Every finding on record at Quantum Rehabilitation and Nursing LLC

Based on observations, record review, and interviews, the facility did not follow proper sanitation practices to prevent outbreak of foodborne illness and did not store and prepare food in accordance with professional standards for food service safety. This was identified during the Kitchen Task. Specifically, the walk-in refrigerator was observed with multiple opened items with no opened date; there were expired milk containers and expired half and half containers; and a milk container soiled with a jellylike substance. A refrigerator containing deli cheeses, had an opened and used block of Swiss cheese that was not dated with the date it was opened. Additionally, the emergency food storage contained several cases of expired pureed carrots and pureed green beans.The findings are: The facility's policy titled food storage, dated 03/11/2025 and last reviewed 02/08/2026, documented the facility will provide safe and sanitary storage, handling and distribution, and consumption of all foods in accordance with professional standards for food safety. Perishable and non-perishable food items will be stored and discarded as per the manufacturer's recommendations. All foods should be covered, labeled, and dated. All foods will be checked to ensure that foods will be consumed by their safe use by date or discarded. The facility's policy titled Emergency Food and Water last reviewed on 03/2025, documented emergency food and water supplies shall be inventoried monthly and expiration dates shall be reviewed quarterly. During an observation of the kitchen with the Dietary Supervisor on 02/08/2026 at 09:55 AM, a walk-in refrigerator had a metal shelf unit with an open jar of mayonnaise and an opened jar of salad dressing. The two jars were not dated with the dates they were opened. A wire rack shelving unit with milk products had an opened container of half and half with a best if used by date of 01/31/2026, an opened container of whole milk with a best if used by date of 02/07/2026, and a container of whole milk that was covered in a sticky, jellylike substance. A refrigerator containing deli cheeses, had an opened and used block of Swiss cheese that was not dated with the date it was opened. During an interview on 02/08/2026 at 10:02 AM, Dietary Supervisor #1 stated the milk and the half and half containers should have been discarded by the best if used by dates. Dietary Supervisor #1 stated staff are expected to date each item when they are opened. They further stated they should have verified that the items in the refrigerator were not expired and were labeled correctly. The Dietary Supervisor #1 stated the sticky substance on the milk container was probably jelly or a berry filling that probably dripped on the milk container. During an observation of the emergency food storage with the Food Service Director on 02/08/2026 at 01:17 PM, several cases of expired pureed carrots dated with an expiration date of 01/2025 and 03/2025, and pureed green beans with an expiration date of 01/2024 were observed. During an interview on 02/08/2026 at 02:22 PM, the Director of Food Services stated the expired pureed carrots, and pureed green beans should have been removed from the emergency food storage area and discarded. The Director of Food Services stated they personally check the emergency food storage every six months and should have removed the expired items. The Director of Food Services stated the Dietary Supervisor #1 is expected to check the refrigerators for expired products and should have checked that all opened items had an open date. The Director of Food Services stated Dietary Supervisor #1 was responsible for labeling the food items and keeping the refrigerators clean and organized. 10 NYCRR 415.14(h)

Based on observations, interviews and record review, the facility did not ensure that each resident was treated with respect and dignity and care in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. This was identified for one (1) (Resident #78) of one (1) resident reviewed for Elopement risk. Specifically, on 01/30/2026, Resident #78 visited the facility bakery for the first time. The facility staff inaccurately assessed Resident #78 to be at high risk for elopement based on the visit to the bakery. A wanderguard bracelet (a device that triggers alarms and can lock monitored doors to prevent the residents from leaving unattended) was erroneously placed on Resident #78. The finding is:The facility's policy titled Elopement, Identifying Resident at Risk for Wandering/Elopement, dated 01/12/2026 documented to identify residents with elopement risk and wandering while encouraging a restraint free environment. An elopement risk assessment will be completed for each resident upon admission, readmission, significant change and episodic occurrences. The interdisciplinary care plan will review the resident's behavior and develop strategies to address the risk factors and the actual behaviors related to wandering, identify triggers, precipitating factors, and ensure that the interventions are included in the resident's care plan.Resident #78 was admitted to the facility with diagnoses that included dementia and Alzheimer's disease. The Minimum Date Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status score of 10, indicating the resident had moderately impaired cognitive function. The Minimum Date Set assessment documented Resident# 78 did not have wandering behaviors. The Resident was ambulatory and required Partial/moderate assistance with Activities of Daily Living.A review of the medical record lacked documented evidence that an elopement risk assessment was completed for Resident #78 upon admission to the facility. During an observation on 02/08/2026 at 10:32 AM, Resident #78 was observed in an elevator. A wander guard alarm was sounding in the elevator. Resident #78 was in their wheelchair and stated- I don't know why I am wearing this bracelet on my legs - I am not trying to leave here. Where would I go? Is it because I am -- years old. It is not right. During an observation on 02/10/2026 at 9:55 AM, Resident #78 was observed in their bed. Resident #78 got up and walked and stated - I don't know why they put the bracelet on me. I never said that I ever wanted to leave the building. I am -- years old, I can walk, and I am aware I am here for therapy and care.The progress notes dated 01/30/2026 at 04:17 PM, written by Licensed Practical Nurse # 2, documented Resident #78 exited the unit and went to the [facility] bakery. Staff accompanied the resident back to the unit. wanderguard bracelet was placed on the resident's left lower extremity. Resident #78 was pleasant and cooperative. The Wanderguard Risk Assessment form dated 01/30/2026 documented to give one (1) point for each answer of Yes. A score of 0-5 would indicate a low risk for elopement/ wandering, and a score above five (5) would be considered high risk for elopement/wandering. The Wanderguard Risk Assessment form was completed by Registered Nurse #2.The surveyor reviewed the Wanderguard Risk Assessment form with Licensed Practical Nurse #2 who stated that the Wanderguard Risk Assessment form inaccurately documented that Resident #78 had a history of wandering behavior within the last six (6) months, was observed moving within the facility with no rational purpose, oblivious to needs/safety within the last six (6) months, attempted to leave unescorted, had exit seeking behaviors with or without rational purpose within last six (6) months, verbalized plans to leave facility with or without authorization (MD order), or repeatedly looked for exit doors or asked others where they were. Licensed Practical Nurse #2 stated that on the Wanderguard Risk Assessment form, Resident #78 was evaluated to have a score of 8 indicating the resident was at high risk for elopement/wandering and was provided with a wander guard bracelet based on the inaccurate evaluation. Licensed Practical Nurse #2 stated the resident did not have wandering or exit seeking behaviors and the risk assessment score should have been a three (3), low risk for elopement/wandering.The comprehensive care plan for wandering behavior dated 01/30/2026 documented Resident #78 was at risk for elopement from unit/facility. A Wander-guard was applied to the left lower extremity.During an interview on 2/12/2026 at 10:21 AM, Registered Nurse Supervisor #2 stated they would not place a wanderguard bracelet on a resident who just goes to the bakery. A resident would not be at risk of elopement if they were just going to the bakery. Resident #78 went to the bakery on 01/30/2026; Registered Nurse #2 was concerned about the resident leaving the building and felt that the placement of the wanderguard bracelet was appropriate. During an interview on 2/12/2026 at 10:45 AM, the Assistant Director of Nursing Services stated that it was not appropriate to place a wander guard for a resident that just wanted to go to the bakery. Resident #78 did not have exit seeking behaviors and the assessment completed by Registered Nurse # 2 on 01/30/2026 was not correct. During an interview on 2/12/2026- at 11:00 AM, the Director of Nursing Services stated the Wanderguard Risk assessment form dated 01/30/2026 for Resident #78 was inaccurate. The Registered Nurse Supervisor #2 should have considered resident's history and spoken to Resident #78 to determine the resident's choices. The assessment score should have been three (3), which would have placed the resident at low risk, and the resident would not have required a wander guard. Director of Nursing Services stated that having a wandergaurd bracelet on Resident #78 potentially affecting the resident's ability to move within the building including going to the bakery.10 NYCRR 415.3(d)(1)(i)

Based on observation, interview and record review conducted during the Complaint survey dated 12/17/2024, the facility did not ensure the each resident's medical record was maintained in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are Complete; Accurately documented; Readily accessible; and Systematically organized. Specifically, one Resident (Resident #1) of three residents reviewed for medical records accuracy reflected documentation for neurological checks (an assessment to determine residents level of conciousness, neurological status and vital signs) dated 11/17/2024 at 6:30 AM thru 11/18/2024 at 2PM. Resident #1 was transferred to the hospital dated 11/17/2024 at 4:40PM via 911. The findings are: The review of the Facility Policy for Neurological Checks dated 9/2018 documented Neurological checks will be completed for 24 hours, unless otherwise indicated by the attending physician. Immediately following a head trauma, the physician shall be immediately notified, and neurological checks should be instituted. The time frame for neurological checks was documented in the policy. A brain MRI/CAT scan will be ordered at the discretion of the physician. Observe for symptoms of increased drowsiness, difficulty arousing the resident, increased confusion, and other symptoms. Resident#1, was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, (a disease that affects brain structure or function. It causes altered mental state and confusion.) esophageal varices with bleeding, status post respiratory failure. The review of the Admission Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score- 9-indicating moderately impaired for decision making. Functional limitation in range of motion-upper extremity/lower extremity-none, toileting-maximum assistance walk 10 feet with maximum assist. The review of the Comprehensive Care Plan (CCP) documented dated 10/9/2024 Falls / Accidents / Incidents, Potential, at Risk for Falls / Injury, the interventions documented, keep bed in lowest position, frequent rounds while resident in bed. Call bell within reach. Updated for the 11/17/2024 incident dated 11/17/2024 at 7:51AM Resident #1 was crying out this morning, bedside table thrown over, was flipping around in bed screaming, stated they were having a bad dream. Noted bleeding from back of head, small laceration noted. The review of the Progress Note dated 11/17/2024 at 7:51AM documented Resident #1 was observed crying out, bedside table thrown over, Resident #1 was flipping around in bed screaming, states they were having a bad dream. Noted bleeding from back of head, small laceration noted. Psychological services ordered. The review of the Facility Investigation dated 11/17/2024 at 6:45AM documented at 6:45AM the assigned Certified Nurses Aide entered the resident's room heard the resident calling for help. Resident #1 was in bed in low position, with bedside tabletop next to right side of head with red drainage. The Registered Nurse Supervisor assessed the Resident. Full range of motion upper and lower extremities. Pressure dressing applied by the Registered Nurse. Neurological Checks in place. The Medical Doctor was made aware of 1.0CM open area to right occipital scalp, and the Next of Kin aware. The staff was interviewed. The Medical Doctor ordered to monitor neurological status of the Resident. The investigation concluded no cause to believe any abuse. The review of the progress note dated 11/17/2024 at 7:59PM documented at 4:15PM the next of kin asked the nurse to assess Resident #1. Neurological checks performed. Resident #1 had a strong grip with left hand, not able to move left arm or left leg. Pupils equal and reactive and included vital signs. The Medical Doctor was made aware and ordered to have Resident #1 sent to hospital for further evaluation. 911 was called and they arrived at about 4:40PM. The review of the Progress Notes dated 11/18/2024 at 7:20AM documented Resident #1 was admitted to the hospital for left sided weakness. The review of the Neurological Observation sheet dated 11/17/2024 documented neurological checks were documented by various staff at 6:30AM, 6:45AM, 7:15AM, 8:15AM, 10:15AM, 12:15AM, 2:15PM,4:15PM and 6:15PM, 8:15PM, 10:15PM 12:15AM 2:15AM 4:14AM 6:15AM and on day 2, (not dated) at 2:00PM. The neurological assessments documented positive response for the assessment despite the 4:15PM nursing progress note documenting Resident #1 had a change in condition requiring hospitalization , The Resident #1 was no longer present in the facility as of 11/27/2024 4:40PM. During and interview conducted with the Director of Nursing on 12/16/2024 at 3:30PM they stated Resident #1 was found flailing both arms in the air, while lying in low bed, in room at a time not recalled. They stated it was reported that the bedside table was lying on the floor on its side, the Resident was assessed to have a small open area on the right side back of head, not actively bleeding. The Registered Nurse Supervisor#2 assessed the resident, called the Next of Kin and also spoke with the Attending Medical Doctor #1, who stated the Resident was alert with eyes reactive to light, alert and not drowsy and the plan was for neurological checks on the set schedule. They further stated they are aware that the staff was documenting Neurological checks on the Neurological Observation Sheet dated 11/17/2024 starting at 6:30AM through 11/18/2024 at 2 :00PM but the Resident transferred out of the facility dated 11/17/2024 at 4:40PM. The staff performing Neurological checks should not have documented anything about Resident #1 if a Resident is not in the facility at the times that are scheduled for those checks. The Director of Nursing stated all of the Nursing staff will be retrained on the Neurological Check Policy starting at this time. 483.20[f](5)

Based on record review and interviews, during the recertification survey initiated on 7/8/2024 to 7/15/2024, the facility did not ensure a comprehensive person-centered care plan was developed with measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. This was identified for one (Resident #58) of four residents reviewed for Antibiotics. Specifically, Resident #58 was prescribed Minocycline (an Antibiotic medication) 100 milligrams capsule in February 2024; however, a Comprehensive Care Plan addressing the long-term use of Antibiotic therapy was not developed. The finding is: The undated policy and procedure for Comprehensive Care Plans documented a Comprehensive Care Plan for a resident's needs should be developed by 14 days of admission and no later than 21 days. Comprehensive Care Plans will be revised or new care plans will be developed quarterly, annually, and as needed. Resident # 58 was admitted with diagnoses that include Paraplegia and Type 2 Diabetes Mellitus. The Quarterly Minimum Data Set Assessment (MDS) dated [DATE] documented a Brief Interview for Mental Status score of 13, which indicated the resident had intact cognition. The Minimum Data Set assessment documented the resident received Antibiotic therapy during the assessment period. A review of the physician's order dated 2/27/2024 documented to administer Minocycline (an Antibiotic) 100 milligrams capsule, give one capsule by oral route every 12 hours for Klebsiella Pneumoniae (a common type of bacteria found in the intestines). There was no stop date indicated for this order. A progress note dated 2/27/2024, written by Registered Nurse #1, documented Resident #58 returned from an Orthopedic Spine Specialist for a biopsy of a mass. The mass was likely to be chronic Vertebral Osteomyelitis (bone infection in the spine). Resident #58 was scheduled to follow up with an Infectious Disease Specialist for long-term Antibiotic therapy and to observe for signs and symptoms of infection. An Infectious Disease consult dated 2/28/2024 documented the resident was seen and evaluated for a right femur Abscess (a painful, swollen lump filled with pus in the thigh bone). The wound incision was dry with minimum serosanguinous (blood-tinged) drainage at this time. The wound improved significantly with the Intravenous Antibiotics with Ertapenem (Antibiotic medication) one gram for 4 weeks. The Infectious Disease Specialist recommended initiating Minocycline 100 milligrams by mouth route every 12 hours. A review of Resident #58's Comprehensive Care Plans revealed there was no care plan developed for the long-term use of Antibiotic therapy. Registered Nurse #2 was interviewed on 7/15/2024 at 12:00 PM and stated any resident on long-term Antibiotic therapy should have a care plan in place with individual goals and interventions for the use of the antibiotics. The Infection Control Preventionist, Registered Nurse # 3, was interviewed on 7/10/2024 at 2:40 PM and stated Resident #58 was on Antibiotic therapy due to infected hardware which was recommended by the Infectious Disease Specialist. Resident #58 should have a care plan in place for long-term Antibiotic therapy. The Director of Nursing Services was interviewed on 7/15/2024 at 12:40 PM and stated any resident on long-term Antibiotics should have a care plan in place. The Comprehensive Care Plan should list interventions for monitoring the use of Antibiotics. The interventions should also include monitoring for signs and symptoms of adverse reactions to the long-term use of Antibiotic therapy. 10 NYCRR 415.11(c)(2)(i-iii)

Based on observation, record review and interviews conducted during the Recertification Survey initiated on 6/20/2023 and completed on 6/27/2023, the facility did not ensure that each resident receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. This was identified for one (Resident #30) of three residents reviewed for positioning. Specifically, Resident #30 was observed on multiple occasions sitting in a wheelchair improperly positioned with their body leaning to the left side. The finding is: The Rehabilitation Referral and Recommendations to Nursing Policy dated 1/2023 documented all residents will be screened/evaluated by Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST). The rehabilitation department will provide nursing with a rehabilitation recommendations to nursing communication form to establish the residents' functional status. Functional categories include bed mobility, transfer status, ambulation, wheelchair locomotion, dressing, feeding, toileting, personal hygiene, bathing, wheelchair positioning, splints/braces, and out of building (on facility grounds) status. As a resident's functional status changes, the nursing team may send a referral to the rehabilitation department. The Rehabilitation Department will screen and evaluate the resident and will update their status by providing nursing with a new rehabilitation recommendation. Resident #30 was readmitted to facility on 11/24/2021 with diagnoses of Lack of coordination, Muscle wasting and Atrophy (decreased muscle mass), Dementia and Alzheimer's disease. The Annual Minimum Data Set (MDS) assessment dated [DATE] documented Resident #30 had Brief Interview for Mental Status (BIMS) score of two which indicated Resident #30 had severely impaired cognition. Resident #30 required extensive assistance of one person for bed mobility. The MDS documented the resident had no limitations in range of motion. The resident utilized a wheelchair as a mobility device. The Comprehensive Care Plan (CCP) for Activity of Daily Living (ADL) Functional Rehabilitation Potential dated 1/17/2018 and last updated on 6/1/2023 documented the resident required assistance with ADLs. The interventions included to anticipate and meet all needs, encourage participation, and utilize a standard wheelchair and cushion with bilateral elevating leg rest. Resident #30 was observed sitting in their wheelchair in the activity room on 6/20/2023 at 11:12 AM. The resident's head and body were observed leaning to the left side in the wheelchair. Resident #30 was observed on 6/23/2023 at 3:45 PM in the activity room. The resident was observed leaning to their left side and was trying to re-position themselves to sit straight in the wheelchair; however, was unable to do so. Resident #30 was observed again in the activity room on 6/23/2023 at 4:00 PM sitting in their wheelchair leaning to their left side. Certified Nursing Assistant (CNA) #2 repositioned the resident in the wheelchair. Three minutes later at 4:03 PM, the Director of Rehabilitation Services was also observed attempting to reposition the resident in the wheelchair while in the activity room. The CNA #2 was interviewed on 6/26/2023 at 11:56 AM and stated they were assigned to Resident #30 three times a week during the 7 AM to 3 PM shift and on Fridays from 7 AM to 11 PM. CNA #2 stated they repositioned Resident #30 on 6/23/2023 at 4:00 PM because Resident #30 was leaning in their wheelchair. CNA #2 stated they often have to reposition Resident #30 as the resident always leans to their left side when sitting in their wheelchair. CNA #2 stated Resident #30 told CNA#2 that they were not comfortable in the wheelchair and CNA#2 reported this to Licensed Practical Nurse (LPN) #2. LPN #2 then instructed CNA #2 to reposition the resident. CNA #2 could not recall the date when they had notified LPN #2 of Resident #30 being uncomfortable in their wheelchair. LPN #2 was interviewed on 6/26/2023 at 12:00 PM and stated they reposition Resident #30 at least twice a day when the resident is in a wheelchair to make Resident #30 comfortable. LPN #2 stated they are supposed to notify the Physical Therapy department regarding poor positioning, but they did not remember if they ever notified the Rehabilitation department of Resident #30's poor positioning. LPN #3 was interviewed on 6/26/2023 at 3:15 PM and stated they are the regularly assigned 3 PM to 11 PM shift nurse for Resident #30. LPN #3 stated they were aware of Resident #30's poor positioning and used a pillow to support and position the resident in the wheelchair. LPN#3 stated they are supposed to notify the Nurse Manager about the resident's poor positioning; however, they never did. Resident #30 was interviewed on 6/26/2023 at 4:00 PM and stated they were not comfortable in their wheelchair because they were leaning to their left side and could not reposition themselves. Resident #30 stated they liked the new arm rest on the left side of the wheelchair that was given to them on 6/24/2023. The Director of Nursing Services (DNS) was interviewed on 6/27/2023 at 1:05 PM and stated the staff should have notified the Rehabilitation Department of the resident's poor positioning and to request an evaluation of Resident #30's positioning in the wheelchair for the resident's safety and comfort. The Director of Physical Therapy was interviewed on 6/27/2023 at 1:22 PM and stated they observed Resident #30 in the wheelchair, in the activity room on 6/23/2023 at 4:03 PM. The Director of Physical Therapy stated they observed that the resident was leaning to the left. The Director of Physical Therapy stated they did a full assessment to evaluate the resident and implemented a lateral support with an arm trough on the left side of the chair. The resident was able to sit up and was better positioned with the use of the new interventions. The Director of Physical Therapy further stated they should have been made aware of the resident's poor positioning by nursing staff. 10 NYCRR 415.12

Based on observation, record review, and interviews during the Recertification Survey initiated on 6/20/2023 and completed on 6/27/2023, the facility did not ensure that the facility was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable, physical, mental, and psychosocial wellbeing. This was identified on one (Unit 3) of two resident units. Specifically, Unit #3 did not have an adequate supply of linens on the nursing unit to address the resident's Activities of Daily Living (ADL) needs. The finding is: Resident #62, who was admitted with diagnoses that include Type II Diabetes Mellitus and Morbid Obesity, resided on Unit 3. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 15, which indicated the resident had intact cognition. The resident had no behavioral symptoms and no rejection of care. The resident required extensive assistance of one staff member for toilet use, was frequently incontinent of urine, and was always incontinent of bowel. The Bowel Bladder Incontinence Comprehensive Care Plan (CCP) dated 05/20/2022 documented Impaired sphincter control. The interventions included but were not limited to perform incontinence care every two to four hours and as needed. During an observation on 6/20/2023 at 1:10 PM Resident #62 was observed in their room sitting on the side of their bed. The beds in the room were made with chucks (a kind of ultra-absorbent incontinence product that are designed to be placed on the top of a bed, wheelchair, or any surface you want to protect) placed underneath the resident. Resident #62 was interviewed on 6/20/2023 at 1:10 PM regarding care provided by staff. The resident stated that staff runs out of chucks and use sheets instead. Resident #62 stated that since their admission the lack of chucks has been an issue. Unit 3 was observed on 6/23/2023 between 12 PM and 1 PM. The main Linen Cart contained no chucks. The cart serving the hallway for the resident had no chucks. There was a cart serving another hallway that had six chucks. Certified Nursing Assistant (CNA) # 2 was interviewed on 06/23/2023 at 12:34 PM and stated that there are times when chucks are not available on the unit. CNA #2 stated that when the chucks are not available, they notify the Charge Nurse or the Nursing supervisor. CNA #2 stated when chucks are not available, they fold the bedsheet to double it up and use the bed sheet in place of the chuck. Licensed Practical Nurse (LPN) # 1 and Registered Nurse (RN) #3 were interviewed concurrently on 6/23/2023 at 12:40 PM. They both stated they were never made aware that there were not enough chucks during the morning shift. They both stated if there was a shortage of chucks, they would call the Laundry Supervisor to bring more chucks to the floor. A subsequent observation was made on 6/23/2023 at 2:30 PM on Unit 3. One package of chucks containing 25 chucks was observed on the main linen cart. Another package was opened that contained approximately 14 chucks. Laundry Supervisor #1 was interviewed on 6/23/2023 at 3:30 PM and stated they send two packets of chucks that contains 50 chucks each to every nursing unit daily. The CNAs are expected to divide the chucks amongst two linen carts. The Laundry Supervisor stated that they were just made aware that the one packet of chucks did not contain 50 chucks each, rather each packet had 25 chucks. Laundry Supervisor #1 stated that they now realized that the units were only receiving half of the supply that was needed. Director of Housekeeping # 1 was interviewed on 06/27/2023 at 12:25 PM and stated the Laundry Supervisor should have checked the number of chucks contained in the packets. Director of Housekeeping #1 stated that the facility recently changed Vendors and the new Vendor supplies 25 chucks in each package instead of the 50 chucks per package supplied by the previous Vendor. Director of Housekeeping #1 stated that a minimum of 100 chucks are required per unit per shift and having half the supply would not be enough for resident care. The Director of Nursing Services (DNS) was interviewed on 6/27/2023 at 12:23 PM and stated if there is a shortage of chucks on the unit, the CNAs could call the Laundry Supervisor to request chucks. There are sufficient chucks in the facility and the CNAs should not be doubling the linen to replace the chucks as this can contribute to skin breakdown. The Administrator was interviewed on 6/27/2023 at 2:46 PM and stated they were not aware that there was a concern with chuck availability. The Administrator stated if they were made aware of the concern regarding the supply of chucks they would have looked into the concern. 10 NYCRR 415.26

Based on record review and staff interviews during the Abbreviated survey (NY 688), the facility did not ensure that medical records were maintained, in accordance with accepted professional standards and practices, that were complete and accurately documented. This was evident for 3 (Resident #1, #2 and #3) of 3 residents reviewed for pressure sores. Specifically, 1) Resident #1's Treatment Administration Record (TAR) documented to apply [MEDICATION(S)] to the left shin incision line daily and Balmex to the bilateral buttocks BID (twice a day). The TAR had no documented evidence that the [MEDICATION(S)] treatment was signed for 12/24 opportunities and the Balmex for 16/34 opportunities. 2) Resident #2's TAR documented to cleanse the sacrum stage 4 pressure ulcer with [MEDICATION(S)] and apply Collagen powder with dry clean dressing (DCD) daily and PRN (as needed). There was no documented evidence that the TAR was signed for on 11/53 opportunities. 3) Resident #3's TAR documented collagen powder and Hydrogel to the sacrum ulcer stage 3 daily and PRN. There was no documented evidence that the TAR was signed for on 6/16 opportunities. The findings are: 1) Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental status (BIMS) score of 15 indicating intact cognition. Resident #1 required total assistance with 2 persons for transfer and toilet use and extensive assistance with other areas of ADLs except for eating. Resident #1 was occasionally incontinent of bowel and bladder. The MDS documented the resident had a surgical wound and received surgical wound care. The Comprehensive Care Plan (CCP) titled skin impairment dated 11/8/21 documented the resident had a surgical incision on the left medial distal leg with excoriation. Interventions included observe surgical site for any signs and symptoms (s/s) of infection. Notify the Medical Doctor (MD) and follow-up if indicated. Treatment to the surgical site as per the MD order. The Certified Nursing Assistant Accountability Record (CNAAR) dated 11/8/21 documented to turn and positioning the resident every 2 hours and PRN and toilet every shift. There was no documented evidence that the CNAAR was signed as completed for the task of turn and positioning 53/77 opportunities in November 2021, and 33/70 opportunities in December 2021. Additionally, the CNAAR had no documented evidence that toilet use was signed for on 52/77 opportunities for November 2021 and 33/71 opportunities for December 2021. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Wound Care Note (WCN) dated 11/23/21 documented the resident was evaluated on 11/19/21. The Resident had multiple incision sites to the left lower leg, with no sutures, or staples in place. The Left distal medial lower leg with an incision line measuring 11 cm x 0.2 cm x 0 cm, with an excoriated area to the top of the incision line. The WCN documented a recommendation of normal saline N/S cleanse followed by [MEDICATION(S)] and DCD once daily and PRN. The MD agreed with the recommendation and an order was obtained. The TAR dated November 2021 had no documented evidence that the [MEDICATION(S)] treatment to the left shin was signed for 1 day on 11/28/21. The CCP dated 12/7/2021 documented the resident had an excoriation to the right and left buttock. Interventions included encourage and assist the resident to turn and position every 2 hours as needed. Monitor for s/s of infection. Monitor the resident for adequate nutrition and hydration. Provide treatment as ordered by MD and monitor for effectiveness of the treatment. The Nurse's Progress Notes (NPN) dated 12/7/21 documented the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The MD was notified, and a treatment was ordered as follows: Balmex BID and PRN. On 12/11/21 the wound care Registered Nurse (RN) documented they evaluated the resident on 12/8/21 due to report of skin breakdown to the bilateral ( B/L) buttocks. An excoriation was observed to the left buttock, measuring 0.4 cm x 0.1 cm x 0.1 cm; linear; 100% pink, no drainage, peri wound intact. A Right buttock excoriation measures 0.2 cm x 0.5 cm x 0.1 cm; no drainage, peri wound intact. The B/L excoriations appear to occur at the diaper line. Balmex is being applied BID and a DCD. A PO dated 12/7/21 documented an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, the PO documented to cleanse the B/L buttocks with NS then dressing BID and PRN. The TAR dated December 2021 had no documented evidence that the [MEDICATION(S)] treatment to the left shin was signed for on 12/24 days as follows: 12/2/21, 12/6-12/9, 12-11-12/13, 12/15-17 and 12/21 scheduled at 7 AM). Additionally, there was no documented evidence that the Balmex to the B/L inner buttocks was signed for on 16/34 opportunities (dated 12/8-12/9, 12/11-12/17, 12/20-12/21 for 7-3 shift and on 12/9, 12/14, 12/16, 12/21 to 12/22/21 for 3-11 shift). 2) Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented that the resident had a BIMS score of 12 indicating moderately impaired cognition. Resident #2 required extensive assistance of one person for bed mobility, transfer, and toilet use. Resident #2 was documented with stage 4 pressure ulcer present on admission and one venous or arterial ulcer. The resident received pressure ulcer/injury care and application of dressing or ointments. The CCP dated 9/25/2021 and titled Potential for further skin integrity alteration secondary to limited mobility, incontinence, [CONDITION(S)], arterial disease, cardiac disease, [CONDITION(S)], DM, Left AKA, PVD, PAD, h/o [CONDITION(S)]. Interventions included monitor skin for [CONDITION(S)], redness, bruising and blisters, turn and position every 2-4 hours and PRN. Toilet the resident every 2-4 hours and PRN. Apply treatment as ordered by the MD. A PO dated 5/2/22 documented an order to cleanse the sacrum with [MEDICATION(S)] solution, then pat dry and apply collagen powder and cover with a DCD every evening and PRN for a stage 4 pressure ulcer. The TAR for May and June 2022 had no documented evidence that treatment to sacrum with [MEDICATION(S)] followed by collagen powder with DCD and was signed on 11/53 opportunities. 3) Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented the resident has a BIMS score of 15 indicating intact cognition. The resident required extensive assistance of one person for bed mobility, transfer, and toilet use. Resident #3 had 1 stage 3 present on admission and was receiving pressure ulcer care. The CCP dated 3/3/22 documented resident with potential for skin integrity alteration secondary to history of pressure ulcer, Diabetes, decrease mobility, obesity, and history of Fourier's gangrene. Interventions included treatment as ordered by MD, monitor skin for redness, [CONDITION(S)], bruising and blisters, turn and position every 2-4 hours and PRN and toilet resident every 2-4 hours or as PRN. The CCP notes the resident had a Stage 3 to the left buttock measuring 3 x 3 x 0.7 cm. A PO dated 5/20/22 documented an order to cleanse sacrum with NaCl, pat dry and apply collagen powder followed by calcium alginate pad and cover with silicone adhesive dressing daily and PRN for pressure ulcer to the sacrum. The TAR for May 2022 lacked documented evidence that treatment to sacrum was signed for on 6/16 opportunities: collagen powder with calcium alginate and cover with silicone dressing daily was not signed on 5/20/21, 5/22/21 and 5/28/21; collagen powder with drop of wound gel and DCD daily was not signed on 5/19/21; and Hydrogel and dry dressing was not signed for on 5/16/21 and 5/17/21. The 5/2022 and 6/2022 CNAAR lacked documented evidence that turning, and positioning was signed for on 12/68 opportunities for May 2022 and 11/24 opportunities for June 2022. Additionally, the CNAAR lacked documented evidence that toilet use was signed for on 14/68 opportunities for May 2022 and 10/24 opportunities for June 2022. During an interview with the RN Educator on 6/8/2022 at 2:15 PM they reviewed the resident's TAR for November 2021 and December 2021. The RN educator stated there were a lot of missing signatures in Resident #1's TAR. The RN educator stated if it is not signed that means it was not done. The RN Educator also stated they could not recall why the treatment was not completed. During an interview with the current Licensed Practical Nurse (LPN) Wound care nurse (WCN) on 6/8/2022 at 2:50 PM they stated they started in March 2022 and was not the wound care nurse for Resident #1 and Resident #3 they were admitted prior to their start date. Resident #2 has had an extensive Stage 4 pressure ulcer. The LPNWCN reviewed the TAR for Resident #2 and stated there are missed signatures and could not state why. The LPNWCN stated during wound rounds the LPN WCN observed that the treatments were dated a day before the wound round day. The LPNWCN stated the treatment was physically done but was just not signed for. During an interview with the Director of Nursing (DON) on 6/8/2022 at 3:19 PM they stated the problem with documentation was not brought to their attention. The DON stated they did review the CNAAR, and the staff were not signing. The unit manager is responsible to ensure the CNAs were signing. During an interview with the Administrator on 6/8/2022 at 3:45 PM they stated that they were not aware of the omissions in the MAR, TAR and CNAAR. During a phone interview with the Registered Nurse (RN) Wound Care nurse on 6/15/2022 at 2:13 PM they stated that they were the wound care nurse from 6/30/21 until 3/23/22. They stated that the LPN on the unit is responsible for administering treatments and CNAs are responsible for turning and positioning the resident. During an interview with the evening shift CNA #1 on 6/29/22 at 1:23 PM they stated that they recalled the resident and was assigned to the resident a couple of times. CNA #1 stated they documented the care they provided. They did not recall if the resident was on turning and positioning. They did not know why the CNAAR did not have their signatures. During a phone interview with the dayshift CNA #2 on 6/29/22 at 1:34 PM they stated that they worked both 7-3 and 3-11 shift as a per diem employee. They were assigned to the resident 5 times, and they documented the care they provided to the resident. CNA #2 stated the resident was able to turn and position in bed. During a phone interview with the evening shift LPN #2 on 6/29/2022 at 2:38 PM they stated that they worked 7 AM to 7 PM as full time. LPN #2 stated they do medication and treatment administration and they documented when they gave medication and treatments to the resident. During a phone interview with the LPN Unit manager (UM) on 6/30/22 at 10:04 AM they stated that they were the unit manager from [DATE] to [DATE]. The LPN UM stated they were not sure if the treatment was completed, or if the nurses were not signing. 415.22(a) (1-4)

Based on record reviews and staff interviews during the Recertification and Abbreviated Survey (Complaint #NY 858) completed on 04/22/2021, the facility did not ensure that each resident received treatment and care in accordance with professional standards of practice. Specifically, Resident #135 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #135 was admitted to the facility on [DATE] with instructions from the hospital to provide [MEDICATION(S)] 100 mg three times a day for a total of 300 milligrams (mg) per day. The resident received half the amount of [MEDICATION(S)] from 3/6/2020-3/23/2020. Subsequently, Resident #135 experienced [CONDITION(S)] activity with a subtherapeutic [MEDICATION(S)] level of 1.3 microgram/milliliter (mcg/mL) (therapeutic range 10-20 mcg/mL). This resulted in harm to Resident #135 that was not an immediate jeopardy. The finding is: The facility's policy, dated 4/2017 titled, Admission Process documented that the attending physician/designee will obtain the resident's medical history and perform a physical examination within 48 hours of admission to the facility. Based on this information the physician will develop a medical plan of care and write orders to meet this plan. The facility policy did not include a process for medication reconciliation upon admission to the facility. Resident #135 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 3/7/2020 Admission Minimum Data Set (MDS) assessment documented no Brief Interview for Mental Status (BIMS) score. The MDS documented that the resident had short- and long-term memory problems and had severely impaired cognitive skills for daily decision making. The Hospital Discharge instructions dated 3/5/2020 documented a discharge order of [MEDICATION(S)] Suspension, 100 mg, orally three times a day. The hospital records available to the facility did not include a [MEDICATION(S)] level (blood test). The facility Physician's (MD) #1 order dated 3/5/2020 ordered [MEDICATION(S)] 50 mg chewable tablet, chew one tablet (50 mg) by oral route three times a day for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Medication Reconciliation Form, created on 3/5/2020 by Registered Nurse (RN) #3 documented that My signature below indicates that discharge medications have been reviewed for accuracy in transcription onto our admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission assessment however was completed by RN #4. The Nursing Admission Progress Note written by the RN #4 (the admission nurse) dated 3/5/2020 documented that the MD (unidentified) was notified of the resident's condition and diagnosis. The orders were reconciled, obtained, and read back for accuracy. Review of the progress note revealed that the resident was stable. There was no documentation regarding the [MEDICATION(S)] dosage or a need to lower the dosage of [MEDICATION(S)]. In addition, there was no order for blood work to obtain a [MEDICATION(S)] level. The Physician History and Physical (H&P), created on 3/5/2020 and completed on 3/6/2020 by Admitting MD #2, documented that medications were reviewed. There was no documentation in the H&P regarding a rationale for decreasing the hospital discharge orders of [MEDICATION(S)] 100 mg three times a day to 50 mg three times a day. There was no documented laboratory follow up for [MEDICATION(S)] levels. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing progress note dated 3/23/2020 documented that the nurse was called into the resident's room by therapy staff due to possible [CONDITION(S)] activity. The resident was noted with clammy skin, scant amount of spit up on the resident's chest, and was pale in color. The Physician Assistant (PA) #1 was notified. PA #1's note dated 3/23/2020 documented that the resident was seen for a one-time episode of [CONDITION(S)]. Orders included bloodwork to obtain a [MEDICATION(S)] level. The nursing progress note dated 3/23/2020 documented the resident was seen by the Nurse Practitioner (NP) (unidentified) and ordered laboratory work up including complete blood count (CBC) with differential, Basic Metabolic Panel (BMP) and [MEDICATION(S)] level. The laboratory results of Resident #135 dated 3/24/2020 documented [MEDICATION(S)] level of 1.3 micrograms/milliliter (mcg/mL) (Therapeutic range 10-20). A nursing progress note dated 3/24/2020 documented that laboratory results were reviewed with the PA #1 and the [MEDICATION(S)] orders were increased to 50 mg twice a day and 100 mg at hour of sleep for 3 days (for a total of 200 mg per day) and then repeat the [MEDICATION(S)] level. PA #1's order dated 3/24/2020 documented to repeat CBC, BMP and the [MEDICATION(S)] Level in three days (3/27/2020). The repeat [MEDICATION(S)] level on 3/27/2020 was 1.9 mcg/ml (Therapeutic range 10-20). A nursing progress note dated 3/27/2020 documented that lab results were reviewed with a PA #2 and ordered to send the resident to the emergency room due to low hemoglobin and hematocrit levels to rule out a Gastrointestinal (GI) bleed. The Director of Nursing Services (DNS) was interviewed on 04/19/2021 at 10:20 AM. She stated that the nurse (RN #4) who completed the admission assessment for Resident #135 on 3/5/2020 is no longer employed at the facility. The 2nd floor unit Licensed Practical Nurse (LPN), charge nurse, was interviewed on 4/19/2021 at 11:00 AM. The LPN stated that she recalled Resident #135 and also recalled the resident having [CONDITION(S)] activity. She stated the general admitting process is for the admitting RN to discuss the medications with the physician based on the hospital discharge instructions and then determinations are made for medications and the dosages. She stated that an RN on the following two nursing shifts is responsible to ensure that the medication orders are being followed and the care plan is being carried out. She stated if a medication dosage was changed from what was written on the hospital discharge instructions, there should have been a note written. Attending MD #1 was interviewed on 4/20/2021 at 8:26 AM. He stated that if a resident is new to the facility, we try to keep the medications consistent with the hospital discharge instructions, unless the medication is not in the formulary (a list of medications approved for use in the facility) or something that is very expensive. He stated the facility does not change any medications until the facility staff gets to know the resident and assesses how the resident is reacting to their prescribed medications. PA #1 was interviewed on 4/20/21 at 10:44 AM. She stated that the facility would only lower the [MEDICATION(S)] dosage if there were high levels of the drug indicating toxicity and the resident was symptomatic. She stated she reads the hospital notes and follows the discharge instructions. PA #1 was re-interviewed on 4/20/2021 at 12:21 PM. She stated that she reviewed the hospital discharge instructions earlier in the day on 4/20/2021 and it appeared that Resident #135 was stable on 300 mg of [MEDICATION(S)] per day for a long time. She stated she was unable to find a [MEDICATION(S)] level prior to admission to the facility. She stated it would be her preference to get a baseline [MEDICATION(S)] level at the time of the admission. She stated that the H&P was done by MD #2. MD #1 was re-interviewed on 4/20/2021 at 2:39 PM. He stated the medications in the hospital discharge paperwork should be reviewed by the physician during the history and physical evaluation. He stated that if there is nothing remarkable, we do not need to change the medications. He stated typically he would order a [MEDICATION(S)] level upon admission if he did not know the [MEDICATION(S)] level. He stated if a resident is stable on 300 mg of [MEDICATION(S)] per day and there are no signs of toxicity upon admission and no known [MEDICATION(S)] level, then the dosage should not be changed. MD #2, who was the admitting MD and had completed the H&P for Resident #135 was interviewed on 4/21/2021 at 9:13 AM. He stated we absolutely follow the medication instructions in the hospital discharge unless there is a reason not to; for instance, if the resident is on a blood thinner and the resident is bleeding. He stated the admitting nurse reviews the medications and calls the doctor. He stated normally we check the discharge instructions from the hospital. However, he could not recall if he reviewed the hospital discharge instruction for Resident #135 when he completed the H&P. He stated he was surprised that this happened, and it was an error. The DNS was re interviewed on 4/21/2021 at 12:22 PM. She stated inconsistency with staffing and education are concerns and could affect admissions being done consistently according to policy and procedures. She stated that she is aware that she has to enforce the admission process, which has to be standardized. The Medical Director, MD #3, was interviewed on 4/22/2021 at 9:10 AM. He stated that if a dosage of a medication was lowered or changed from the hospital discharge instructions upon admission, there should be a medical justification for the change in the dosage and documentation in the notes. He stated the general procedure is for the physician or physician's team member to review the hospital discharge instructions to ensure accuracy. He stated if a resident is having seizures, it could indicate that the dosage of medication is subtherapeutic. He stated that the dosage of [MEDICATION(S)] should not have been changed upon admission without medical justification and that the admitting physician or associate is expected to review the hospital paperwork. 415.12

Based on observations, interviews, and record review during the Recertification Survey completed on 4/22/2021, the facility did not ensure that a safe, functional, sanitary, and comfortable environment for residents, staff and the public was provided. Specifically, a patio exit door, situated in the 1st floor dining room was not secured with a properly functioning alarm or door hardware to secure authorized entry and exit. The findings are; The Policy and Procedure for Identifying Residents at Risk for Elopement/Wandering, dated August 2013, was reviewed. The facility policy documented under item #14 Environmental Services is responsible to check for functionality daily at exits and maintain a log. During an observation on 04/20/2021 at 4:00 PM, the patio exit door, situated in the dining room, was observed to have opened on its own due to a draft which caused the door alarm to sound. The alarm reset (stopped sounding) within 15 seconds without any intervention from facility staff. On 04/20/2021, at 4:10 PM, the Administrator was called to observe the exit door alarm at which time surveyor opened the door with no mechanical resistance. The alarm immediately sounded and reset itself without intervention from facility staff. The door was examined and appeared to have the latch hardware removed and the panic bar disabled thus making it possible to open the door from the inside or the outside without any physical resistance. At 4:12 PM the Administrator stated that his understanding was that the door could not be opened from the outside and that the alarm had to be reset via a code entry by staff. He was not aware of the keypad re-setting itself or the absence of the latch hardware. On 04/20/21, at 4:15 PM, the door alarm was triggered again in the presence of the Administrator to confirm that the alarm and door were not functioning properly. The alarm reset itself within 15 seconds of triggering without intervention from staff and the door opened without any mechanical resistance. On 04/20/21 at 4:40 PM, two maintenance workers entered the dining room and examined the door. Maintenance Worker # 1 and # 2 stated that they did not know how the alarm should function regarding resetting itself without staff intervention. They both were unaware of who removed the latch hardware or disabled the panic bar. On 04/20/2021, at 5:30 PM, an outside vendor (electrical contractor) was called to assess the door alarm. A review of the contractor's invoice documented that he was unable to reprogram the door alarm and would have to order a replacement to make proper adjustments. On 04/20/2021, at 5:35 PM, the Administrator stated that a new alarm keypad/alarm hardware was on order and that the facility would ensure that the room would remain locked and secured, with door closed until the device was repaired. On 04/21/21, at 08:15 AM, the 1st floor dining room door was observed to be open and unsecured upon arrival by surveyor. No staff were observed in the local vicinity supervising the room. The Director of Engineering was interviewed on 04/21/2021 at 11:00 AM. He stated that he checks the different areas, including the 1st floor dining room daily and documents his findings in the logbook. He stated that the door hardware was likely removed because staff were getting locked out when going onto the patio but could not recall by whom or when it was removed. He was not aware that the alarm was resetting itself after 15 seconds. He stated that the alarm should require staff intervention to reset. A locksmith was observed on 4/21/2021, at 1:00 PM to remove a defective panic bar and install a new device. The surveyor observed a new panic bar and latch hardware. The alarm keypad/alarm was not repaired. On 04/22/2021, at 11:22 AM, the Administrator demonstrated that a Sti-Exit alarm device was installed on the dining room / patio exit door. 415.29

Based on observations, interviews, and record review during the Recertification Survey completed on 4/22/2021, the facility did not ensure that the resident environment remained as free of accident hazards as possible. Specifically, a patio exit door, situated in the 1st floor dining room was not secured with a properly functioning alarm or door hardware to prevent unauthorized entry and exit. The findings are: The Policy and Procedure for Identifying Residents at Risk for Elopement/Wandering, dated August 2013, was reviewed. The facility policy documented under item #14 Environmental Services is responsible to check for functionality daily at exits and maintain a log. During an observation on 04/20/2021 at 4:00 PM, the patio exit door, situated in the dining room, was observed to have opened on its own due to a draft which caused the door alarm to sound. The alarm reset (stopped sounding) within 15 seconds without any intervention from facility staff. The door had a keypad situated immediately to the right of the exit door which displayed red led lights indicating that the alarm is activated. The red lights no longer remained illuminated after 15 seconds when the alarm stopped sounding. On 04/20/2021, at 4:10 PM, the Administrator was called to observe the exit door alarm at which time surveyor opened the door with no mechanical resistance. The alarm immediately sounded and reset itself without intervention from facility staff. The door was examined and appeared to have the latch hardware removed and the panic bar disabled thus making it possible to open the door from the inside or the outside without any physical resistance. At 4:12 PM the Administrator stated that his understanding was that the door could not be opened from the outside and that the alarm had to be reset via a code entry by staff. He was not aware of the keypad re-setting itself or the absence of the latch hardware. He stated that the 1st floor dining room has not been in use since the outbreak of Covid in March 2020, however, stated the 1st floor was accessible to residents for the purpose of visiting the bakery or attending rehabilitation sessions. On 04/20/21, at 4:15 PM, the door alarm was triggered again in the presence of the Administrator to confirm that the alarm and door were not functioning properly. The alarm reset itself within 15 seconds of triggering without intervention from staff and the door opened without any mechanical resistance. On 04/20/21 at 4:40 PM, two maintenance workers entered the dining room and examined the door. Maintenance Worker # 1 and # 2 stated that they did not know how the alarm should function regarding resetting itself without staff intervention. They both were unaware of who removed the latch hardware or disabled the panic bar. On 04/20/2021, at 5:30 PM, an outside vendor (electrical contractor) was called to assess the door alarm. A review of the contractor's invoice documented that he was unable to reprogram the door alarm and would have to order a replacement to make proper adjustments. He documented that the room would have to be on staff access only until proper repair can take place. On 04/20/2021, at 5:35 PM, the Administrator stated that a new alarm keypad/alarm hardware was on order and that the facility would ensure that the room would remain locked and secured, with door closed until the device was repaired. A letter dated 4/20/2021 was provided by the Administrator to the surveyor which documented the 1st floor dining room will remain locked and residents will not have access to this room. A copy of the Door Lock Test Log for the period of January 2021-April 2021 was reviewed. The log indicated that daily checks of the Dining Room were completed. On 04/21/2021, at 08:15 AM, the 1st floor dining room door was observed to be open and unsecured upon arrival by a surveyor. No staff were observed in the local vicinity supervising the room. The Director of Engineering was interviewed on 04/21/2021 at 11:00 AM. He stated that he checks the different areas, including the 1st floor dining room daily and documents his findings in the log- book. He stated that the door hardware was likely removed because staff were getting locked out when going onto the patio but could not recall by whom or when it was removed. He was not aware that the alarm was resetting itself after 15 seconds. He stated that the alarm should require staff intervention to reset. A locksmith was observed on 4/21/2021, at 1:00 PM to remove a defective panic bar and install a new device. The surveyor observed a new panic bar and latch hardware. The alarm keypad/alarm was not repaired. The Director of Recreation was interviewed on 4/21/2021, at 4:30 PM and stated that residents of both the 2nd and 3rd floor were permitted to go to the first floor, except the residents who were on contact and droplet precautions. The Director of Recreation stated that it was common for residents to come to the 1st floor bakery and request snacks and beverages. She further stated that residents of the 3rd floor did have access to the first floor, via the elevator, up until 4/18/2021, at which time the unit was placed on contact and droplet precautions. On 4/22/2021, at 3:00 PM, the Director of Nursing Services confirmed that the residents on the third floor were not on droplet/contact precautions until 4/18/21 as identified by the Recreation Director. 415.12(h)(1)

Based on observation, record review, and staff interviews during the Recertification Survey, the facility did not ensure that each residents' drug regimen was free from unnecessary medication. This was identified for one (Resident #63) of 5 residents reviewed for unnecessary medications. Specifically, Resident #63 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The finding is: Resident #63 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Significant change Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) Score as 6, which indicated severe cognitive impairment. The resident had no behavior problems and required extensive assistance of one to two staff members for all activities of daily living. The resident received Antipsychotic and Antidepressant medications during seven of seven assessment days. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The Physician Desk Reference documented a Boxed Warning: Phenothiazine- Antipsychotic are not approved for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #63 was observed in bed on 4/16/2021 at 11:49 AM. The resident was awake and responsive. No behaviors were observed A Second observation was made on 4/19/2021 at 3:05 PM. Resident #63 was observed sitting in a wheelchair in the resident's room. No behaviors were identified. A Comprehensive Care Plan (CCP) for Cognition dated 11/6/2019 documented the resident had cognitive loss and Dementia. The resident had a BIMS Score of 8 (moderately impaired cognitive status), difficulty making decisions, and was disoriented to time and situation. A CCP dated 8/14/2018 for [CONDITION(S)] Drug use related to Major Depressive Disorder as evidence by altered mood state (Depression/Anxiety/Mania) documented the resident was on Antipsychotic medications as Adjunct treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] An Interdisciplinary Team Conference Note dated 3/4/2021 documented the resident is pleasant, cooperates but is withdrawn, and remains on medication for Depression. The resident interacts with staff, relates well with roommate, and selectively participates in activities. The resident has no behavior issues but does have episodes of restlessness. Social worker visits for support, monitors mood and behavior, reviews Advance Directives and remains available for issues or concerns. A Psychiatry Consult dated 4/2/2020 documented the resident was seen for regular scheduled follow up visit and current medication was [MEDICATION(S)] 20 mg by mouth daily. The resident was delusional with poor judgement. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Progress note dated 4/2/2020 at 3:02 PM documented the resident was seen on rounds by the Psychiatrist and new orders to start [MEDICATION(S)] 1 mg every 12 hours. A Progress note dated 4/2/2020 at 4:03 PM documented the resident was seen on rounds by the attending Psychiatrist and recommended to start [MEDICATION(S)] 1mg twice daily for Moderate Depression. The Attending Physician was made aware and in agreement with the recommendations. A review of the nurse's notes dated 3/26/2020 to 4/2/2020 was conducted and there was no documented evidence of behaviors except the nursing progress note dated 3/30/2020 when the resident refused a shower. The staff offered a bed bath and the resident agreed. A Psychiatry Consult dated 5/21/2020 documented the resident was depressed, sad, very fearful, needed a lift to get out of bed. Current medication: [MEDICATION(S)] 20 mg daily and [MEDICATION(S)] 1 mg twice daily. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Recommendations was made to increase [MEDICATION(S)] to 2 mg twice daily. A Progress note dated 5/21/2020 documented the resident was seen by phone visit with Psychiatrist who is aware of the resident's fearful behavior. The resident voiced the same to the Physician who recommended to increase [MEDICATION(S)] to 2 mg twice daily from 1 mg. The Progress notes dated 5/21/2020 to 5/28/2020 documented increase [MEDICATION(S)] was in progress due to Depression with no adverse reaction. A Progress note dated 5/28/2020 at 5:04 PM documented the resident was seen by Psychiatrist on rounds today on the 7:00 AM-3:00 PM shift and ordered to discontinue [MEDICATION(S)] 2mg and to give [MEDICATION(S)] 1 mg twice daily. A Progress note dated 5/29/2020 at 1:25 PM documented the resident was followed up by the Psychiatrist on 5/28/2020 and the resident was noted with Extrapyramidal Symptom (EPS) with the increased [MEDICATION(S)] 2 mg dose. Recommendation to resume 1 mg twice daily A Pharmacy recommendation dated 6/15/2020 at 4:21 PM recommended to taper [MEDICATION(S)] ([MEDICATION(S)]) then discontinue and indicate use for Depression. The recommendation was denied by the Physician due to behavioral symptoms. A Psychiatry Evaluation dated 6/18/20 documented the resident wants to leave the unit with the roommate and was even more confused than previously and was more depressed. The current medications were [MEDICATION(S)] 20 mg daily and [MEDICATION(S)] 1 mg twice daily. A Progress note dated 6/18/2020 documented the resident had a facetime follow-up with the Psychiatrist due to anxiety, accusatory behavior, and elopement attempts. The resident was to start [MEDICATION(S)] at 5:00 PM. The day shift Certified Nursing Assistant (CNA) was interviewed on 4/20/21 at 2:54 PM and stated that she has cared for the resident for the past three years. The CNA stated that the resident is confused and voiced she was afraid today. The CNA stated during care that the resident was not combative and that she has never seen the resident being combative with the roommate. The CNA stated the resident does not have a happy personality and was not tearful. The CNA stated occasionally the resident tries to leave the unit but does not seek out exit doors. The CNA further that stated for the past several months the resident has not tried to get on the elevator. The 7:00 AM-3:00 PM shift Licensed Practical Nurse (LPN) was interviewed on 4/20/21 at 3:08 PM and stated the LPN has cared for the resident for years. The LPN stated the resident is cooperative and was not combative with staff or other residents. The LPN stated that the resident was started on the Psychotic medication because she was more depressed. The LPN stated that the resident was not coming out of the resident's room as much and had a decrease in appetite. The LPN further stated that the resident was usually pleasant and cooperative. The 3:00 PM - 11:00 PM shift LPN was interviewed on 4/20/21 at 3:36 PM and stated that they have cared for the resident for about a year and a half. The LPN stated normally the resident is docile and very quiet, and that sometimes the resident would ask staff to talk to the resident. The LPN stated after talking and reassurance the resident was okay. The LPN stated the resident was not confrontational and did not have altercations with the roommate. The LPN stated that the resident never exhibits any aggressive behavior during care and staff did not report any resident behaviors to the LPN. The LPN stated that the resident is very fearful at times and always ask if staff was mad at the resident. The 3:00 PM - 11:00 PM CNA was interviewed on 4/20/21 at 3:58 PM and stated when the regularly assigned CNA was not working then she was assigned to care for the resident. The CNA stated the resident was on the quiet side, mostly stays in the room and would propel the wheelchair around the room. The CNA further stated that the resident was not combative with care. The 3:00 PM-11:00 PM Registered Nurse (RN) Supervisor was interviewed on 4/20/21 at 4:07 PM and stated she was familiar with the resident. The resident was very calm. The RN stated the resident would ask the staff if they were mad at the resident and that after the staff reassurance the resident would be okay. The RN stated that there were no reports of combative behavior regarding the resident. The resident's Physician was interviewed on 4/22/21 at 2:00 PM. The physician stated that he does not start residents on [CONDITION(S)] medications, and that he defers the start of all Antipsychotic medications and the evaluation of the medication to the Psychiatrist, who are the experts. The Physician stated when the resident developed EPS from the use of [MEDICATION(S)], that the medication was discontinued. The Physician stated that he respects recommendations made by the consultant Psychiatrist and that the Psychiatrist would be the person to answer questions regarding the use of the Antipsychotic medication. The Physician stated that at the time of the Pharmacy recommendation he did not feel the resident was ready for a reduction as the resident was upset and crying all the time. An attempt was made to interview the current Psychiatrist on 4/22/21 at 1:59 PM, no response, unable to leave message as the mailbox was full. The Director of Nursing Services (DNS) was interviewed on 4/22/2021 at 4:39 PM and stated that the resident did not have a Psychotic diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The DNS further stated that non-pharmacological interventions should be attempted prior to the start of an Antipsychotic medication. The DNS further stated that behaviors that warranted the start of the medication should be documented. 415.12(l)(1)

Based on record review, observation, and interviews during the COVID-19 Focused Infection Control Survey conducted on 10/7/20, the facility did not establish and maintain 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. Specifically, the facility did not ensure all staff and visitors were adequately screened for respiratory-related symptoms and illness upon entrance to the facility (Community Liaison #1). The findings are: The Executive Order 202.11 dated 3/27/20 documented the following: Any guidance issued by the New York State Department of Health-related to prevention and infection control of COVID-19 shall be effective immediately and shall supersede any prior conflicting guidance issued by the New York State Department of Health and any guidance issued by any local board of health, any local department of health, or any other political subdivision of the State related to the same subject. The Health Advisory from New York State Department of Health (NYSDOH) Bureau of Healthcare-Associated Infections (BHAI) Memorandum dated March 13, 2020, to all Nursing Homes and Adult care Facilities, provided: Immediately implement health checks for all HCP and other facility staff at the beginning of each shift. HCP and other facility staff with symptoms or with a temperature greater than or equal to 100.0 F should be sent home, and HCP and other facility staff who develop symptoms or fever while in the facility should immediately go home. Any permissible visitors shall be checked as if they are the staff. The Centers for Medicare & Medicaid Services (CMS) memo (Ref: QSO-20-14-NH) titled Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in Nursing Homes (REVISED) dated 3/13/20, documented guidance to facilities to implement active screening of residents and staff for fever and respiratory symptoms; to screen all staff at the beginning of their shift for fever and respiratory symptoms; and to actively take their temperature and document absence of shortness of breath, new or change in cough, and sore throat. The facility policy on COVID-19 Virus Screening of employees/visitors and restrictions dated 3/14/20 documented that it is the policy of the facility to screen all individuals who enter the facility for potential illness before the start of each shift to limit the transmission of COVID-19. Individuals with symptoms following our screening process and or with a temperature of 100.0 F or greater will be sent home. All staff before the start of their shift will have temperature taken before beginning work on patient care areas. During an interview with Screener #1 (Front desk receptionist) on 10/6/20 at 11:08 AM, Screener #1 stated that she screens people that come through the front door for COVID-19 by taking their temperatures and filling out a questionnaire. Screener #1 stated that an abnormal temperature was 99 or higher. Screener #1 stated that if there was an employee with an abnormal temperature or they answered 'Yes' to any of the questions on the screening sheet, she would send them up to the nurse on the second floor. During an interview with Screener #2 (Housekeeping Supervisor) on 10/6/20 at 11:49 AM, Screener #2 stated that he stands at the back entrance from 6 am-9 am, takes the employee's temperature, and has them fill out a screen form. He stated that he thought an abnormal temperature was 101 or higher. Screener #2 stated that if there was an employee with an abnormal temperature or they answered 'Yes' to any of the questions on the screening sheet, he would send them to the nurse on the second floor. Screener #2 stated that no one screens the employees after 9 AM and that there could be employees who enter after 9:00 AM without being screened. On 10/6/20 at 1:15 PM, Community Liaison #1 was observed walking through the back door of the building without being screened. The Community Liaison proceeded to walk into the Recreation Department office. During an interview with Community Liaison #1 on 10/6/20 at 1:18 PM, she stated that she was a Community Liaison for this facility and another facility next door. The Community Liaison stated that she just came over to speak with another employee and to drop some stuff off. She stated that she didn't think it was necessary to be screened because she was coming for only a little bit to quickly speak with the other employee and drop something off. There was no documented evidence that Screener #1 or #2 were trained to screen staff and visitors upon entrance to the facility. There was no policy or procedure for training or in-services. The Infection Control Preventionist (ICP) was interviewed on 10/6/20 at 3:47 PM. The ICP stated that the nursing supervisor is responsible to send an employee home if they have a temperature or answer yes to any of the screening questions. The ICP stated that the Registered Nurse supervisor is supposed to go downstairs to the lobby on the first floor because the facility should not have symptomatic staff members in resident areas. Housekeeper #1 was interviewed on 10/6/20 at 4:21 PM. Housekeeper #1 stated that he works the 4 PM-12 AM shift. He stated he came in using the facility's back entrance. Housekeeper #1 stated a nurse is usually checking the temperature but is not present today. He stated he checked his temperature and answered the questionnaire. The Director of Nursing Services (DNS) was interviewed on 10/6/20 at 4:37 PM. The DNS stated that the front desk receptionist, nursing coordinator, and housekeeping supervisor are screeners for the employees at the front and back entrances. All employees are expected to do undergo screenings at the back entrance, and if the RN Supervisor needs to do a further assessment, the RN Supervisor is expected to go downstairs to the area where the employee entered. The screeners should know what temperatures are considered a fever and they were expected to be trained on screening by the in-service coordinator. When there are no screeners available to screen employees, the employees screen themselves. The employees are expected to consult their supervisor if they answer yes to any of the questions. The DNS stated that no one is checking the self-reported screening logs to ensure that none of the employee's answer yes or documents a temperature within a febrile range (temperature above 100.0 F). The DNS stated that the employees should not enter the facility without any screening completed. Community Liaison #1 should not have proceeded to the recreation office to interact with the staff members without being screened because of potential exposure concerns. 10NYCRR 415.19(a)(1)

Based on interview and record review, during a Focus Infection Control Survey conducted on 10/6/2020 through 10/7/2020, the facility failed to take action to prevent the transmission of COVID-19 based on parameters set forth for Outbreak Testing frequency. Specifically, the facility did not test every resident in the facility every 3-7 days for 14 days, upon identification of Certified Nursing Assistant (CNA) #1's positive test. The finding is: Center for Medicare and Medicaid Services (CMSQSO-20-38-NH, dated 8/26/2020, titled Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy, and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements and Revised COVID-19 Focused Survey Tool, documented: For outbreak testing, all staff and residents should be tested and all staff and residents that tested negative should be retested every 3 to 7 days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result. The undated facility COVID-19 Testing policy and procedure documented that an outbreak is defined as a new COVID-19 infection in a staff member or any nursing home onset of COVID-19 infection in a resident. The facility will test all residents and staff in the event of a new positive COVID-19 infection in the facility. For outbreak testing, all staff and residents should be tested , and all staff and residents that tested negative should be retested every 3 to 7 days until testing identifies no new positive cases of COVID-19 infection among staff or residents for at least 14 days since the most recent positive result. The laboratory clinical report dated 9/24/20 documented that CNA #1 had a nasopharynx COVID-19 test on 9/23/20 and the result was positive. The facility COVID-19 testing log dated 10/7/20 documented, one resident was tested on [DATE], 7 residents tested on [DATE], 43 residents were tested on [DATE], and 46 residents were tested on [DATE] out of a census of 97 residents. There were no other dates of mass testing documented on the log. During an interview with the Administrator on 10/6/20 at 5:58 PM, the Administrator stated that the facility did not do testing every 3-7 days as per the federal regulation for outbreak testing. He stated that the facility only tested the residents on 9/28/20 and did not do repeated testing. He stated that the facility did not continue testing because CNA #1 had no patient contact and was assigned to work in the lobby area. During an interview on 10/7/20 with the Infection Control Preventionist (ICP) at 11:31 AM, the ICP stated that the facility policy for outbreak testing calls for testing every 3-7 days for 14 days. The ICP stated that all residents were tested on [DATE] in response to CNA #1's positive result. She stated that she was not sure why the tests were not repeated 3-7 days after 9/28/20. The ICP stated that the Director of Nursing or the Administrator determines how often to test all the residents. During an interview with the Director of Nursing Services (DNS) on 10/7/20 at 12:35 PM, the DNS stated that the facility only did one test for all residents on 9/28/20 in response to CNA #1's positive result. The DNS stated that the facility would do repeated testing for those who were symptomatic or had direct exposure to a positive staff member. She stated that the testing regulation mandated testing once a week during the 14 days of isolation. 415.19(a)(1),(3)

Based on interviews, and record reviews during an abbreviated survey on 8/5/20 through 8/6/20 (Complaint number NY 781) the facility did not immediately consult with the resident's physician when there was a significant change in the resident's physical condition for 1 (Resident #1) of 3 residents reviewed. Specifically, on 3/8/20 Resident #1 complained of severe pain (10/10 on the numerical scale) to the right ankle, an X-ray on 3/9/20 indicating [MEDICAL CONDITION] tibia and fibula. Qualified medical personnel, Physician/Nurse Practitioner/Physician Assistant was not notified of Resident #1's complaint of pain, or the x-ray results until 3/10/20. The findings were: The facility's policy titled Notification of Physician for Change in Resident Status dated April 2020 documented to notify a physician when a resident displays a change in status including fall/trauma, abnormal laboratory values, and pain not alleviated by existing and prescribed medication. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-an assessment tool) dated 1/31/20 documented the resident had intact cognition. The resident required extensive assistance of 2 persons for transfer and did not walk. The Comprehensive Care Plan (CCP) dated 7/22/19 documented potential for alteration in comfort evidence by verbalization of pain and non-verbal sounds. Interventions included observing for signs and symptoms of verbal complaints of pain, facial grimacing, or moaning, monitor the effectiveness of the medication. The Nursing Progress Notes (NPN) dated 3/8/20 at 7:41 PM by Registered Nurse Supervisor (RNS) #1 documented resident complained of right ankle pain that she believed was sustained status [REDACTED]. The ankle was tender to touch, and the resident cringed when moved. The pain level was 10/10. Tylenol (pain medication) 650 mg was given with a positive effect. The physician (MD) was made aware through the communication book for possible right ankle x-ray. The MD communication book lacked documented evidence of note related to Resident #1's complaint of pain dated 3/8/20. A telephone order was written by RNS #1 dated 3/9/20 at 7:41 PM for an x-ray of the right ankle. The x-ray result dated 3/9/20 documented non-displaced [MEDICATION NAME] tibia and fibula with Osteopenia (decrease in bone mass). The result was conveyed to the RNS at 9:19 PM. The NPN and the physician (MD) communication book dated 3/9/20 documented x-ray for Resident #1 showed right lower ankle fracture, MD to be notified. Resident requesting stronger medications for pain. The medical record lacked documented evidence that the MD was notified of the x-ray results on 3/9/20. The Medical Progress Notes (MPN) dated 3/10/20 at 10:17 AM documented the x-ray showed right ankle fracture, moderate pain with minimal response to Tylenol (per patient). Fracture likely pathological. The NPN dated 3/10/20 at 1:20 PM documented the resident continued with complaints of pain 10/10. PMD was notified. Orders obtained to send to ER for evaluation of the right ankle. The resident was admitted at 11:30 PM. On 3/16/20 the resident was readmitted to the facility with a cast to the right foot. The 3:00 PM- 11:00 PM RNS #1 was interviewed via phone on 8/6/20 at 12:11 PM and 8/11/20 at 1:01 PM. RNS #1 stated on 3/8/20 the resident reported that somebody (staff) moved her wrongly on prior shift and she had pain on her leg. The resident did not allow the RNS to touch or move the leg. RNS #1 thought the leg was broken. RNS #1 left a note in the physician's communication book but did not call the physician. On 3/9/20 the x-ray results came back with the fracture. RNS #1 did not notify the physician of the x-ray results. RNS #1 stated he was supposed to call the physician but did not because he knew the physician did not like to be called and wanted all concerns written in the communication book. The PMD/Medical Director was interviewed via phone on 8/6/20 at 3:20 PM and stated he was not aware of Resident #1's complaint of pain or the right ankle fracture until 3/10/20. The PMD stated that RNS #1 decided to give the pain medication to the resident. The PMD stated that he expected to be notified of the x-ray results and the unrelieved pain however, the PMD was not called. The DNS was interviewed on 8/6/20 at 3:58 PM and she stated RNS #1 assessed the resident, but he did not call the MD for the pain. RNS #1 should have called the MD for x-ray orders and pain medications because the resident had a change in condition. 10 NYCRR 415.3(e)(2)(ii)(b)

Based on record review and interviews during an abbreviated survey on 8/5/20 through 8/6/20 (NY 781), the facility did not ensure that a resident received the necessary care and services to maintain the highest practicable well-being promptly for 1 (Resident #1) of 3 residents reviewed. Specifically, Resident #1 complained of right ankle pain on 3/8/20 with a pain level of 10/10 (severe) on a numeric scale. X-ray results on 3/9/20 indicated Tibia and Fibula fracture, and the resident continued to complain of intermittent pain. The Physician was not notified of the resident's complaint of pain or the results of the x-rays until 3/10/20. The findings were: The facility's policy titled pain management dated 2/2011 documented the licensed staff should assess the nature, onset, frequency, location intensity of pain. The 0-10 numeric pain scale must be utilized when defining the intensity of pain. 0 - no pain, 1-3 mild pain, 4-6 moderate pain, 7-9 severe pain, and 10 worst pain. The facility's policy titled Notification of Physician for Change in Resident Status dated April 2020 documented to notify a physician when a resident displays a change in status including fall/trauma, abnormal laboratory values, and pain not alleviated by existing and prescribed medication. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-an assessment tool) dated 1/31/20 documented the resident's cognitive status as intact. The resident required extensive assistance of 2 persons for transfer and was non ambulatory. The resident reported moderate pain occasionally. The Comprehensive Care Plan (CCP) titled Potential for alteration in comfort as evidence by verbal and non-verbal signs of pain such as crying, moaning, or groaning. The interventions included observing for signs and symptoms of pain and to monitor for effectiveness of the medication. The physician's orders [REDACTED]. The Medication Administration Record [REDACTED]. Upon reassessment, the resident continued to have moderate pain 5/10 on the numeric scale. The Nursing Progress Notes (NPN) dated 3/8/20 at 7:41 PM by Registered Nurse Supervisor (RNS) #1 documented the resident complained of right ankle pain that she believed was sustained status [REDACTED]. The ankle was tender to touch and the resident cringed when moved. The pain level was 10/10 on the number scale. Tylenol 650 mg was given with a positive effect. The physician (MD) was made aware in the communication book for possible right ankle x-ray. The physician communication book lacked documented evidence of note related to Resident #1's complaint of pain on 3/8/2020. The MAR indicated [REDACTED]. The NPN dated 3/9/20 at 2:21 PM by Licensed Practical Nurse (LPN) #2 documented the resident transported to [MEDICAL TREATMENT] at 10 AM and is expected to return by 5 PM. The right ankle was sensitive to touch, no redness or [MEDICAL CONDITION] was noted. The Physician's telephone orders (PO) dated 3/9/20 entered by RNS #1 at 7:41 PM documented x-ray of the right ankle. The x-ray result dated 3/9/20, documented a [MEDICAL CONDITION] Tibia and Fibula with Osteopenia (bone loss). The result was conveyed to RNS #1 at 9:19 PM. The NPN dated 3/9/20 at 10:15 PM by RNS #1 documented x-ray results of the right lower ankle positive for fracture, MD (physician) to be notified. Resident #1 requesting stronger medications for pain. The NPN dated 3/9/20 at 10:21 PM by LPN #1 documented the resident returned from [MEDICAL TREATMENT] at 4:45 PM, complained of pain 10/10 to the right ankle. Tylenol 650 mg given with no effect. The NPN lacked documented evidence of a note from the 11-7 shift. The MD communication book dated 3/9/20 documented the resident with a positive fracture to the right ankle. X-ray results. Requesting for stronger medication for the patient. The MAR indicated [REDACTED]. The Medical Progress Notes (MPN) dated 3/10/20 at 10:17 AM documented the x-ray showed right ankle fracture, moderate pain with minimal response to Tylenol (as per patient). The resident was alert. Pain scale of 1-2/5 pain scale noted minimal soft tissue swelling, right ankle without discoloration. Fracture likely pathological. Added [MEDICATION NAME] as needed. Repeat x-ray in 4 weeks, non-weight-bearing, immobilization. Elective ortho appointment when available. The facility investigation summary dated 3/10/20 documented on 3/8/20 the resident reported injuring the right ankle during transfer to the 3-11 shift RNS (#1) and was experiencing pain. RNS #1 assessed the resident. The MD was notified, an x-ray was done and was positive for [MEDICAL CONDITION] tibia and fibula. There was no evidence of abuse, neglect, or deliberate mistreatment. The 7:00 AM-3:00 PM CNA #2 was interviewed on 8/5/20 at 3:01 PM and she stated the Resident was on her assignment on 3/9/20. The resident refused to lift the leg when CNA #2 was dressing the resident because the leg was hurting too much. CNA #1 informed LPN #2 who went and looked at it and informed the RNS. The 7:00 AM - 3:00 PM LPN #2 was interviewed on 8/5/20 at 4:35 PM and stated on 3/9/20 she checked Resident #1 before [MEDICAL TREATMENT], the resident had no pain. LPN #2 stated she did not recall communication with CNA #2 related to Resident #1's complaint of pain. The 11:00 PM- 7:00 AM CNA #1 was interviewed via phone on 8/6/20 at 10:02 AM and stated she worked 7-3 shift on 3/8/20 and was assigned to Resident #1. CNA #1 transferred Resident #1 from bed to chair by herself. CNA #1 stated there was no incident and the resident did not hurt herself. The resident did not complain of pain. On 3/9/20 she was again assigned to Resident #1. CNA #1 stated that Resident #1 was sleeping and did not complain of pain. The 3:00 PM- 11:00 PM RNS #1 was interviewed via phone on 8/6/20 at 12:11 PM and 8/11/20 at 1:01 PM. On 3/8/20 Resident #1 reported pain to the right leg after a staff (don't recall who) moved her the wrong way. The resident did not allow RNS #1 to touch or move the leg. RNS #1 thought the leg was broken, however, there was no swelling. RNS #1 did not call the MD and wrote a note in the communication book regarding the resident's complaint of pain and the need for an x-ray of the ankle. RNS #1 stated he did not call the PMD because the MD had previously instructed RNS #1 not to call him. RNS #1 stated that LPN #1 did not tell him that the pain was not relieved with Tylenol. RNS #1 stated he knew that Resident #1's X-ray results showed fractures. RNS #1 stated he did not call the PMD to notify him of the results, he wrote the results in the PMD communication book. The PMD/Medical Director was interviewed via phone on 8/6/20 at 3:20 PM and stated he was not aware of Resident #1's complaint of pain or the right ankle fracture until 3/10/20. The PMD stated that RNS #1 decided to give the pain medication to the resident. The PMD stated that he expected to be notified of the x-ray results and the unrelieved pain however, the PMD was not called. The DNS was interviewed on 8/6/20 at 3:58 PM and she stated RNS #1 assessed the resident, but he did not call the MD for the pain. RNS #1 should have called the MD for x-ray orders and pain medications because the resident had a change in condition. 415.12

Based on interview and record review, during the COVID-19 Focused Infection Control Survey (Complaint # NY 364) the facility did not ensure that 1 (Resident #3) of 3 resident representatives was immediately notified of a significant change in the resident's physical condition. Specifically, Resident #3's Health Care Proxy (HCP) was not notified that Resident #3 was tested for COVID-19 due to symptoms on 4/24/20 and was diagnosed with [REDACTED]. The finding is: The facility Notification of Significant Changes in Resident's Medical Status policy dated 8/2019 documented that the facility shall consult with the resident, if competent, and notify the designated representative of any significant changes in the resident's condition and/or status. Significant changes include a need to alter treatment significantly and deterioration in health status. Resident #3 was admitted to the facility with the [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #3 had a Brief Interview for Mental Status (BIMS) Score of 4, indicating severely impaired cognition. The physician's orders [REDACTED]. The physician's orders [REDACTED]. The physician's orders [REDACTED]. The Physician's Note dated 4/24/20 at 10:53 AM documented Resident #3 was in bed with fever and prescribed Tylenol (fever reducer medication), Isolation Precautions, and Monitoring for temperature, cough, shortness of breath and lethargy. The Nursing Progress Note dated 4/25/2020 at 6:13 AM. The Registered Nurse (RN) Supervisor #1 documented that she performed the COVID-19 nasal test and would continue to monitor Resident #1. The Nursing Progress Note dated 4/27/20 at 1:15 AM documented that Resident #3 was positive COVID-19. The Nursing Progress Note dated 4/27/2020 at 11:01 AM documented that the Unit Manager received the Nurse Practitioner's orders for positive COVID-19 Status which included Tylenol 650 milligrams (mg), every 6 hours for 3 days, [MEDICATION NAME] (antibiotics) 250mg twice a day for 4 days, and continued the Isolation Precautions. The Nursing Progress Note dated 4/30/20 at 6:34 PM documented that RN Supervisor #2 spoke with Resident #3's Representative and notified that the physician ordered intravenous (IV) fluid and IV antibiotics. The family member (HCP) for Resident #3 was interviewed on 5/8/20 at 9:47 AM and stated that the HCP was never informed that Resident #3 was sick, tested for COVID-19, and confirmed positive COVID-19 on 4/27/20. On 4/30/20, the family member received a phone call from the Suffolk County Department of Health and was informed that Resident #3 was positive COVID19. The family member then called the facility and spoke with Unit Manager #1 who informed her that the family member was on the list to be called on 4/27/20 but Unit Manager #1 did not get a chance to make the call. Unit Manager #1 was interviewed on 5/8/20 at 10:38 AM. Unit Manager #1 stated that if a resident is sick, tested for COVID-19, and confirmed positive COVID-19, the next of kin is called by a nurse on the same day. She stated that she generates a list of calls to make when a change of status occurs and thinks she told the Wellness nurse to make the call for Resident #3 on 4/27/20. She stated that the call should be documented in the Nursing progress notes. RN Supervisor #2 was interviewed on 5/8/20 at 12:30 PM. RN Supervisor #2 stated that she received a call from Resident #3's HCP on 4/30/20. She stated that Resident #3's HCP was upset that she got a call from the Department of Health stating that Resident #3 was positive COVID-19. She confirmed Resident #3 was positive COVID-19 and updated the HCP on the medications that were being administered. She stated that same day notifications are expected when residents have a new infection, require IV fluids and antibiotics. The Wellness Nurse was interviewed on 5/8/20 at 1:29 PM. The Wellness Nurse stated that Unit Manager #1 did not instruct her to reach out to Resident # 3's HCP on 4/27/20. The Director of Nursing Services (DNS) was interviewed on 5/8/20 at 2:53 PM. The DNS stated that any change in the resident condition has to be communicated with the designated representatives of the affected residents. She stated that it was the Unit Manager's responsibility to contact the HCP. 415.3(e)(2)(ii)(b)

Based on interview and record review during the COVID-19 Focused Infection Control Survey (Complaint # NY 364), the facility did not ensure that it was in compliance with all applicable Federal, State, and local laws, regulations, and codes. Specifically, the facility did not comply with New York State Executive Order (EO) 202.18, and ensure that residents' family members and their next of kin were notified of either a single confirmed infection of COVID-19 or COVID-19 death within 24 hours from the date of occurrence for three of three residents reviewed The findings are: The Executive Order #202.18 dated [DATE] documented the following: Any skilled nursing facility, nursing home, or adult care facility licensed and regulated by the Commissioner of Health shall notify family members or next of kin if any resident tests positive for COVID-19, or if any resident suffers a COVID-19 related death, within 24 hours of such positive test result or death. The family notification policy dated [DATE] documented that the facility will notify residents and the residents family members or next of kin for all residents if any resident tests positive for COVID-19, or if any resident suffers a COVID-19 related death, within 24 hours of such positive test or death, if that resident/family member/next of kin chooses to be notified via telephone call or email. Information related to communication is shown on the facility website. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #1 had a Brief Interview for Mental Status (BIMS) Score of 2 indicating severely impaired cognition. Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #2 had a Brief Interview for Mental Status (BIMS) Score of 14 indicating intact cognition. Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #3 had a Brief Interview for Mental Status (BIMS) Score of 4 indicating severely impaired cognition. There was no documented evidence of communication regarding facility COVID-19 updates to the representatives of Resident #1, Resident #2, and Resident #3 from [DATE]-[DATE]. The facility website entitled Family Communication Letter documented the facility does not want to add to the insurmountable stress loved ones are already under. The facility goal is to communicate effectively within the boundaries of the requirements while maintaining our resident's right to privacy and allowing you to make the choice of the information you receive. We will provide the necessary information that satisfies the Department of Health (DOH) communication as well as your desire for this information, should you want to hear it. An untitled log documented Residents Notified and Family Notified of positive COVID-19 case via call on [DATE], COVID-19 Death on [DATE], and COVID-19 Death on [DATE]. The document did not indicate which residents and families were notified. The document did not indicate who made the phone call. The facility COVID-19 Death listing documented 7 in-facility deaths from [DATE] to [DATE]. The facility COVID-19 New Case listing documented 39 new cases of positive COVID-19 in the facility from [DATE] to [DATE]. The Family Member for Resident #1 was interviewed on [DATE] at 2:39 PM. Resident #1's family member stated that she was never informed of any new COVID-19 cases in the facility and was not aware that it was in the facility until she was notified that her mother was tested for COVID-19 on [DATE]. The administrator did not answer her questions regarding the number of new cases or deaths in the facility. Resident #1's family member stated that she did not receive a letter from the facility in [DATE]. The family member for Resident #2 was interviewed on [DATE] at 3:05 PM. Resident #2's family member stated that the facility has not contacted him to give updates on new facility COVID-19 cases or deaths. He stated that he was not offered to opt into any regular communication regarding the facility's status with new COVID-19 cases and deaths. Resident #2's family member stated that he did not receive a letter from the facility in [DATE]. He stated that he was not aware that the facility had a website. He stated that he is interested in receiving all facility notifications. The family member for Resident #3 was interviewed on [DATE] at 9:47 AM. She stated that the facility has not contacted her regarding new cases of COVID-19 and COVID-19 related deaths in the facility. Resident #3's family member stated that she did not receive a letter from the facility in [DATE]. She stated that she called the Administrator on [DATE] to address her grievance regarding a lack of communication from the facility. She stated that the Administrator told her that he was thinking of starting an email and took her email address. She stated that she never received any emails since he noted her email address. The Wellness Nurse was interviewed on [DATE] at 1:29 PM and stated she was instructed to make phone calls on [DATE]. Any communication before [DATE] was done by the Administrator. She stated that the contact list provided to her to make the phone calls did not include all families. She stated that on [DATE] she finalized a list of family representatives who wanted to be notified. The list provided documented Resident #1's family member wanted to be contacted and Resident #2's and Resident #3's family members did not want to be contacted. She stated that she did not make the calls to the family members for Resident #2 and Resident #3. She could not account for the discrepancy. The Wellness Nurse that she did not start documenting the phone calls until [DATE]. The administrator was interviewed on [DATE] at 3:58 PM. He stated that the facility was mandated to inform residents and resident representatives of new cases of COVID-19 and COVID-19 Deaths within 24 hours. The Administrator stated that he was contacted by some families and residents who wished to not receive the information and decided to make the notifications elective for all families. He stated that the facility sent out a letter on [DATE] addressing the COVID-19 family notifications policy. Families were directed to contact himself and the Wellness Nurse regarding COVID-19 information. The Administrator stated that he also placed the letter on the website and that all families are told about the website upon admission. The administrator stated that he handed over the responsibility to notify families to the Wellness Nurse on [DATE] and he began to document calls made on the log he provided. He stated that the call log is not resident specific and does not reflect each of resident representatives who elected to be notified. He stated that there was phone outreach by his team to all the families to establish their choice in being contacted regarding COVID-19 notifications. He stated that the list of residents and representatives who elected to be notified was finalized on [DATE]. 400.2

Based on interviews and record review during an abbreviated survey (Complaint # NY 109), the facility did not ensure that one of three residents reviewed for pressure ulcers received necessary care and treatments to prevent development of new pressure ulcers and deterioration of the pressure ulcers (Resident #1). Specifically, Resident #1 was assessed with [REDACTED]. The resident's skin integrity deteriorated over a five-day period resulting in open areas, pain and crying. The change in skin condition was not promptly reported to, or assessed by, a Registered Nurse (RN), Medical Doctor (MD) or other qualified health professional, and appropriate treatment was not implemented, until a week after the skin changes were first noted. At that time skin integrity had further deteriorated and the resident was assessed with [REDACTED]. Narcotic pain medication was ordered at that time. This resulted in actual harm to Resident #1 that is not Immediate Jeopardy. The findings are: The facility policy titled Pressure Injury Management dated 11/2015 documented an evaluation shall be done to identify the resident at risk of developing a pressure injury and the resident with existing pressure injury or areas of skin that are at risk for breakdown. Any change in skin integrity requires notification of the Physician/Nurse Practitioner (NP), Wound Care Nurse (WCN), Dietician, Minimum Data Set (MDS) Coordinator, Director Nursing Services (DNS) and designated representative (if the resident lacks capacity). An appropriate, individualized care plan utilizing preventive interventions for those residents at risk for pressure injury development or present injury shall be initiated by the admitting nurse upon admission or by the WCN for any change of condition. Staff shall be alert to potential changes in skin condition and should evaluate and document identified changes. Each resident's skin integrity shall be observed by the nursing assistant with care at least daily and documented in the Certified Nursing Assistant (CNA) accountability record, any change in the skin condition shall be reported to the nurse immediately. Any change in skin condition may require immediate documentation, an order for [REDACTED].>Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) dated 07/03/2018 documented that the resident had severe cognitive impairment, required extensive assistance of two persons for bed mobility, transfers and toilet use, was continent of bowel and bladder and had no unhealed pressures ulcers. The Nursing Admission assessment dated [DATE] indicated that the resident had no pressure ulcers to the buttocks. The Comprehensive Care Plan (CCP) for Skin Integrity- Potential for Alteration dated 06/27/2018 documented Resident #1 had a history of [REDACTED]. Interventions included to monitor skin for redness, [MEDICAL CONDITION], openings, rashes, bruising, blister etc. The CCP for Moisture Associated [MEDICAL CONDITION] initiated on 10/31/2018 documented moisture associated [MEDICAL CONDITION] to the right inner buttocks that resolved on 12/27/2018. Interventions were revised to include Balmex (skin protective cream) to be placed to bilateral buttocks and leave open to air every shift as a preventive. physician's orders [REDACTED]. A Braden Scale (pressure ulcer risk assessment tool) dated 12/14/2018 documented Resident #1 was at mild risk for developing pressure ulcers. The MDS of 12/24/2018 indicated that the resident required limited assistance of one person for bed mobility, transfers, toilet use, was always continent of bowel and bladder and had no unhealed pressure ulcers or other skin problems. An entry in the CCP for Pain dated 01/11/2019 documented no pain noted during quarterly care plan review. An entry in the CCP for Pain on 01/23/2019 and a Nursing Progress Note (NPN) dated 01/23/2019 3:53 PM documented Resident #1 had increased complaints of pain to his buttocks. An entry by the RN WCN in the NPN dated 01/23/2019 8:18 PM documented the WCN was called and evaluated bilateral buttocks skin impairment as per nursing request. Findings of Stage 3 bilateral upper buttocks were seen. Left buttock 5.2 centimeters (cm) x 4.0 x 0.1 cm, 20 % yellow slough (dead tissue), 20 % eschar (dead tissue), 60 % with minimal serosanguous exudate (thin liquid produced by the body in response to tissue damage), with blanchable [DIAGNOSES REDACTED] (reddening) to peri-wound (tissue surrounding wound). Right buttock 5.0 x 1.0 x 0.1 cm 30% yellow slough, 40 % eschar, 30% pink with minimal serosanguinous exudate with blanchable [DIAGNOSES REDACTED] to peri wound. Stage 3 pressure wound. The resident appeared to be in some discomfort after assessment and the PA (Physician's Assistant) was made aware and ordered [MEDICATION NAME] (narcotic pain medication) by mouth every eight hours for pain. The resident was given a dose with positive effect. There was no documented evidence that deterioration of the resident's skin condition was reported to, or assessed by, an RN, MD or other qualified health professional until 01/23/2019. The CCP for Skin Integrity- Potential for Alteration was revised on 01/23/2019 with interventions that included to notify the MD and dietician of abnormalities, low air loss alternating mattress and protective skin care. The physician's orders [REDACTED]. An undated Pressure Ulcer/Injury Investigation Report that included Wound Care Investigation Employee Statements was completed by the WCN and documented that, on 01/23/2019, the 11:00 PM - 7:00 AM shift discovered two stage 3 pressure injuries to Resident #1's left and right buttock. The facility investigation and staff statements revealed CNA #2 noted the wound was identified as closed, red and dark on 01/17/2019 and she notified Licensed Practical Nurse (LPN) #1. The wound opened on 01/21/2019. The statement by CNA #1 noted the wound got worse on 01/21/2019 and she reported it to LPN #2. The area was open and pink. Resident #1 had discomfort to the site and was crying. The investigation concluded that the pressure ulcers were unavoidable. According to the Medication Administration Record [REDACTED]. No medications to address pain were administered over that time. The Record of Corrective Warning completed by the WCN dated 01/24/2019 documented LPN #1 failed to notify the Nursing Supervisor/WCN of a change in resident's skin condition. The resident's skin had slight excoriation to the left buttocks as seen by the WCN and nurse on 01/16/2019. LPN #1 signed treatments of Balmex on 01/15/2019 -01/17/2019, 01/19/2019 - 01/22/2019 with failure to notify an RN of a change in skin condition leading to bilateral Stage 3 pressure ulcers. The WCN was interviewed on 04/05/2019 at 1:48 PM and stated Resident #1 was admitted in (MONTH) (YEAR) with no pressure ulcers to the buttocks. It was reported that his skin was impaired on 01/23/2019. The WCN stated she went to see Resident #1 and noted Stage 3 pressure ulcers to his bilateral buttocks. An investigation was started by herself on how it happened. She got statements from staff and discovered the skin impairment was reported by CNAs. She determined LPN #1 was aware of the skin impairment. It was about a week from when it was reported until the WCN stated she found out and assessed the resident's skin. LPN #1 was interviewed on 04/05/2019 at 3:00 PM. Inconsistent with facility investigation and conclusion, LPN #1 stated she knew Resident #1's skin became red in (MONTH) and she reported it to the WCN. She came in a day later and the area was a darker red and was open a little. She stated she reported it again to the WCN who said she looked at it said it didn't need any further treatment and that the WCN would do the documentation. CNA #2 was interviewed on 04/05/2019 at 3:15 PM and stated that she reported to LPN #1 around 01/17/2019 that Residents #1's wound looked like the color of her uniform (burgundy) and it looked fragile and ready to open. LPN #1 came to look at it, she wrote it down and they told someone at the nurses' station to call the WCN. CNA #1 was interviewed on 04/05/2019 at 3:30 PM and stated she worked from 7:00 AM - 11:00 PM on 01/21/2019 and it looked like Resident #1 had a skin tear on both buttocks and in the middle. CNA #1 stated she reported it to LPN #1. The Registered Nurse Manager (RNM) was interviewed on 04/05/2019 at 4:00 PM and stated he was told by the WCN that Resident #1 had a Stage 3 pressure ulcers to the bilateral buttocks on 01/23/2019. The resident had moisture areas that were red. Nothing was reported to him by the CNA or nurses about worsening of the wounds. He did not do an assessment of the resident because he was not notified of any change in the resident's skin condition. The Director of Nursing (DON) was interviewed on 04/05/2019 at 5:58 PM and she stated Resident #1's change in condition for his buttocks was never reported. The denuded (loss of epidermis) reddened area is what LPN #1 would be watching while applying the Balmex. The CNA went to LPN #1 and notified her that there was a change in the red area, in his skin. On 01/23/2019 the WCN was involved. It started out as an excoriation on 01/17/2019, every assigned nurse put Balmex on the area, however she was concerned more with LPN #1, because she was the continuous nurse on the assignment and did not report a change in the resident's skin to the RNS. The RNS should have also been notified on 01/21/2019 3-11 shift. The 3:00 PM - 11:00 PM RN Supervisor (RNS) was interviewed on 04/05/2019 at 6:00 PM and stated she was not notified of any new or worsening skin areas for Resident #1. The Nurse Practitioner (NP) was interviewed on 04/09/2019 at 12:13 PM via telephone and stated he was a wound care specialist and saw Resident #1 for the first time 1/25/2019 for left and right buttock Stage 3 pressure injuries. That was the first time it was brought to his attention. The NP stated that usually you want to put a treatment in place right away and the wound would need to be covered if the skin was open and had drainage. The NP stated that a wound can get worse overnight, over hours, it changes drastically. The Medical Director was interviewed on 04/09/2019 and stated that Balmex is not a treatment for [REDACTED]. He would expect with a change in skin condition the RN to assess the wound and appraise the attending MD, followed up by the wound care team (NP/MD). 415.12 (c) (2)

Based on record reviews and staff interviews during the recertification survey, the facility did not ensure that the attending physician documented his or her rationale in the medical record of irregularities identified by the Pharmacist in the medication regimen review. This was evident for 3 (Residents #77 # 87, and #88) of 6 residents reviewed for unnecessary medication. Specifically, 1) Resident #77 had Pharmacy Medication Regimen Reviews that identified irregularities on [MEDICATION NAME], and [MEDICATION NAME] continued use. The Physician did not have a rationale documented in the medical record on [MEDICATION NAME], and [MEDICATION NAME] continued use. 2) Resident #87 had Pharmacy Medication Regimen Reviews that identified irregularities for [MEDICATION NAME] continued use. The Physician did not have a rationale documented in the medical record for [MEDICATION NAME] continued use. 3) Resident #88 had a Pharmacy Medication Regimen Review that identified irregularities on [MEDICATION NAME] continued use. The Physician did not have a rationale documented in the medical record on [MEDICATION NAME] continued use. The findings are: 1) Resident #77 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 5 indicating the resident was severely impaired in cognition. The Pharmacy Medication Regimen Review dated 1/28/19 documented that the current dose of [MEDICATION NAME] had been prescribe for greater than 6 months. The Review recommended a Gradual Dose reduction (GDR) should be attempted since the resident exhibited no new or worsening behavioral symptoms over the last 6 months. The Physician responded No, continue current [MEDICATION NAME] order. review of the resident's medical record revealed [REDACTED]. The Pharmacy Medication Regimen Review dated 2/27/19 documented the resident was on the current [MEDICATION NAME] dose for greater than 4 months. The review documented that the resident was a candidate for GDR. It recommended that a GDR should be attempted since the resident exhibited no new or worsening behavioral symptoms over the last 6 months. The Physician responded No, continue current [MEDICATION NAME] order. review of the resident's medical record revealed [REDACTED]. The Pharmacy Medication Regimen Review dated 3/18/19 documented the resident was on the current dose of [MEDICATION NAME] for greater than 8 months. The Review recommended that GDR should be attempted. The Physician responded No, continue current [MEDICATION NAME] order. review of the resident's medical record revealed [REDACTED]. An interview with the Attending Physician was conducted on 4/9/19 at 9:45 AM. The Physician stated that a rationale should have been completed and that he will be working on responding to the review timely the next time. 2) Resident #87 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Significant Change MDS assessment dated [DATE] documented the resident's BIMS score was 5 indicating the resident was severely impaired in cognition. The resident had active [DIAGNOSES REDACTED]. The Pharmacy Medication Regimen review dated 3/17/19 documented [MEDICATION NAME] does not have a Food And Drug Administration (FDA) approved indication for generalized pain. The Physician responded No, continue [MEDICATION NAME]. review of the resident's medical record revealed [REDACTED]. An interview with the Attending Physician was conducted on 4/9/19 at 9:47 AM. The Physician stated that a rationale should have been completed and that he will be working on responding to the review timely the next time. 3) Resident #88 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Quarterly MDS assessment dated [DATE] documented the resident's BIMS score was 3 indicating the resident was severely impaired in cognition. The MDS documented the resident received 7 days of antianxiety medication during the review period. The physician's orders [REDACTED]. The Pharmacy Medication Regimen Review dated 2/27/19 documented that the resident's current [MEDICATION NAME] order was greater than 4 months with no gradual dose reduction (GDR). The Attending Physician disagreed with the Pharmacist's finding. The Physician responded No, continue [MEDICATION NAME]. review of the resident's medical record revealed [REDACTED]. An interview with the Attending Physician was conducted on 4/9/19 at 9:47 AM. The Physician stated that a rationale should have been completed and that he will be working on responding to the review timely the next time. 415.18(c)(2)

Based on observations, record reviews, and staff interviews during the recertification survey, the facility did not ensure that each resident the receives services in the facility with reasonable accommodation of the resident needs. This was evident for 2 (Residents #77 and #87) of 2 residents reviewed for accommodation of needs. Specifically, the call bell, designated for Residents #77 and #87, was observed on the floor behind the resident's beds. The call bell was not placed within the resident's reach. The findings are: 1) Resident #77 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 5 indicating the resident was severely impaired in cognition. The resident required total assistance of two persons for toileting and extensive assistance of one-person for personal hygiene. The resident had a functional limitation in range of motion of one upper extremity and both lower extremities. The resident was not on toileting program and was always incontinent of bladder. The resident was observed sleeping in bed on 4/3/19 at 9:00 AM. The resident was again observed in bed calling for help on 4/3/19 at 12:00 PM. On both occasions the resident's call bell was on the floor behind the resident's bed. The call bell had a clip that could be utilized to place the call bell within reach of the resident. The resident was interviewed on 4/3/19 at 12:00 PM and stated that he needs help. The covering CNA#2 was interviewed on 4/3/19 at 12:00 PM. He stated that the assigned CNA#1 was on break and the call bell should be clipped within the resident's reach. CNA #1 was interviewed on 4/4/19 at 9:00 AM. CNA #1 stated that she did not know that the resident's call bell was on the floor. 2) Resident #87 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Significant Change MDS assessment dated [DATE] documented the resident's BIMS score was 5 indicating the resident was severely impaired in cognition. The resident required extensive assistance of two-persons for toileting and one-person assist for personal hygiene. The resident had active [DIAGNOSES REDACTED]. The resident was observed sleeping in bed on 4/3/19 at 9:45 AM and on 4/9/19 at 7:30 AM. The resident's call bell was on the floor behind the resident's bed. The device had a clip that could be utilized to place the call bell within the resident's reach. An interview with CNA #1 was conducted on 4/9/19 at 7:34 AM. CNA #1 stated that she did not know that the call bell was on the floor. She stated that the call bell should be clipped at the resident's bedside. She also stated that the resident can activate the call bell for assistance. An interview with the Registered Nurse (RN) Charge Nurse was conducted on 4/9/19 at 8:00 AM. The RN stated that the call bell should be placed within reach of the resident. 415.5(e)(1)

Based on staff interviews and record review during an abbreviated and partial extended survey it was determined that the administration failed to ensure that each resident reached and maintained the highest practicable physical, mental and psychosocial well-being. Specifically, the administration failed to have an effective system in place to identify, communicate and supervise residents at risk for unsafe wandering/elopement; failed to train staff and ensure staff competency on resident identifiers for being at risk for elopement and reassess residents who have exhibited wandering or exit seeking behavior. The Administration failed to have a policy and procedure for the maintenance of the Roam Alert system. Additionally, the Administration failed to thoroughly investigate incidents of elopement to determine the root cause and report to officials in accordance with State law. This resulted in the potential for a pattern of serious harm that is Immediate Jeopardy. Complaint Number: NY 817 Cross References: F 225 - Failure to Report F 323 - Accidents and Supervision F 520 - Quality Assessment and Assurance The findings are: The Policy and Procedure on Identifying Residents at Risk for Elopement/Wandering dated 6/12 documented that each resident will be assessed for the potential of elopement/wandering within 24 hours of admission, quarterly, upon a significant change and/or episodic discovery. The undated Policy and Procedure on Elopement/Missing Resident (PPEMR) documented that each resident who has been assessed as a potential elopement risk will be identified by wearing a purple arm band and/or purple identification on any assistive devices as a visual aide for staff identification. The PPEMR documented that, if a resident is missing, Administration will contact the DOH (Department of Health) as necessary. A detailed Accident/Incident Report will be completed noting the investigative procedure and resolution. If the DOH has not yet been notified of the elopement and the resident has returned to the facility, they will be notified. Roam alert bracelets shall be tested weekly for proper functioning and expiration date and signed for by the DNS (Director of Nursing Services)/designee in the log book. The Roam Alert Audit Log lacked documented evidence of consistent weekly testing of the roam alerts. The Policy and Procedure on Wandering Monitoring System/Roam Alert dated 9/12 documented that residents who are identified as being at risk for wandering out of the facility will be monitored for safety utilizing the Wanderer Monitoring/Roam Alert System. There was no documented evidence of a policy and procedure for maintenance of the roam alert system. An interview was conducted with a 7:00 AM to 3:00 PM Registered Nurse Supervisor (RNS #2) on 8/18/14 at 1:08 PM. RNS #2 stated that he does not know how often elopement assessments are done but RNS #2 is assigned to check the functioning of residents' roam alerts weekly. RNS #2 then stated that he doesn't actually check the functioning of roam alerts; "I only check the placement on the resident and basically rely on the expiration date (of the roam alert) to decide the functioning. I take the expiration date for granted." An interview was conducted with the Director of Maintenance (DOM) on 8/18/14 at 2:10 PM. The DOM stated that there is no specific policy regarding checking the roam alert system but, in October 2013, he started checking the system once a month. The DOM stated that, prior to October 2013, there is no record of checking the roam alert system. The DOM further stated that the roam alert system is also checked after each elopement incident but there is no record of this. An interview was conducted with the Risk Manager (RM), who is part of the Quality Assurance team, on 8/19/14 at 9:36 AM. The RM stated that residents with roam alerts used to be allowed to sit outside and staff would bypass the roam alert alarm but this doesn't happen anymore. The RM stated that she investigated each incident involving Resident #6 leaving the facility and concluded that there was no abuse or neglect. She was unable to explain how this decision was made, stating "I don't remember." The RM further stated that, since there was no abuse or neglect, there was no reportable incident. An interview was conducted with the Director of Nursing (DON) on 8/19/14 at 11:45 AM. The DON stated that, prior to 7/16/14, Resident #6 never verbalized he wanted to leave or made any attempts to leave the facility. She then stated that, in June 2014, the resident "had gone to the deli but he never verbalized that he was going to leave so it wasn't elopement." The DON stated that this was not a reportable incident "because he (Resident #6) wanted to leave and we try to be home-like." The DON stated that there are a couple of residents with roam alerts who like to sit outside; "we'll (staff) turn off the alarm to let them out. It's their home. It's not like they're (residents) leaving." The DON further stated that there is a color code system in place for recognizing residents at risk for elopement. She started looking at the back of her identification badge and stated, "It's not here. I don't remember what it is." An interview was conducted with the Administrator on 8/19/14 at 12:30 PM. The Administrator stated that she was not the administrator at the time of any of Resident #6's elopements but she has reviewed the incidents and believes that they should have been reported to the State agency. She further stated that she is not aware of any recent Quality Assurance measures taken with regard to elopement and unsafe wandering. 415.26

Based on staff interviews and record review during an abbreviated and partial extended survey the facility failed to thoroughly investigate incidents of resident elopements and report to other officials in accordance with State Law, including to the State survey and certification agency. Specifically, one (Resident #6) of nine residents reviewed for abuse prohibition exited the facility undetected by staff on 5/18/14 and 6/22/14. Key personnel was reportedly aware but failed to fully investigate and implement interventions to protect the resident's health and safety. The facility failed to report to officials in accordance with State Law. On 7/16/14 the resident again exited the facility undetected and was missing for two hours before being found in a fetal position against a tree in the woods one mile away. The facility's failure to report and thoroughly investigate elopement incidents and to implement strategies to prevent abuse/neglect has the potential of jeopardizing the health and safety of nine residents at risk for unsafe wandering and elopement. This resulted in the potential for a pattern of serious harm that is Immediate Jeopardy and Substandard Quality of Care. Complaint Number: NY 817 Cross References: F 323 - Accidents and Supervision F 490 - Administration F 520 - Quality Assessment and Assurance The findings are: The undated Policy and Procedure on Elopement/Missing Resident (PPEMR) documented that residents will be maintained in a safe and secure manner and make every effort to identify residents who have the potential for elopement. The PPEMR documented that, if a resident is missing, Administration will contact the DOH (Department of Health) as necessary. A detailed Accident/Incident Report will be completed noting the investigative procedure and resolution. If the DOH has not yet been notified of the elopement and the resident has returned to the facility, they will be notified. The Nursing Progress Notes (NPN) dated 5/18/14 documented that Resident #6 was noted wandering outside, wheeling himself in between two buildings. The resident claimed he thought he can wheel around the area with no limitation; suggested to resident that he can go outside just in front of the building for his safety and code alert placed. There was no documented evidence of an Accident/Incident Report or investigation of Resident #6's wandering. The Wandering/Elopement Risk Assessment (WERA) dated 5/18/14 documented that Resident #6 was assessed to be at risk for wandering and not at risk for elopement. The Resident Incident/Accident Report (RIAR) dated 6/22/14 at 10:00 AM documented that Resident #6 was witnessed entering the deli. Resident escorted back to facility by staff; supervisor made aware. The Supervisor's Summary documented that roam alert and visuals were instituted; resident was seeking a snack; unavoidable incident. The investigation revealed that there is no reasonable cause to believe any resident abuse or neglect has occurred. The WERA dated 6/22/14 documented that Resident #6 was assessed to be no risk for wandering and elopement. The RIAR dated 7/16/14 (3rd elopement attempt) documented that, at 2:45 PM, Resident #6 had left the grounds of the facility unattended with the intent of going to the VA. The Supervisor's Summary documented that the resident was witnessed off grounds by off-duty staff member; staff went out to locate the resident. Police made aware. Resident returned safely; unavoidable incident. The investigation revealed no reasonable cause to believe any resident abuse or neglect has occurred. The Investigation Report dated 7/16/14 documented that Resident #6 had an unapproved out on pass. Based on investigation, the resident left the facility without informing staff. All systems were in place; staff failed to bring resident back. There is insufficient evidence to support that abuse, neglect and mistreatment has occurred. An interview was conducted with the Risk Manager (RM), who is part of the Quality Assurance team, on 8/19/14 at 9:36 AM. The RM stated that residents with roam alerts used to be allowed to sit outside and staff would bypass the roam alert alarm but this doesn't happen anymore. The RM stated that she investigated each incident involving Resident #6 leaving the facility and concluded that there was no abuse or neglect. She was unable to explain how this decision was made, stating "I don't remember." The RM further stated that, since there was no abuse or neglect, there was no reportable incident. An interview was conducted with the Director of Nursing (DON) on 8/19/14 at 11:45 AM. The DON stated that, prior to 7/16/14, Resident #6 never verbalized he wanted to leave or made any attempts to leave the facility. She then stated that, in June 2014, the resident "had gone to the deli but he never verbalized that he was going to leave so it wasn't elopement." The DON stated that this was not a reportable incident "because he (Resident #6) wanted to leave and we try to be home-like." An interview was conducted with the Administrator on 8/19/14 at 12:30 PM. The Administrator stated that she was not the administrator at the time of any of Resident #6's elopements but she has reviewed the incidents and believes that they should have been reported to the State agency. She further stated that she is not aware of any recent Quality Assurance measures taken with regard to elopement and unsafe wandering. 415.4(b)(1)(ii)

Based on observation, staff interviews and record review during an abbreviated and partial extended survey the facility failed to ensure a safe environment and to provide visual supervision and monitoring to protect the health and safety of each of nine residents reviewed for accidents and supervision. The facility failed to develop and implement an effective system to identify, communicate and supervise residents at risk for unsafe wandering and elopement. Specifically, Resident #6 exited the facility undetected by staff on three separate occasions from 5/18/14 to 7/16/14 and was on 30 minute visual checks which were not being done consistently. On 7/16/14, the resident was missing for two hours before being found sitting in a fetal position against a tree in the woods one mile away. A second resident (Resident #9) at risk for elopement was found outside the facility unattended on 8/19/14 by the State surveyor. The facility further failed to develop a policy and procedure for maintenance of the Roam Alert (a device worn by residents that sounds an alarm at exit doors) system. This resulted in no actual harm with the potential for a pattern of serious harm that is Immediate Jeopardy and Substandard Quality of Care. Complaint Number: NY 817 The findings are: The Policy and Procedure on Visual Checks dated 9/27/06 documented that the nursing staff will provide an aggressive monitoring program visually observing the residents and documenting their location. The purpose is to closely monitor residents who are at risk for accidents/incidents/occurrences. These residents are, but not limited to, residents who are at risk for elopement. The Policy and Procedure on Identifying Residents at Risk for Elopement/Wandering dated 6/12 documented that each resident will be assessed for the potential of elopement/wandering within 24 hours of admission, quarterly, upon a significant change and/or episodic discovery. The nurse will determine if the resident requires a roam alert bracelet and/or visual checks. Roam alert bracelets shall be tested weekly for proper functioning and expiration date and signed for by the DNS (Director of Nursing Services)/designee in the log book. The Roam Alert Audit Log lacked documented evidence of consistent weekly testing of the roam alerts. The undated Policy and Procedure on Elopement/Missing Resident documented that each resident who has been assessed as a potential elopement risk will be identified by wearing a purple arm band and/or purple identification on any assistive devices as a visual aide for staff identification. A purple dot will also be placed on the spine of the medical record. Photographs of those residents identified as at risk for wandering and elopement are posted at the reception area, RN (Registered Nurse) Supervisor's binder and all nursing stations. The social work department will maintain a current list and post this list at the reception desk, on both nursing stations and in the RN Supervisor's binder. The list is updated monthly and as necessary with changes. If a resident is missing the attending physician is notified. When the resident is located the attending physician/nurse practitioner will examine the resident within 24 hours if no apparent injuries are noted. The Policy and Procedure on Wandering Monitoring System/Roam Alert dated 9/12 documented that residents who are identified as being at risk for wandering out of the facility will be monitored for safety utilizing the Wanderer Monitoring/Roam Alert System. There was no documented evidence of a policy and procedure for maintenance of the roam alert system. 1) Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) (an assessment tool) dated 4/22/14 documented that Resident #6 was cognitively intact. The Wandering/Elopement Risk Admission Screen dated 4/15/14 documented that Resident #6 has no risk for wandering/elopement. The undated Morse Scale for Falls documented that Resident #6 is at high risk for falls. The Psychiatric Consultation dated 4/22/14 documented that Resident #6 has poor cognitive function; poor judgment and insight. The Nursing Progress Notes (NPN) dated 5/18/14 documented that Resident #6 was noted wandering outside, wheeling himself in between two buildings. The resident claimed he thought he can wheel around the area with no limitation; suggested to resident that he can go outside just in front of the building for his safety and code alert placed. The Comprehensive Care Plan (CCP) effective 5/18/14 documented that Resident #6 is at risk for elopement due to wandering. Interventions included roam alert and visual checks. The Wandering/Elopement Risk Assessment (WERA) dated 5/18/14 documented that Resident #6 was assessed to be at risk for wandering and not at risk for elopement. The NPN dated 6/22/14 documented that resident was noted by staff member across the street from facility at the deli. Resident redirected and escorted by staff member back to the facility. Resident reports that he wanted to get something from the deli and felt he could go and come back before anyone was aware. Resident educated for safety and instructed that he may not egress from the property unattended. Resident and staff instructed may not sit outside unattended, to remain within the facility until further notice. Resident placed on visual checks for safety. The Resident Incident/Accident Report (RIAR) dated 6/22/14 at 10:00 AM documented that Resident #6 was witnessed entering the deli. Resident escorted back to facility by staff; supervisor made aware. The Supervisor's Summary documented that roam alert and visuals were instituted; resident was seeking a snack; unavoidable incident. The investigation revealed that there is no reasonable cause to believe any resident abuse or neglect has occurred. The WERA dated 6/22/14 documented that Resident #6 was assessed to be no risk for wandering and elopement. The NPN dated 7/16/14 at 2:12 PM documented that 30 minute visual check in place; no attempt to leave facility; roam alert in place. The 30 Minute Visual Checks form dated 7/16/14 documented that the last visual check performed on Resident #6 was at 7:00 AM. The remainder of the form was blank. The Video Surveillance Timeframe dated 7/16/14 recorded Resident #6 exiting the lobby door at 2:01 PM; the resident returned escorted by police at 4:00 PM. The NPN dated 7/16/14 at 3:30 PM documented that the nurse last saw the resident at approximately 2:00 PM when he took his medications; he said he was going to the main dining room and entered the elevator. At approximately 2:30 PM this nurse called reception to send resident back up to the unit for nail care; was advised by receptionist that resident was not in the main dining room. A phone call was received by co-worker stating that she may have observed the resident walking in the street; Code 10 instituted. ADON (Assistant Director of Nursing), supervisor and MD (Medical Doctor). Presently waiting for further information as to whereabouts. The NPN dated 7/16/14 at 5:10 PM documented that body check was completed on resident status [REDACTED]. Resident denies acute distress. Resident complained of numbness to left ankle which he reports as chronic in nature from old animal bite. Resident reports he left the facility to go to the VA (Veteran's Affairs). Resident then noted to ramble on, appeared confused, speaking about past occurrences. Placed on 1:1 (one to one) observation. MD notified of resident return to facility. The RIAR dated 7/16/14 documented that, at 2:45 PM, Resident #6 had left the grounds of the facility unattended with the intent of going to the VA. The Supervisor's Summary documented that the resident was witnessed off grounds by off-duty staff member; staff went out to locate the resident. Police made aware. Resident returned safely; unavoidable incident. The investigation revealed no reasonable cause to believe any resident abuse or neglect has occurred. The Investigation Report dated 7/16/14 documented that Resident #6 had an unapproved out on pass. Based on investigation, the resident left the facility without informing staff. All systems were in place; staff failed to bring resident back. There is insufficient evidence to support that abuse, neglect and mistreatment has occurred; however, due to resident exiting the building the incident was reported to the Department of Health. The Nursing Elopement Risk Assessment (NERA) dated 7/16/14 documented that Resident #6 was assessed to be at risk for elopement as evidenced by a tendency to wander. The NPN dated 7/17/14 at 2:50 AM documented that the resident returned from the hospital alert and verbally responsive. No acute distress. The Psychiatric Consultation dated 7/21/14 documented that Resident #6 is alert but not oriented; paranoid; poor judgment and insight. Diagnosis: [REDACTED]. The Psychiatric Consultation dated 8/5/14 documented that Resident #6 has a [DIAGNOSES REDACTED]. An interview was conducted with the Receptionist on 8/15/14 at 11:30 AM. The Receptionist stated that she has a list of residents with roam alerts and a board with those residents' pictures. If a resident with a roam alert approaches the lobby door an alarm will sound and she will announce it overhead on the paging system. The Receptionist stated that, at times, there are residents who want to go outside for fresh air and she will bypass the alarm at the door in order to let the resident go out to the patio. An interview was conducted with the assigned 7:00 AM to 3:00 PM Certified Nursing Assistant (CNA #2) on 8/18/14 at 11:20 AM. CNA #2 stated she didn't know that Resident #6 was on 30 minute visual checks. CNA #2 stated that she knows the resident wears a roam alert but she never heard that Resident #6 had gone out of the facility. CNA #2 further stated that residents at risk for elopement "have some kind of dot. It might be blue. There's so many color codes I don't know what's what." An interview was conducted with the Speech Therapist (ST) on 8/18/14 at 11:34 AM. The ST stated that, on 7/16/14, she saw Resident #6 in the parking lot. She went in to the facility and asked the receptionist if she was looking for someone; the receptionist said she was, so the ST said she saw the resident in the parking lot. The ST stated that the resident had already disappeared. The ST stated that she did not know the resident was an elopement risk. The ST further stated, "Nursing does some kind of assessment (elopement) but I'm not told who's at risk for elopement. The only way I know is if there's a roam alert that goes off." An interview was conducted with the Director of Admissions (DA) on 8/18/14 at 12:17 PM. The DA stated that, on 7/16/14, he helped in the search of Resident #6 by driving around the neighborhood to look for the resident. The DA stated that his office is across from the lobby exit door and he hears roam alert alarms go off all the time but is not aware of which residents are at risk for elopement. An interview was conducted with a 7:00 AM to 3:00 PM Registered Nurse (RN #1) on 8/18/14 at 12:26 PM. RN #1 stated that, on 7/16/14 around 2:30 PM, she received a call from an off-duty Licensed Practical Nurse (LPN #2) who said that she thought she saw Resident #6 in the road. RN #1 stated that she thought the resident was in the main dining room. RN #1 stated that a Code 10 for missing resident was announced and all staff began to search for the resident; the off-duty LPN #2 called the police. RN #1 stated that the resident was brought back to the facility around 4:00 PM by the police. RN #1 stated that she never heard of the resident trying to elope before 7/16/14; "That was completely out of the blue." She further stated, "He (Resident #6) has episodes of confusion but I never heard that we had to worry about elopement." An interview was conducted with a 7:00 AM to 3:00 PM Registered Nurse Supervisor (RNS #2) on 8/18/14 at 1:08 PM. RNS #2 stated that Resident #6's decision-making skills are impaired and there was no monitoring of the resident prior to the 7/16/14 elopement. RNS #2 stated that Resident #6 would often spend time sitting near the lobby door which would sound the roam alert alarm; staff would bypass the alarm and the resident could go to the patio if he wanted. There is no staff on the patio. RNS #2 stated that, on 7/16/14 after the resident was noted missing, he drove out looking for the resident; LPN #2 was parked on the side of the road one mile away saying the resident went into the woods. RNS #2 stated that he combed through thick woods but could not find Resident #6; he drove around a little longer and decided to re-enter the woods. RNS #2 stated he found the resident sitting in a fetal-like position against a tree deep into the woods; police retrieved the resident and brought him back to the facility. RNS #2 stated that he does not know how often elopement assessments are done but RNS #2 is assigned to check the functioning of residents' roam alerts weekly. RNS #2 then stated that he doesn't actually check the functioning of roam alerts; "I only check the placement on the resident and basically rely on the expiration date (of the roam alert) to decide the functioning. I take the expiration date for granted." He further stated that Resident #6's roam alert has not been checked consistently but could not explain why. An interview was conducted with a 7:00 AM to 3:00 PM LPN #2 on 8/18/14 at 1:40 PM. LPN #2 stated that, on 7/16/14, she was driving in her car about a mile away when she saw Resident #6 walking in the road. She tried to stop the resident but Resident #6 looked very agitated and ran into the woods. LPN #2 called the facility and spoke with RN #1, who didn't believe LPN #2 that the resident was missing; "No one knew he was missing." LPN #2 called back again and explained the situation and then called police because she lost sight of the resident. LPN #2 stated that staff and police came and searched for a while before finding the resident in the woods. LPN #2 further stated that the way to know if a resident is at risk for elopement is if that resident has a roam alert. An interview was conducted with the Director of Maintenance (DOM) on 8/18/14 at 2:10 PM. The DOM stated that all exit doors, stairwell doors and elevators have roam alert alarms. The DOM stated that there are surveillance cameras on the outside patios which are supposed to be visible at the nursing station monitors but are not. The DOM stated that there is no specific policy regarding checking the roam alert system but, in October 2013, he started checking the system once a month. The DOM stated that, prior to October 2013, there is no record of checking the roam alert system. The DOM further stated that the roam alert system is also checked after each elopement incident but there is no record of this. An interview was conducted with the Social Worker (SW) on 8/18/14 at 2:32 PM. The SW stated that Resident #6 is confused and has tunnel vision with thoughts at times. The SW stated that, on 7/16/14 at 3:30 PM, she was told that the resident had eloped and she went out in her car to search for the resident; the police brought the resident back to the facility. The SW stated that social work types a list of residents that have roam alerts for nursing. She further stated, "Social work would only update a list of residents with actual roam alerts but I wouldn't know of who has been assessed at risk for elopement." An interview was conducted with a 7:00 AM to 3:00 PM RN #2 on 8/18/14 at 2:57 PM. RN #2 stated that, on 7/16/14, she administered medication to Resident #6 at 2:00 PM. Around 2:20 PM, an off-duty nurse found the resident walking in the street. RN #2 stated that she thought the resident was in the main dining room on the first floor. RN #2 stated that she was never aware that Resident #6 was on 30 minute visual checks. RN #2 stated, "No one ever told me about him (Resident #6) being an elopement risk. Unless someone tells you, that's the only way you would know." She further stated, "I don't know who does elopement assessments. I think one of the Psych doctors comes in to do them." An interview was conducted with a 7:00 AM to 3:00 PM RN #3 on 8/18/14 at 3:11 PM. RN #3 stated that, on 7/16/14, another nurse gave medication to Resident #6 around 2:00 PM. RN #3 wanted to clip the resident's nails around 2:30 PM on 7/16/14 and called downstairs to the front desk, thinking the resident was in the main dining room. RN #3 stated that another nurse then received a call that the resident was seen walking in the road somewhere in the neighborhood, so a search for the resident began. RN #3 stated that Resident #6 wore a roam alert bracelet because he had once verbalized he wanted to leave but never actually tried; "I don't believe he ever tried to elope." RN #3 stated that she wasn't sure if Resident #6 was on 30 minute visual checks. An interview was conducted with the Director of Staff Development (DSD) on 8/18/14 at 3:33 PM. The DSD stated that there should be pictures of residents with roam alerts at the front lobby desk, with the nursing supervisor and at the nursing stations. If a resident ' s roam alert sounds it comes up on the computer monitor at each nursing station. The DSD stated that she thinks the night supervisor checks residents' roam alerts each night but she is not sure. The DSD stated that, on 7/16/14, the police returned Resident #6 to the facility around 4:00 PM and she performed a body check; there were no injuries. The DSD further stated that Resident #6 wore a roam alert "but didn't have any incident prior as far as eloping. He just had a prior incident that he was confused and was found at the deli." During an observation of the third floor on 8/18/14 at 3:43 PM the nursing desk roam alert computer monitor was not working and there was no list of residents at risk for elopement at the nursing desk. Resident #6 was observed not to have a purple dot identifier on his identification bracelet. An interview was conducted with the Risk Manager (RM), who is part of the Quality Assurance team, on 8/19/14 at 9:36 AM. The RM stated that residents with roam alerts used to be allowed to sit outside and staff would bypass the roam alert alarm but this doesn't happen anymore. The RM stated that she investigated each incident involving Resident #6 leaving the facility and concluded that there was no abuse or neglect. She was unable to explain how this decision was made, stating "I don't remember." An interview was conducted with the Nurse Practitioner (NP) on 8/19/14 at 10:50 AM. The NP stated that she is the practitioner working with the attending physician for Resident #6. The NP stated that Resident #6 has been seen by Psychiatry several times and is not capable of making decisions; the resident is at risk for elopement and requires supervision. The NP further stated that she has never been made aware of any incidents of elopement involving Resident #6. An interview was conducted with the Director of Nursing (DON) on 8/19/14 at 11:45 AM. The DON stated that, prior to 7/16/14, Resident #6 never verbalized he wanted to leave or made any attempts to leave the facility. She then stated that, in June 2014, the resident "had gone to the deli but he never verbalized that he was going to leave so it wasn't elopement." The DON stated that this was not a reportable incident "because he (Resident #6) wanted to leave and we try to be home-like." The DON stated that there are a couple of residents with roam alerts who like to sit outside; "we'll (staff) turn off the alarm to let them out. It's their home. It's not like they're (residents) leaving." The DON further stated that there is a color code system in place for recognizing residents at risk for elopement. She started looking at the back of her identification badge and stated, "It's not here. I don't remember what it is." An interview was conducted with the Administrator on 8/19/14 at 12:30 PM. The Administrator stated that she was not the administrator at the time of any of Resident #6's elopements but she has reviewed the incidents and believes that they should have been reported to the State agency. She further stated that she is not aware of any recent Quality Assurance measures taken with regard to elopement and unsafe wandering. 2) Resident #9 was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented that Resident #9 is cognitively intact. The Resident Nursing Instructions effective 5/12/14 documented that Resident #9 is confused. The CCP effective 6/2/14 documented that Resident #9 has cognitive loss/dementia with inattention and disorganized thinking. Interventions included monitoring altered level of consciousness and wandering. The CCP effective 7/14/14 documented that Resident #9 wanders in the wheelchair, sits in lobby by exit doors, wears a roam alert and is an elopement risk. The NERA dated 7/18/14 documented that Resident #9 was assessed to be at risk for elopement. The NERA documented that the resident can only go sit outside with escort. The CCP effective 8/4/14 documented that Resident #9 is at risk for elopement due to a history of elopement, attempts to leave the facility and wanders to exit doors. During an observation on 8/19/14 at 1:15 PM Resident #9 was seen by the surveyor outside the facility unattended. The DSD was seated at the lobby reception desk. The Nursing Secretary was making photo copies behind the desk. An interview was conducted with the DSD on 8/19/14 at 2:41 PM. The DSD stated that she was covering the reception desk for a few minutes around 1:15 PM on 8/19/14. The DSD stated that she was not aware that Resident #9 was outside the facility. She further stated that Resident #9 is an elopement risk. An interview was conducted with the Nursing Secretary (NS) on 8/19/14 at 2:55 PM. The NS stated that she was assigned to cover the lobby reception desk while the receptionist was on break on 8/19/14. The NS stated that Resident #9 had wanted to go outside and the roam alert was sounding. The NS stated that she disarmed the roam alert alarm at the lobby door to allow the resident to go outside; "this happens all the time." The NS further stated that she intended to "peek on her (Resident #9) every few minutes." 415.12 (h)(1)(2)

Based on staff interviews and record review during an abbreviated and partial extended survey the facility failed to provide a quality assessment and assurance program that identified system failures pertaining to residents at risk for unsafe wandering and elopement. Specifically, the Quality Assessment and Assurance (QAA) committee failed to investigate the root cause of Resident #6's unsafe wandering to prevent further occurrences. Subsequently, the resident was able to exit the facility undetected by staff on three separate occasions from 5/18/14 to 7/16/14. The QAA committee failed to conduct quality assessment and assurance to ensure the development and implementation of policies for the monitoring and supervision of residents with unsafe wandering and maintenance of the Roam Alert system. This resulted in the potential for a pattern of serious harm that is Immediate Jeopardy. Complaint Number: NY 817 Cross References: F 225 - Failure to Report F 323 - Accidents and Supervision F 490 - Administration The findings are: The Policy and Procedure on Visual Checks dated 9/27/06 documented that the nursing staff will provide an aggressive monitoring program visually observing the residents and documenting their location. The purpose is to closely monitor residents who are at risk for accidents/incidents/occurrences. These residents are, but not limited to, residents who are at risk for elopement. The Policy and Procedure on Identifying Residents at Risk for Elopement/Wandering dated 6/12 documented that each resident will be assessed for the potential of elopement/wandering within 24 hours of admission, quarterly, upon a significant change and/or episodic discovery. The undated Policy and Procedure on Elopement/Missing Resident (PPEMR) documented that each resident who has been assessed as a potential elopement risk will be identified by wearing a purple arm band and/or purple identification on any assistive devices as a visual aide for staff identification. The PPEMR documented that, if a resident is missing, Administration will contact the DOH (Department of Health) as necessary. A detailed Accident/Incident Report will be completed noting the investigative procedure and resolution. If the DOH has not yet been notified of the elopement and the resident has returned to the facility, they will be notified. Roam alert bracelets shall be tested weekly for proper functioning and expiration date and signed for by the DNS (Director of Nursing Services)/designee in the log book. The Roam Alert Audit Log lacked documented evidence of consistent weekly testing of the roam alerts. The Policy and Procedure on Wandering Monitoring System/Roam Alert dated 9/12 documented that residents who are identified as being at risk for wandering out of the facility will be monitored for safety utilizing the Wanderer Monitoring/Roam Alert System. There was no documented evidence of a policy and procedure for maintenance of the roam alert system. An interview was conducted with the Risk Manager (RM), who is part of the Quality Assurance team, on 8/19/14 at 9:36 AM. The RM stated that residents with roam alerts used to be allowed to sit outside and staff would bypass the roam alert alarm but this doesn't happen anymore. The RM stated that she investigated each incident involving Resident #6 leaving the facility and concluded that there was no abuse or neglect. She was unable to explain how this decision was made, stating "I don't remember." The RM further stated that, since there was no abuse or neglect, there was no reportable incident. An interview was conducted with the Director of Nursing (DON) on 8/19/14 at 11:45 AM. The DON stated that, prior to 7/16/14, Resident #6 never verbalized he wanted to leave or made any attempts to leave the facility. She then stated that, in June 2014, the resident "had gone to the deli but he never verbalized that he was going to leave so it wasn't elopement." The DON stated that this was not a reportable incident "because he (Resident #6) wanted to leave and we try to be home-like." The DON stated that there are a couple of residents with roam alerts who like to sit outside; "we'll (staff) turn off the alarm to let them out. It's their home. It's not like they're (residents) leaving." The DON further stated that there is a color code system in place for recognizing residents at risk for elopement. She started looking at the back of her identification badge and stated, "It's not here. I don't remember what it is." The DON was unable to explain whether or not there has been any recent QAA activities regarding elopement and unsafe wandering. An interview was conducted with the Administrator on 8/19/14 at 12:30 PM. The Administrator stated that she was not the administrator at the time of any of Resident #6's elopements but she has reviewed the incidents and believes that they should have been reported to the State agency. She further stated that she is not aware of any recent Quality Assurance measures taken with regard to elopement and unsafe wandering. 415.27 (a-c)