding #1 The hospital discharge plan/instructions dated 7/15/10, included [MEDICATION NAME], (HCTZ),( used to reduce extra body fluid and retention ) 25 milligrams (mg) daily, with the next scheduled dose to be given in the morning on 7/16/10 and for [MEDICATION NAME] (a blood thinning medication), 1 mg to be given at 6:00 pm on 7/15/10. The instructions also included documentation for the facility to arrange an appointment with the orthopedic surgeon in 7-10 days. The telephone admission orders [REDACTED]. an order for [REDACTED]. On 7/15/10 at 10:50 pm, an interim physician's order documented to check left hip incision daily and apply dry protective dressing after cleanse with normal saline. The Treatment Administration Record (TAR) dated 7/15/10- 7/31/10, documented that the treatment to the left hip was performed on 7/16/10 and not again until 7/24/10. There is a large "X" handwritten over the squares where the treatment is written. The treatment is rewritten and signed as performed on 7/24/10. The Physician's Progress note dated 7/16/10, titled Admission Note, documented that the resident had a left femur fracture with surgical repair on 7/10/10. The note documented that the plan for the resident was to include; Tylenol (pain medication) for pain management, to follow-up with the orthopedic surgeon for removal of the surgical staples on post operative day 14, to continue with HCTZ for high blood pressure, and [MEDICATION NAME] for [MEDICAL CONDITION] (preventive treatment for [REDACTED]. An interim physician's order dated 7/16/10 at 3:57 pm, documented an order for [REDACTED]. The Medication Administration Record (MAR) dated 7/15/10-8/10/10, documented the HCTZ was administered at 9:00 am on 7/17/10. The nurse's note dated 7/18/10, documented that the resident complained of discomfort due to increased [MEDICAL CONDITION] (fluid retention) of both lower legs and questioned, whether he should take [MEDICATION NAME] (a diuretic), as he did at home. The note documented the presence of swelling and fluid retention in both lower legs and feet. The physician was made aware of the fluid retention and the resident's concern. A new order was obtained for the use of compression stockings. The nutrition progress note dated 7/23/10, documented that the resident had an 8.8 pound weight increase since 7/16/10. This was initialed as having been reviewed by the physician on 7/23/10. The Physician's Progress note dated 7/23/10, documented to "continue [MEDICATION NAME]" for lower extremity [MEDICAL CONDITION]. There was no documented evidence of a physician's order for [MEDICATION NAME]. The nurse's note dated 7/26/10 at 8:00 pm, documented that the staples on the left hip were intact and a scant amount of yellow drainage was noted from the incision site. The same note documented that the resident continued with [MEDICAL CONDITION] in the lower extremities. There was no documented evidence the physician was notified of the drainage or the [MEDICAL CONDITION] at this time. An undated consultation report, from the follow-up orthopedic appointment, on 7/28/10, documented for the resident to be weight bearing as tolerated, the [MEDICATION NAME] therapy to be discontinued on 8/1/10, and to start Keflex 500 mg every six hours for 10 days. The facility 24 hour report dated 7/28/10 for the 7:00 am-3:00 pm shift, documented the resident returned from the orthopedic appointment and the resident was to start Keflex for infection of the incision. The 24 hour report did not include the recommendation to discontinue the [MEDICATION NAME], as written on the orthopedic consult report. The interim physician's order dated 7/29/10 at 4:06 am, documented an order for [REDACTED]. The physican signed the order on 8/7/10. The MAR dated 7/27/10- 8/26/10 documented an order for [REDACTED]. The MAR documented that the Keflex 500 mg was first administered at 2:00 am on 7/29/10. The nurse's note dated 7/30/10, documented the the upper area of the incision site to be red, warm and hard to touch. A scant amount of tan drainage was noted from the upper area of the incision. The resident complained of soreness to the area. The facility was unable to produce documented evidence that the primary care physician (PCP) was notified of the recommendation to discontinue the [MEDICATION NAME] and start Keflex therapy at that time. In an interview on 10/18/10 at 10:50 am, the resident's family member stated that a few days after the resident was admitted to the facility, it was noticed that the resident developed a large amount of swelling of his feet, legs and hands. The family member recalled reporting the swelling to a nurse as well as inquiring about the medications the resident was receiving. The family member told the nurse that the resident had been taking both [MEDICATION NAME] and HCTZ at home. The nurse informed the family member that the resident was not receiving [MEDICATION NAME] (a medication used to reduce extra body fluid). The family member met with the PCP, who stated she, (the physician) didn't want to change any medications because she would be going on vacation. The family member requested to meet with the physician who would be covering for the PCP, but this physician never came to see her. In an interview on 10/18/10 at 10:50 am, the resident's family member further stated, that on or about 7/24/10, she noticed a big brown stain on the resident's bed pad. She stated the resident had been laying on his left side and the stain was located in the same spot as the incision on his hip. She stated that she reported it to a nurse, who inspected the stained linen. The nurse stated, "I'll take care of it". The family member stated that the next day, she spoke to the Registered Nurse Manager (RNM) regarding the drainage from the incision and asked when the follow-up appointment with the orthopedic surgeon was scheduled. The RNM stated that she had not heard anything about the drainage and did not know about a follow-up appointment. The family member stated that she herself called the surgeon's office and scheduled an appointment. The family member accompanied the resident to the orthopedic appointment on 7/28/10. She stated that the physician told her and the resident that [MEDICATION NAME] would no longer be needed and it would be stopped on 8/1/10. The orthopedic physician also informed her and the resident that he was ordering the antibiotic Keflex for the infection in the incision site. In an interview with the Registered Nurse Manager (RNM) on 10/18/10 at 11:20 am, the RNM stated that she was not aware of any of the specific issues documented in this report. She stated, that it was brought to her attention that consultation recommendations were not always being addressed. This was identified during facility audits. She stated that the charge nurse on duty, who received the consultation report would be the nurse responsible for calling the PCP to confirm and obtain orders recommended by the consulting physician. She stated that she was aware of some of the issues. She stated she was aware of the nurses poor performanceincluding medication errors. The RNM stated that a care conference meeting was held for the resident on 8/2/10, with the family and resident, and thought that all issues and concerns were addressed. She stated she was not aware that the resident was having drainage from the incision site, prior to his orthopedic appointment. She stated that she would have expected any signs of infection would be documented and reported to the physician. The RNM further stated, that she was aware that the resident's family scheduled the follow-up appointment with the orthopedic. She did not realize the hospital discharge instructions dated 7/15/10, included to arrange for a follow-up visit in 7-10 days post admission. In an interview on 10/18/10 at 1:00 pm, with the orthopedic physician's Registered Nurse (RN), the RN stated that the physician was not available for interview. She stated, if the physician ordered an antibiotic for the "patient" that she would expect for the patient to start the medication that same day, as soon as possible. In a telephone interview on 10/18/10 at 1:10 pm with the PCP, she stated she could not recall specific events regarding this resident. She stated in general she would expect any medication to be given as ordered by a physician. She stated any delay in the administration of a medication could contribute to complications. In an interview on 10/19/10 at approximately 9:30 am, with the LPN#1 who administered the Keflex at 2:00 am on 7/29/10, the LPN#1 stated that he was told verbally at change of shift report that the resident was starting Keflex for an infection in the left hip incision. When he went to administer the Keflex, the medication had not been received from the pharmacy. The LPN stated he then went to the resident's chart for the physician's order, so he could order the medication from the pharmacy. He was unable to find an order. He notified the supervisor, who stated the resident was to receive Keflex. He stated he was instructed to write an order for [REDACTED]. Finding #2 The Comprehensive Care Plan (CCP) dated 7/15/10, documented the resident was receiving anticoagulation/antiplatelet therapy secondary to a [MEDICAL CONDITION]. The CCP included that the resident was at risk for bleeding/hemorrhage related to anticoagulant therapy. The interventions included; to observe, record and report, bruises, fever, rash, [MEDICAL CONDITION], and signs and symptoms of internal bleeding to include tarry stools, blood in the urine, abnormally fast heart rate, low blood pressure, change in mental status, and weakness. Additionally documented was to observe, record, and monitor abnormal lab values and to administer medication, as ordered by the physician. An interim physician's order dated 7/15/10 at 9:04 pm, documented an order for [REDACTED]. The MAR dated 7/15/10-8/14/10 documented that [MEDICATION NAME] 2.5 mg was administered on 7/15/10. The physician's orders, dated 7/15/10, included orders for the medication [MEDICATION NAME] 40 mg daily ( an acid reducer), and [MEDICATION NAME] 650 mg every 4 hours as needed ( Tylenol). Documentation from the Nursing 2009 Drug Handbook, documented that these medications in combination with the use of [MEDICATION NAME] would place the resident at an increased risk for bleeding. The same reference documented that the peak level for [MEDICATION NAME] was 4 hours with a duration of 2-5 days and a half life of 20-60 hours. The MAR dated 7/16/10- 8/14/10, documented a type printed order for [MEDICATION NAME] Sodium, ([MEDICATION NAME],) one tablet by mouth one time a day. A hand written notation under the order, documented per MD order. The order did not include the dosage to be administered. The same MAR documented [MEDICATION NAME] 2.5 mg was administered on 7/16/10 at 9:00 pm. The laboratory report dated 7/16/10 timed 8:54 am documented an INR of 1.6. There was no evidence that the physician was notified on 7/16/10 with these results. The physician's telephone order dated 7/17/10 at 11:47 pm, documented an order for [REDACTED]. The lab report dated 7/19/10 documented an INR of 1.8. The physician's interm telephone order dated 7/19/10, documented an order for [REDACTED]. The lab report dated 7/21/10, was not available in the resident's medical records. The facility was able to obtain a lab report for 7/21/10, which documented an INR of 1.8. There was no documentation that the physician was notified of this results. The MAR dated 7/21/10 and 7/22/10, documented [MEDICATION NAME] 4.5 mg was administered. There were no physician's order documented for this doseage change. A laboratory report dated 7/23/10 documented an INR was drawn with results of 1.6. There was no physician's order documented for this laboratory test. The physician's interim telephone order dated 7/23/10, documented an order for [REDACTED]. The laboratory report dated 7/26/10 documented an INR of 1.9. The physician's interim order dated 7/26/10, documented an order for [REDACTED]. The facility 24 hour report dated 7/28/10 for the 7:00 am-3:00 pm shift, documented the resident returned from an orthopedic appointment. An undated consultation report from 7/28/10 report from the follow-up orthopedic appointment, recommended for the resident to be weight bearing as tolerated and discontinue the [MEDICATION NAME] therapy on 8/1/10. There was no evidence that the residents primary physician was made aware of this recommendation. The typed printed order for "[MEDICATION NAME] Sodium, ([MEDICATION NAME]) documented on the MAR, dated 7/16/10- 8/14/10,on the right hand side of this order, included a hand written notation, Discontinue 8/1/10. The document did not include a date to identify when this notation was made. There were no physician's order documented in the medical record to discontinue the [MEDICATION NAME]. The lab report dated 8/2/10, documented an INR of 2.1. The physician's interim telephone order dated 8/2/10, documented to continue [MEDICATION NAME] 5 mg and obtain an INR on 8/9/10. (A lab report for the INR dated 8/9/10 was not available for this report.) The MAR dated 8/2/10-8/10/10 documented that the resident continued to receive [MEDICATION NAME] 5 mg. The documentation from the hospital emergency room (ER) dated 8/11/10, documented the resident was admitted to the hospital. The blood work obtained in theER on [DATE] documented a [MEDICATION NAME] (PT) of 25.9 (normal range 9.6-10.7), an INR of 2.8, a Hemoglobin of 10.2 (normal range 13.5-17.0), and Hematocrit of 29.9 (normal range 41.0-53.0). The last CBC obtained prior to this ER visit was on 7/16/10, and documented the Hemoglobin at 12.4 and the Hematocrit at 35.8 . The nurse's note from the hospital dated 8/13/10 at 5:46 am, documented the resident passed 450 millimeters (ml) of frank red blood from the rectum. The hospital documentation included that the resident was treated with multiple blood [MEDICAL CONDITION]. In an interview on 10/20/10 at 2:15 pm, with the LPN#2 who administered the 4.5 mg dose of [MEDICATION NAME] on 7/21/10 and 7/22/10, the LPN#2 stated that the charge nurse reviews the INR results, then notifies the physician. After the physician has been notified the charge nurse will document on the MAR, in the box area below the signature box the dosage of [MEDICATION NAME] to be given. The charge nurse would be responsible to obtain and document the order in the resident chart. The LPN stated that typically, she would not go to the chart to verify the order, although when this particular nurse ( RN#1) is in charge she should. When the surveyor asked why is that? The LPN stated, because this nurse was very sloppy and careless, it was not a new thing for her to not write orders after receiving them. This nurse makes a lot of mistakes. The surveyor asked the LPN, if the RNM and nursing supervisors were made aware of this nurse's practice, the LPN stated they were, but was not aware of what was done about the situation. In an interview on 10/18/10 at 10:50 am, the family member who accompanied the resident to the Orthopedic appointment on 7/28/10, stated that the physician told her the resident would no longer need the [MEDICATION NAME] and it would be stopped on 8/1/10. The family member stated that on 8/11/10, she was notified by the facility that the resident was being sent to the hospital, because he had a high fever and rectal bleeding. When the resident was seen in the emergency room , it was discovered that the [MEDICATION NAME] was never stopped. She stated that the resident was admitted to the hospital with [REDACTED]. In an interview the Registered Nurse Manager (RNM) on 10/18/10 at 11:20 am, stated that she was not aware of the specifics regarding the [MEDICATION NAME]. She stated, that in the past several weeks new policies regarding consultations have been put in place. She stated that the charge nurse on duty, who received the consultation report, would be the nurse responsible for calling the PCP to confirm and obtain orders recommended by the consulting physician. In an interview on 10/18/10 at 1:00 pm the orthopedic physician's RN stated that the physician was not available for interview. The RN stated that the resident was seen on 7/28/10 and that the [MEDICATION NAME] was to be discontinued on 8/1/10. The RN stated that the physician prescribed [MEDICATION NAME] therapy for a period of three weeks following surgery as a preventive measure for blood clots. The RN stated that the physician would only continue anticoagulant treatment in the event that the resident had been taking the medication prior to the surgery or if the resident had developed a blood clot. The RN stated that the physician documented that the [MEDICATION NAME] was to stop on 8/1/10. In an interview on 10/18/10 at 1:10 pm the PCP stated that she could not recall being notified of the recommendation to discontinue the [MEDICATION NAME]. The PCP stated that she would have followed the recommendations of the surgeon and not have ordered the [MEDICATION NAME] to be continued. She stated the only reason she would continue the [MEDICATION NAME] was in the event the resident had a medical [DIAGNOSES REDACTED]. The PCP stated she could not recall if she reviewed the written consultation report from the orthopedic visit but stated her ususal practice was to initial and date reports. The orthopedic consultation report was not initialed or dated by the PCP. Finding #3 The Hospital Discharge Summary dated 7/15/10 documented the resident to have a past medical history of [REDACTED]. The CCP dated 7/15/10, documented the resident at risk for respiratory distress secondary to chronic [MEDICAL CONDITION]. The interventions documented were to observe, record and report, signs and symptoms of difficulty breathing, increased respirations, congestion, shortness of breath, [MEDICAL CONDITION] (low oxygen level ), signs of infection, or elevated temperature. The CCP further documented to, listen to breath sounds to assess for wheezing or diminished breath sounds, and to monitor vital signs as needed. The physician admission orders [REDACTED]. The physician's orders dated 7/25/10, documented an order for [REDACTED]. Wean as tolerated. The progress note dated 8/3/10 at 2:00 pm, documented by the Occupational Therapist (OT) during the treatment session that the resident's oxygen saturation (SPO2) was checked and remained at 90 %. The SPO2 level "post rest and 45 minutes of treatment", the SPO2 level dropped to 88 %, with O2 on at 2L. The treatment was stopped and the resident's O2 level returned to 92%. There was no documentation made by the 7:00 am-3:00 pm and 11:00 pm-7:00 am shifts regarding the respiratory status of Resident #1. The note did not include that the nursing staff or physician were notified. The nursing note dated 8/5/10 at 5:15 pm, documented that the resident was on O2 at 3L, the resident was sleeping deeply and SPO2 level was at 89 %. The O2 was increased to 4L. The resident was instructed to deep breathe and the SPO2 recovered to 92 % and maintained O2 back to 3 L. There was no documentations made by the 7:00 am -3:00 pm and 11:00 pm - 7:00 am shifts regarding the respiratory status of the resident.. There was no documented evidence that the physician was notified. The nurse's note dated 8/6/10 at 6:30 pm, documented the resident's SpO2 level at 99%, and the resident appeared short of breath (SOB) upon exertion with desaturation and the resident recovered quickly with rest. There was no documentations made by the 7:00 am -3:00 pm and 11:00 pm - 7:00 am shifts of the respiratory status of the resident. The nurse's note dated 8/9/10 at 9:00 pm, documented that the resident was without respiratory distress. The nurse's note dated 8/10/10 at 2:00 pm, documented the resident was short of breath on exertion when moving in bed, speaking, or eating. The resident's SPO2 was documented as 90% on 3L of O2. There was no documented evidence that the physician was notified. The nurse's note dated 8/11/10 at 12:15 am, documented the resident's temperature at 101.5. The SPO2 at 80% on 3L of O2. The resident's heart rate (HR) was 111 beats per minute. The residents' lung sounds were decreased in the lower bases and the resident was using accessory muscles to breath. A small amount to moderate amount of rectal bleeding was noted. The Respiratory Therapist (RT) was summoned, by the RN supervisor, to assess the resident. The RT increased the oxygen to 10 L via non rebreather mask. The resident continued with respiratory distress, a HR of 100, a respiratory rate (RR) of 30, oxygen level averaging 80% with O2 at 10 L. The physician was notified at 1:10 am and ordered to transfer the resident to the emergency room . The hospital History and Physical documentation dated 8/11/10, documented that the resident was admitted to the Intensive Care Unit with [MEDICAL CONDITION] present on admission, acute urinary tract infection present upon admission, acute pneumonia, acute [MEDICAL CONDITION] and [MEDICAL CONDITION]. In an interview on 10/18/10 at 1:10 pm with the physician, she stated she could not recall the details of this particular resident, but stated if she had seen the resident on an interim visit she would have written a progress note. The last physicians' progress note documented in the medical record was dated 7/23/10. In an interview on 10/20/10 at 2:35 pm with the RN supervisor, she stated that on 8/11/10, the Certified Nursing Assistant (CNA), summoned for her to come to the resident's room. The CNA reported the resident had blood from his rectum. The RN stated she noted a small amount to maybe a moderate amount of darkish, brownish, blood on the bed pad. The RN could not signify an amount for small or moderate amounts. The RN stated she was more focused on his respiratory distress and status and did not think the blood was of a significance to this resident. She stated the physician was notified and the resident was transferred to the emergency room . 10 NYCRR 415.12