Every finding on record at Robinson Terrace

Based on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice for three of three (3 of 3) medication carts and one of two (1 of 2) medication rooms reviewed. Specifically, (a.) Five (5) bottles of eye drops had no open and or expiration dates; (b.) Five (5) insulin pens had no open dates; (c.) Two (2) vial of insulin and two (2) insulin pens had no open and or expiration dates; (d.) One (1) insulin pen had two open dates; (e.) Two (2) inhalers had no open and or expiration dates; (f.) One (1) bottle of Tuberculin Purified Protein Derivative (a sterile mixture of antigens used in the Mantoux skin test to detect Mycobacterium tuberculosis infection) had no open and or expiration date; (g.) Narcotic box #2 (two) only had one of two (1 of 2) locks in a locked position. This is evidenced by: The facility's Policy and Procedure titled, Storage of Medications reviewed 1/2025, documented the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Before and after opening, all medications shall expire on the date specified by the manufacturer on the product label, unless the manufacturer has specifically indicated a shortened expiration once opened on the product label itself. The facility's Policy and Procedure titled, Administering Medications reviewed 1/2025, documented the expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened shall be recorded on the container. During an observation on 02/02/2026 at 12:17 PM, the Courtyard Unit Medication Cart two (2) contained two (2) bottles of GenTeal Tears eye drops with no open and or expiration dates; one (1) bottle of Systane eye drops with no open and or expiration date; and one (1) bottle of Refresh Tears eye drops with no open and or expiration dates. The cart also contained two (2) Lantus insulin pens, one (1) Admelog Solostar insulin pen, one (1) Humalog pen and a Lantus Kwik Pen, with no open dates. One (1) Novolog insulin pen, One (1) Lantus insulin vial, with no open and or expiration dates. One (1) fluticasone inhaler and one (1) Ventolin haler both had no open or expiration dates. During an observation on 02/02/2026 at 12:20 PM, the Courtyard Medication Room refrigerator contained one (1) bottle of Tuberculin Purified Protein Derivative with no open and or expiration dates. During an observation on 02/02/2026 at 12:20 PM, the Courtyard Medication Room Narcotic box #2 (two), the inside lock was left open. During an observation on 02/02/2026 at 12:30 PM, the Courtyard Medication Cart #1 (one) contained one (1) bottle of GenTeal tears eye drops with no open and or expiration date. During an observation on 02/02/2026 at 1:05 PM, the Bathgate Unit Medication Cart #2 (two) contained two (2) Humalog Kwik insulin pens with no open or expiration dates, and one (1) Humulin R Insulin vial with no resident name and no open or expiration dates. There was also one (1) Insulin Aspart pen with two open dates of 01/09/2026 and 01/23/2026. During an interview on 02/02/2026 at 12:20 PM, Licensed Practical Nurse #2 stated they were unaware of a shortened expiration date after opening any medications. They check the expiration date on the bottle. During an interview on 02/02/2026 at 1:05 PM, Licensed Practical Nurse #4 was unable to identify the expiration date of an opened Humalog insulin Kwin pen. (The surveyor noted that the pen had no open or expiration date.) Licensed Practical Nurse #4 stated they administered Humalog insulin this morning without knowledge of the open or expiration date. They think insulin expires after 30 days of opening, but they were not sure. During an interview on 02/02/2026 at 12:25 PM, Assistant Director of Nursing #1 stated there was a grid of medications with shortened expiration dates after opening in each medication room. They accompanied the surveyor to the medication room on the Courtyard Unit and were unable to locate the grid. They stated it must have been removed. During an interview on 2/11/2026 at 10:30 AM, Director of Nursing #1 stated that Assistant Director of Nursing #1 assumes the role of Nurse Educator. The Nurse Educator completes nursing competencies on each Registered Nurse and Licensed Practical Nurse prior to the nurse administering medications without supervision. The nurse would be observed for competence, then signed off. A checklist of competencies would be completed with one competency for medication administration. 10 New York Codes, Rules, and Regulations 415.18(d)

Based on record review and interviews during a recertification and abbreviated survey, the facility did not ensure that alleged violations involving abuse, were reported immediately, but not later than two (2) hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to officials (including to the State Agency). Additionally, the facility did not ensure a report of the results of all investigations were submitted to the State Agency, within five (5) working days of the incident, in accordance with State law for one (1) (Resident #125) of four (4) residents reviewed for abuse. Specifically, for Resident #125 an allegation of physical abuse reported by the resident on 2/05/2024 at 12:15 PM was not reported to The New York State Department of Health until 7:01 PM and the results of the investigation were not submitted until 2/13/2024. This is evidenced by: Facility policy titled, Abuse-Prohibition Protocol, Types of Abuse, Response/Reporting, last revised 1/2025, documented any alleged violations involving mistreatment, neglect or abuse, including serious injuries of an unknown source must be reported to the Administrator/Designee, Director of Nursing/Designee or department director immediately. An immediate investigation must be made, and the findings of such investigation must be reported to the: Administrator/Designee within 24 hours of the occurrence/discovery of such incident. To the NYSDOH (New York State Department of Health) via the Electronic Incident Reporting form within 24 hours of occurrence/discovery. The facility must report any suspected resident abuse immediately, and no later than (2) two hours after the allegation if the incident resulted in physical injury. All other reportable incidents are to be communicated to the New York State Department of Health within 24 hours. The facility is required to report the results of an investigation into an alleged abuse incident to the relevant authorities, such as the state Department of Health, within five business days of the incident occurring; essentially, they must provide a full report on their findings within that timeframe. Resident #125: Resident #125 was admitted to the facility with diagnoses of metabolic encephalopathy (a brain dysfunction caused by chemical imbalances in the body due to underlying metabolic disturbances), cerebral infarction (blood supply to part of the brain is blocked or reduced), hemiplegia (paralysis) of right dominant side. The Minimum Data Set (an assessment tool) dated 1/13/2024, documented the resident could usually be understood, could usually understand others, and had moderate cognitive impairment. The facility Investigation Summary dated 2/05/2024 documented on 2/05/2024 at 11:35 AM, the resident reported to a Certified Nurse Aide that a Licensed Practical Nurse shoved them in the chest the prior evening. A Nursing Home Incident Submission Report documented the facility submitted a report of the suspected physical abuse to The New York State Department of Health on 2/05/2024 at 7:01 PM. The New York State Department of Health Nursing Home Investigative Report Submission form documented the investigation report was submitted on 02/13/2024. During an interview on 2/12/2026, Administrator #1 stated that in subsequent interviews, Resident #125 reported the Nurse did not touch them, and the witness confirmed this information, so the allegation was unfounded. They further stated that they did not recall why reporting of this was not completed within the reporting time frames. 10 New York Codes, Rules, and Regulations 415.4(b)(2)

Based on observation, record review, and interviews conducted during the recertification survey, the facility did not develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for two (2) (Residents #s 4 and 14) of 23 residents reviewed for Care Plans. Specifically, (a) Resident #4 did not have a person-centered care plan for pain, although they were receiving scheduled pain medication and were being monitored for pain, and (b) for Resident #14, a comprehensive care plan for hospice was not developed or implemented when the resident was admitted to hospice care on 12/29/2025. This is evidenced by: The facility policy titled, Care Plans, Comprehensive Person-Centered, last reviewed on 1/2026, documented a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs was developed and implemented for each resident. Care plan interventions were derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Resident #4 Resident #4 was admitted to the facility with diagnoses of Alzheimer's disease (a progressive brain disorder that causes memory loss, confusion, and other cognitive decline. It is the most common form of dementia), right thigh bone break, and type 2 (two) diabetes (a chronic condition that happens when a person has persistently high blood sugar levels). The Minimum Data Set (an assessment tool) dated 1/14/2026, documented the individual was usually able to understand and be understood by others, and had severe cognitive impairment. A physician order dated 12/29/2025, documented Acetaminophen Extra Strength Tablet 500 milligram, give 2 (two) tablets by mouth 2 (two) times a day for pain. Resident #4's Medication Administration Record for January 2026 documented pain assessment every shift (when awake), and documented score every shift. There was no documented evidence that a care plan for pain was developed, although the resident was receiving pain medication and being monitored for pain. During an interview on 2/13/2026 at 12:52 PM, Registered Nurse #2 stated there should be a care plan for a resident who gets pain medications such as Tylenol (Acetaminophen) and was being monitored for pain. During an interview on 2/13/2026 at 11:05 AM, Administrator #1 stated that each unit manager and each department head developed and updated the care plan. They stated there should be a pain care plan for a resident who was receiving pain medication and was being monitored for pain. Resident #14 Resident #14 was admitted to the facility with diagnoses of metastasized cancer (a disease that has spread from its original site to other parts of the body), hypertension (high blood pressure, a condition where the force of blood against the artery walls is consistently too high), and type 2 (two) diabetes. The Minimum Data Set, dated [DATE], documented the resident was usually able to understand and be understood by others, and had severe cognitive impairment. A hospice skilled nursing assessment dated [DATE], documented Resident #14 was admitted to hospice services on 12/29/2025. There was no documented evidence that a care plan was developed for hospice care that began on 12/29/2025. During an interview on 2/02/2026 at 11:53 AM, Licensed Practical Nurse #1 stated there was no written communication between the contracted hospice group and the facility. The hospice nurse would visit the resident and then talk with them about the resident. During an interview on 1/30/2026 at 10:14 AM, Administrator #1 stated there should be a hospice care plan in place for Resident #14. 10 New York Code of Rules and Regulations 415.11(c)(1)

Based on the record review and interview conducted during the survey, the facility did not ensure that Resident #123 was free of a significant medication error. Specifically, two (2) prescribed anti-seizure medications, carbamazepine and primidone, were omitted after the resident's readmission from the hospital on [DATE]. The medications resumed after the resident experienced a seizure on 11/21/2022. Resident #123 was admitted to the facility with diagnosis of epilepsy (a chronic neurological disorder characterized by recurrent, unprovoked seizures caused by sudden, abnormal electrical activity in the brain); Post-polio syndrome (muscle and joint weakness and pain that gets worse over time), and other schizophrenia (a chronic, severe mental disorder characterized by a distorted interpretation of reality, including hallucinations, delusions, and disorganized thinking/behavior). The Minimum Data Set (an assessment tool) dated 10/30/2022, documented that the resident could usually understand and was understood by others with intact cognition. Comprehensive Care Plan revised 1/28/2022 documented Resident #123 had Seizure Disorder related to diagnosis of epilepsy. Interventions included to give medications as ordered, and monitor/document for effectiveness and side effects. Physician Nursing progress note dated 11/07/2022 documented Resident #123 was ordered Carbamazepine and Primidone, both for seizures. Resident #123's Medication Administration Record for 11/2022 Primidone 250 milligram tablet was not administered from 11/16/2022 through 11/21/2022; carbamazepine 200 milligrams and carbamazepine 100 milligrams were not administered from 11/16/2022 through 11/20/2022. The hospital Discharge summary dated [DATE] documented to start medications upon discharge, including: Carbamazepine 200 milligram tablet. Take 400 milligrams by mouth three times a day. Take at 9 AM, 2 PM, 7 PM; Carbamazepine 100 milligram chewable tablet. Take 100 milligrams by mouth twice daily, at 9 AM and 7 PM, in addition to 400 milligrams, three times a day, so at 9 AM and 7 PM gets a total of 500 milligrams. Primidone 250 milligram tablet, take 1 tablet by mouth daily. During an interview on 2/11/2026 at 10:30 AM, Administrator #1 stated Resident #123 was on anti-seizure medications prior to 11/11/2022. They further stated that on 11/11/2022, Resident #123 was sent to the hospital for shortness of breath, was admitted and returned to the facility on [DATE]. Administrator #1 stated Registered Nurse #1 readmitted Resident #123. On 11/21/2022, Resident #123 had a seizure. They further stated a Registered Nurse reviewed the resident's chart and noted the resident's seizure medications had not been reinstated upon return from the hospital. Surveyor requested documentation of post-incident, all nursing staff education but was not provided. Record review and interview revealed the facility took the following corrective actions prior to the start of the survey: The nurse education post incident dated 11/21/2022 documented that during a recent readmission, medication reconciliation was completed with review and double-checking of medications. However, because the medication list spanned multiple pages, one page was unintentionally not entered. As a result, prescribed medications were not resumed upon readmission. Medical Doctor #2 progress note dated 11/25/2022, documented Resident #123 was admitted from the hospital on 11/16/2022; the Medical Director completed a readmission History and Physical on 11/18/2022. It appears, however, that Resident #123's anti-seizure medications, carbamazepine, were inadvertently omitted per the reconciled medication list. This was discovered on Monday, 11/21/2022, and the medications were restarted at that time. During an interview on 2/11/2026 at 10:30 AM, Administrator #1 stated a facility investigation was launched; the provider was notified and reinstated the resident's seizure medications. Registered Nurse #1 was re-educated on the medication reconciliation process and verbalized competency in the admission process. Administrator #1 stated that medication reconciliation education was provided to all nursing staff. All new admissions and readmissions within the past 30 days were audited for possible medication reconciliation, and no errors were noted. Administrator #1 stated the incident was brought to Quality Improvement for review. 10 New York Codes, Rules, and Regulations 415.4 (b)(1)(i)

Based on observation, record review, and interviews conducted during the survey, the facility did not ensure that resident menus were followed to meet the resident's' nutritional needs for two (2) (Resident #'s 10 and 11) of four (4) residents reviewed. Specifically, Resident #10 was not served an adequate portion of chicken on their meal tray, and Resident #11, who had a care plan of fluid deficit, did not receive tomato juice as listed on their meal ticket for two (2) observed meals. This is evidenced by: The facility policy titled Dietary Portion Control, revised 9/2025, documented that all foods served would follow standardized recipes and prescribed portion sizes to ensure nutritional adequacy, regulatory compliance, cost control, and resident satisfaction. The procedure included: #1.) standardized recipes: all menu items were prepared using standardized recipes and recipes identified yield and exact portion size; #2.) portion control methods: food scales were used for protein verification , and that free-pouring or estimated portions were not permitted; and #3.) tray line accuracy: tray tickets were verified before plating, and the portion must match the daily production sheet. The facility policy titled Dietary Menu Planning Policy, revised on 1/2026, documented that menus were planned, reviewed, and approved by a Registered Dietitian to ensure nutritional adequacy, therapeutic accuracy, and resident satisfaction. Food preferences were obtained at admission and reviewed quarterly. Under Monitoring, it documented tray audits, verified menu compliance, and resident satisfaction was reviewed. Resident #10 Resident #10 was admitted to the facility with diagnoses of radiculopathy lumbosacral region (a condition caused by compression of nerve roots in the lower back, leading to symptoms such as pain, numbness, or weakness that radiates down the legs), age-related physical debility (gradual decline in physical function and strength that occurs with aging), and type two (2) diabetes ( a chronic condition that happens when a person has persistently high blood sugar levels). The Minimum Data Set (an assessment tool) dated 1/29/2026, documented that the resident was cognitively intact, was understood, and could understand others. During an interview on 1/29/2026 at 9:28 AM, Resident #10 stated food was a big concern and was often discussed at the Resident Council Meetings. They stated sandwiches were served without much on them such as tuna or egg salad. During a meal observation on 2/02/2026 at 11:46 AM, Resident #10's meal tray was tested in the dining room, and a replacement tray was requested. The meal ticket read: chicken cacciatore with tomato, peppers, and mushrooms, egg noodles, green beans, and mandarin oranges. There were no mushrooms or peppers observed on the plate. Some of the tomatoes were slightly hard. The egg noodles were dry and stuck together when lifted with a fork and some egg noodles were observed to be brown/burnt. There was one (1) bite sized (1 inch) piece of chicken observed on the plate. During an interview on 2/02/2026 at 12:06 PM, Certified Nurse Aide #2 was asked to observe Resident #10's test tray and asked if the meal should have included mushrooms, peppers, and a larger portion of chicken. Certified Nurse Aide #2 stated that, according to the ticket, they should have gotten mushrooms and peppers, but all they saw were tomatoes. They further stated that there should have been a larger portion of chicken. During an interview on 2/13/2026 at 9:04 AM, Certified Nurse Aide #3 stated that sometimes the residents complained about the way the food looked and that the vegetables were overcooked. They stated the residents did not always get the condiments that they should on their tray like butter or creamer. They stated if a resident did not like the food served, they would offer them another meal or an alternative such as a sandwich. During an interview on 2/13/2026 at 9:14 AM, Licensed Practical Nurse #4 stated the residents complained about the food. They stated there was a lot of inconsistency with the food. The residents would not receive the items that they should on their trays , and they would have to constantly call the kitchen to get them. During an interview on 2/13/2026 at 10:14 AM, Food Director #1 stated they attended the food committee meetings. They stated they measured out three (3) to four (4) ounces of protein for a meal. This surveyor showed Food Director #1 pictures of Resident #10's test tray, and they stated mushrooms and peppers should have been included in the meal. They further stated the resident should have received a full piece of chicken thigh. Resident #11 Resident #11 was admitted to the facility with diagnoses of congestive heart failure (a weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), and type 2 (two) diabetes. The Minimum Data Set dated 12/11/2025, documented the resident was usually able to understand others, was usually understood by others, and was cognitively intact. Resident #11's Comprehensive Care Plan for fluid deficit initiated 5/20/2025, documented the resident had actual/potential for fluid deficit related to chronic diarrhea and poor intake. Under interventions it was documented to ensure the resident had access to thin liquids of choice whenever possible. During an interview on 1/28/2026 at 12:39 PM, Resident #11 stated the food was terrible and they were often not served everything on their ticket. They stated most food did not have a taste to it. They have talked with dietary about their concerns and have discussed it at Resident Council Meetings During a lunch observation on 2/10/2026 at 11:52 AM, Resident #11's meal ticket was observed to say tomato juice, however the resident was not served tomato juice. During a lunch observation on 2/12/2026 at 12:14 PM, Resident #11's meal ticket was observed to say tomato juice and margarine, however the resident was not served tomato juice or margarine. The cup of cranberry juice provided was observed to only be half full. During an interview on 2/13/2026 at 11:05 AM, Administrator #1 stated food complaints waxed and waned. They stated about a year and a half ago, there were some issues with the food, but it had gotten significantly better over the past year. Communication was better now if the kitchen was out of something, and it would be discussed at morning report and shared with the residents. 10 New York Codes, Rules, and Regulation 415.14(c)(1-3)

Based on observations, record review, and interviews conducted during the recertification survey and an abbreviated complaint survey, the facility did not ensure residents were provided food and drink that was palatable, flavorful, and/or at an appetizing temperature for two (2) of four (4) meals reviewed. Specifically, appetizing and palatable food was not served during a lunch meal on 2/02/2026, and diluted cranberry juice was served at a lunch meal on 2/10/2026. Additionally, six (6) residents (Residents #'s 10, 11, 36, 88, 96, 110) interviewed stated the food did not taste good. This is evidenced by: The facility policy titled, Dietary Menu Planning Policy, revised on 1/2026, documented menus were planned, reviewed, and approved by a Registered Dietitian to ensure nutritional adequacy, therapeutic accuracy, and resident satisfaction. Under Monitoring, it documented tray audits, verified menu compliance, and resident satisfaction was reviewed. During an interview on 1/28/2026 at 12:39 PM, Resident #11 stated the food was terrible and they were often not served everything on their ticket. They stated most food did not have a taste to it. They spoke with dietary about their concerns and discussed it at Resident Council Meetings. During an interview on 1/28/2026 at 1:35 PM, Resident #36 stated the food was not the best, and the vegetables were too soft. They further stated the turkey served at lunch did not taste appealing to them and that it did not taste like real turkey. During an interview on 1/29/2026 at 11:36 AM, Resident #96 stated the food was horrible. They stated potatoes were served rock hard and the vegetables could be flattened like paste with a fork. They often ordered food deliveries and takeout because they did not like the food. They further stated they rarely ate the breakfast or lunch offered at the facility. During an observation on 1/29/2026 at 12:06 PM, Certified Nurse Aide #1 brought a meal tray to Resident #96's room. The resident told Certified Nurse Aide #1 that they did not want it and asked them to take it away without having looked at it. During an interview on 1/29/2026 at 1:21 PM, Resident #88 stated the food was bad and cold. They stated the potatoes were so hard that they could not chew them. During an interview on 1/29/2026 at 1:40 PM, Resident #110 stated the food did not look good and it did not taste good. During an interview on 1/29/2026 at 9:28 AM, Resident #10 stated food was a big concern and was often discussed at the Resident Council Meetings. They stated there were complaints about the quality and the presentation of the food. The vegetables were not prepared well and either overcooked or undercooked. They stated they had received black bananas, noodles with nothing on them, and meat that was so tough it could not be cut through. They stated the juice was watered down. During a meal observation on 2/02/2026 at 11:46 PM, Resident #10's meal tray was tested in the dining room, and a replacement tray was requested. The meal ticket read: chicken cacciatore with tomato, peppers, and mushrooms, egg noodles, green beans, and mandarin oranges. There were no mushrooms or peppers observed on the plate. Some of the tomatoes were slightly hard. The egg noodles were dry and stuck together when lifted with a fork and some egg noodles were observed to be brown/burnt. There was one (1) bite sized piece of chicken observed on the plate. During an interview on 2/02/2026 at 12:06 PM, Certified Nurse Aide #2 was asked to observe Resident #10's test tray and asked if the meal should have included mushrooms, peppers, and a larger portion of chicken. Certified Nurse Aide #2 stated that, according to the ticket, they should have gotten mushrooms and peppers, but all they saw were tomatoes. They further stated that there should have been a larger portion of chicken. During an observation on 2/02/2026 at 12:08 PM, Resident # 10 was observed leaving the table. Their replacement meal was untouched other than for the mandarin oranges. During an interview on 2/10/2026 at 11:52 AM, Resident #11 stated their cranberry juice was lighter than the resident's juice that was sitting across from them. During an observation on 2/10/2026 at 11:52 AM, Resident #11's cranberry juice was observed to be lighter in color than the resident's cranberry juice that was sitting across from them in the dining room. The resident sitting next to Resident #11 was observed to have cranberry juice that was lighter in color than Resident #11s, almost clear. Dining Committee meeting notes dated 11/10/2025, documented new issues consisted of vegetables being overcooked or undercooked. It was also documented that some pasta was hard, and the cooking process was explained. During an interview on 2/13/2026 at 9:04 PM, Certified Nurse Aide #3 stated that sometimes the residents complained about the way the food looked and that the vegetables were overcooked. They stated the residents did not always get the condiments that they should on their trays like butter or creamer. They stated if a resident did not like the food served, they would offer them another meal or an alternative such as a sandwich. During an interview on 2/13/2026 at 9:14 AM, Licensed Practical Nurse #4 stated the residents complained about the food. They stated there was a lot of inconsistency with the food. The residents would not receive the items that they should on their tray, and they would have to constantly call the kitchen to get them. During an interview on 2/13/2026 at 10:14 AM, Food Director #1 stated they attended the food committee meetings. They stated residents complained about overcooked pasta and undercooked vegetables, but they found that this complaint depended on the residents' diet consistency. They had conversations with the staff about different ways to hold food to prevent mushiness with the vegetables and reviewed the policy and procedure with their staff. Food Director #1 stated the Registered Dietitian was on the unit and would receive complaints made by the residents and would bring the complaints to them. If there were complaints, they were also brought to their attention at the morning meeting or by the unit managers. This surveyor showed Food Director #1 pictures of Resident #10's test tray, and they stated mushrooms and peppers should have been included in the meal. They further stated the brown/burnt-looking egg noodles were held in the oven instead of the steam table, and that should not have been done. When questioned about the cranberry juice, Food Director #1 stated they had an issue with the juice machine and called the vendor, which was why the cranberry juice appeared watered down. They stated the machine was fixed. During an interview on 2/13/2026 at 11:05 AM, Administrator #1 stated food complaints waxed and waned. They stated about a year and a half ago that there were some issues with the food, but it had gotten significantly better over the past year. Communication was better now if the kitchen was out of something, and it would be discussed at morning report and shared with the residents. They stated they got a new vendor for chicken when the residents complained about the chicken. 10NYCRR 415.14(d)(1)(2)

Based on observation, record review, and interviews during the recertification survey dated 02/21/23 through 03/02/23, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety in the main kitchen and three (3) of 3 unit kitchenettes. Specifically, in the main kitchen, the automatic dishwashing machine final rinse was 171 degrees Fahrenheit (F) at 37 pounds per square inch water pressure (psi); the concentration of Quaternary Ammonium Compound (QAC) used in the sanitizing rinse sink was found to be zero (0) parts per million (ppm); food temperature thermometers were not in calibration; food and non-food contact surfaces were not clean and in good repair; and the bulk food containers were not labeled; in the kitchenettes, the cabinets below the sinks were in disrepair, and refrigerators were not clean. This is evidenced as follows: Finding #1: Main Kitchen During observations on 02/21/23 at 11:28 AM, in the main kitchen, the automatic dishwashing machine final rinse was 171 F at 37 psi. The automatic dishwashing machine information date plate states that the minimal final rinse water temperature is to be 180 F with a water pressure between 20 psi and 25 psi. The concentration of QAC used in the sanitizing rinse sink was found to be zero (0) parts per million (ppm) when measured at 67 degrees Fahrenheit (F). The manufacturer's label directions stated the concentration is to be between 200 ppm and 400 ppm when the solution is measured between 65 F and 75 F. Two of 3 food temperature thermometers were found not in calibration when tested in a standard ice-bath method as follows: zero (0)F and 28F. The table mixer, walk-in freezer door, and fire extinguisher were soiled with food particles or grime and required cleaning. The edges of 3 rubber spatulas were split and not cleanable; the bulk flour, bulk fortified milk, and bulk thickener were not labeled; the bottom plastic panel in the reach-in freezer was missing exposing the fiber backing; and the reach-in refrigerator door gaskets were split. Finding #2: Kitchenettes During observations on 02/21/23 at 12:35 PM, the bottoms of the cabinets below the sinks in the Courtyard kitchenette, Mountainview kitchenette, and [NAME] kitchenette were heavily stained brown and partially warped from water damage. The countertop behind the sink in the Courtyard kitchenette was worn. The refrigerator and drawers in the Mountainview kitchenette were soiled with food particles. And the cabinets in the [NAME] kitchenette was soiled with food particles. Interviews: During interviews on 02/21/23 at 12:46 PM, the Food Service Director and Regional Director of Food Service stated that the vendor will be contacted to adjust the dishwashing machine final rinse temperature and water pressure; maintenance will be contacted to fix the refrigerator door gaskets and reach-in freezer, the vendor will be contacted to adjust the chemical sanitizer concentration, the split rubber spatulas have been discarded, the bulk food containers will be labeled, and staff will be educated on calibrating thermometers and cleaning procedures. Food Service Director and Regional Director of Food Service stated that the areas found in the kitchenettes will be cleaned, and maintenance will be contacted to repair the stained cabinets below the sinks in the kitchenettes. During an interview on 02/21/23 at 3:46 PM, the Administrator stated that the items found in the main kitchen and in the kitchenettes will be addressed with the dietary staff and maintenance 10 NYCRR 415.14(h)

Based on observation, interviews, and record review during the recertification survey dated 02/21/23 through 03/02/23, the facility did not ensure necessary housekeeping and maintenance services were provided to maintain a clean, sanitary, comfortable, and homelike environment for three (3) of 3 resident units and the Lobby. Specifically, wallpaper was ripped and curling at the seams and/or bubbling off the wall on the [NAME] Unit (Unit B), Courtyard Unit (Unit C), Mountainview Unit (Unit M), Lobby, and the corridor outside the Beauty Salon; walls were soiled with dirt and/or damaged with holes, scrapes or [NAME] marks, or had missing coving base on Unit B, Unit C and Unit M; on Unit C, the ceiling was peeling in the bathing suite and the kickplate on the outside wall of the nurse station was attached with duct tape; in the Unit M bathing suite, the ceiling light covers had dead flies and were yellowed, and the floor fan was dusty; floors were scrapped or soiled with a wax buildup or dirt in corners and next to walls on Unit B, Unit C, and Unit M; sections of floor were worn to the subfloor on the Unit B nurse station, and floor tiles were cracked in the 2nd floor vending area; furniture upholstery was damaged on Unit B and Unit C; and a resident wheelchair was soiled with food particles on Unit B. This is evidenced as follows: During observations on 02/21/23 at 2:46 PM, on 02/24/23 at 2:30 PM, and again on 02/27/23 at 10:29 AM, the following environmental observations were noted: Finding #1 Wallpaper was ripped and curling at the seams and/or bubbling in the following area: the corridors and in the Solarium on the Courtyard Unit, the corridors and by the elevator on the Mountainview Unit, by the housekeeping closet on the [NAME] Unit, in the Lobby, and in the corridor outside the Beauty Salon. Finding #2 Walls were soiled with dirt or scrape marks and/or damaged with [NAME] marks in the following areas: Resident room #s B1, B4, C16, C17, C3, C6, C8, C10, C14, C18, M9, M20, and M23; the Courtyard activity room and nurse station; the [NAME] corridor walls, bathing suite, and nurse station; and the Mountainview nurse station. A two-foot by 4-inch scrape was on the wall behind the bed in resident room #C17. The Coving base was missing in resident room #B4 and in the bathroom in resident room #C16. On the Courtyard Unit, the bathing suite ceiling was peeling, and duct tape was holding the kick plate to the base of the desk in the nurse station. On the Mountainview Unit, a 3-inch hole was found by the dining room bathroom; and in the bathing suite, a 3-inch hole was found by the shower, the walls had scrape marks, the ceiling light covers had dead flies and/or were yellowed from the light bulbs, and the floor fan dusty. Finding #3 The floors were soiled with dirt in corners and next to walls in the following areas: resident room #s B1, B4, B8, B10, C3, C6, C8, C10, C12, C14, C18, M9, M12, M16, M18, M19, M20, and M23; the [NAME] Unit dining room; the nurse station stations on the Courtyard, Mountainview, and [NAME] Units. Floors were soiled with wax build-up in resident room #s B8 and M12. Floors were soiled with dirt where door frames meet the floor on the Courtyard Unit, Mountainview Unit, and [NAME] Unit. In the nurse station on the [NAME] Unit, three 2-foot sections of floor were worn to the subfloor. Floor tiles were cracked on the 2nd floor vending area. Finding #4 Chair upholstery was ripped in resident room #s B4 and B7 and the Courtyard Unit Solarium. The wheelchair in resident room #B4 was soiled with food particles. Interviews: During interviews on 02/27/23 at 3:51 PM, the Administrator and Director of Environmental Services stated that the cleaning and maintenances items identified will be corrected. 483.10(i)(2); 10 NYCRR 415.5(h)(4)

Based on record review and interview during the recertification survey on 2/21/2023 through 3/2/2023, the facility did not ensure development and implementation of comprehensive person-centered care plans for each resident, consistent with the residents rights, that included measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 5 (Resident #s 55, 73, 86, 96, and #100) of 23 residents reviewed for comprehensive care plans (CCPs). Specifically, for Resident #55, the facility did not ensure the CCP for Actual Alteration in skin integrity included resident specific goals and interventions and did not address compliance with positioning; for Resident #73, the facility did not ensure a CCP was developed to address the resident's pain; for Resident #86, the facility did not ensure a CCP was developed for the diagnoses of seizures and dementia, and for the resident's noncompliance with care to prevent further decline; for Resident #96, the facility did not ensure a CCP was developed to address the resident's pain; and for Resident #100, the facility did not ensure a CCP was developed to address the needs of a resident requiring oxygen therapy, nebulized medications, and bilevel positive airway pressure (BIPAP). This is evidenced by: The facility policy titled Care Plan, Comprehensive Person-Centered, last revised 1/2023 documented; A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Identifying problem areas, their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. The facility policy titled Care Planning- Interdisciplinary Team, last revised 1/2023 documented; A comprehensive care plan for each resident will be developed within seven days of completion of the resident's assessment (MDS). Resident #73 Resident #73 was admitted to the facility with diagnoses of multiple sclerosis, polyneuropathy, arthritis, and pain. The Minimum Data Set (MDS-an assessment tool) dated 1/15/2023, documented the resident was without cognitive impairment, had received pain medication, and reported almost constant pain in the previous 5 days. Physician's Orders documented the following medication orders that addressed the resident's pain; gabapentin 800 mg three times daily for pain,order date 1/7/2022; Meloxicam (non-steroidal anti-inflammatory drug) 15 mg one time a day for pain, order date 1/3/2022; oxycodone HCL (opioid analgesic) 5mg three times a day for pain, order date 1/6/2023 discontinued 2/28/2023; oxycodone HCL 5mg four times a day for pain, order date 2/28/2023; pain assessment every shift when awake, order date 1/3/2022. A 30-Day Follow-up signed by the physician on 2/7/2023, documented the resident had a significant medical history including multiple sclerosis with generalized pain and body spasms. The Follow-up documented that the physician agreed to increase oxycodone to 5mg four times daily because the resident reported continued pain. A Pain Assessment Interview completed on 1/16/2023, documented the resident reported frequent moderate pain, and was receiving a scheduled pain medication regimen of gabapentin and oxycodone. The resident's medical record did not include a Comprehensive Care Plan to address pain management. During an interview on 02/28/23 at 1:45 PM, Resident #73 stated the nurses will offer to help when they complain of pain, but don't usually bother because only the medication will help. Resident #73 stated that since the doctor increased the dose it has been better. During an interview on 02/28/23 at 1:50 PM, Certified Nurse Aide (CNA) #2 stated Resident #73 complains of pain in their legs occasionally. CNA #2 stated they tell the nurse and offers repositioning and distracting activities for the resident when they complain. During an interview on 02/28/23 at 2:05 PM, Registered Nurse (RN) #2 stated they would have been responsible for ensuring all necessary care plans were done. RN #2 stated this resident has pain related to multiple sclerosis and it should be care planned and was not sure how this got missed. Resident #55 Resident #55 was admitted to the facility with diagnoses of status post fracture hip, anemia, existing pressure sore, and history of respiratory failure. The Minimum Data Set (MDS-an assessment tool) dated 1/23/2023, documented the resident was understood and understands others with intact cognition for decisions of daily living. During an observation on 02/23/23 at 10:23 AM, Resident #55 was lying in bed on their back, enabler bars were in place on both sides of the bed, and an air mattress was in place over the bed mattress. The CCP for actual alteration in skin integrity, implemented on 2/1/2023 did not include documentation of resident specific goals and interventions for the resident's existing pressure sore and did not address the resident's compliance with positioning. A nursing progress note dated 1/20/2023 documented Resident #55 entered the facility with a wound on their back measuring 1 cm by 1 cm. A nursing progress note dated 2/7/2023, documented wound showing improvement. Compliance with positioning a problem. During an interview on 2/28/2023 at 1:07 PM, Registered Nurse Unit Manager (RNUM) #4 for Unit #1 stated the admission CCP had not been finished and not all the goals and interventions had been added. During an interview on 3/2/2023 at 11:27 AM, the Director of Nursing (DON) stated the facility needed to address and work on better care planning for the residents. There had been changes in staff with the Nursing Education role being vacant and RN's that develop the CCP are not always available. This would be addressed moving forward. During an interview on 3/2/2023 at 11:45 AM, the Administrator stated the facility was currently working on following up on documentation with CCP and treatments. These were areas that have been identified as needing review and education to ensure policies and procedures are followed. Resident #100: Resident #100 was admitted to the facility with diagnoses of chronic obstructive pulmonary disease (COPD), obesity, and obstructive sleep apnea (intermittent airflow blockage during sleep). The MDS dated [DATE] documented the resident was cognitively intact and was able to make their needs known. During a review of the medication administration record (MAR) dated 2/2023, a physician order dated 11/3/2022 documented; Oxygen 3 liters via nasal canula at all times (AATs) for COPD. During a review of the treatment administration record (TAR) dated 2/2023, a physician order dated 11/3/2022 documented, BIPAP (bilevel positive airway pressure) every HS (hours of sleep) BIPAP Settings O2:3 at bedtime for COPD. During a review of the TAR dated 2/2023, a physician order dated 11/3/2022 documented; Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/ML- 1 vial inhale orally two times a day for COPD. During a review of the TAR dated 2/2023, a physician order dated 11/9/2022 documented; change nebulizer tubing every Wednesday day shift. During a review of the TAR dated 2/2023, a physician order dated 11/9/2022 documented; change oxygen tubing and ear cushions every Wednesday day shift. The comprehensive care plan (CCP) did not address the respiratory care needs of the resident with the diagnosis of chronic obstructive pulmonary disease (COPD) and the use of oxygen therapy, nebulized medications, and bilevel positive airway pressure (BIPAP) at hour of sleep. During an interview on 2/27/2023 at 3:55 PM, the Admissions Registered Nurse (RN) #1 stated the CCP did not document respiratory care needs with goals and interventions for the resident with COPD. During an interview on 2/28/2023 at 1:52 PM, the Registered Nurse Educator RN #2 stated a respiratory care plan should have been developed for the resident who use oxygen, nebulized medications and BIPAP at night. During an interview on 2/28/2023 at 02:21 PM, the Director of Nursing (DON) stated that a care plan with goals and interventions to the manage Resident #100's respiratory care should have been developed. 10 NYCRR 415.11(c)(1)

Based on record review and interviews during an abbreviated survey (Case #NY 840), the facility did not ensure that each resident was treated with respect and dignity for 1 (Resident #1) of 3 residents reviewed. Specifically, on 9/25/2022, the facility did not ensure Resident #1 was treated with respect and dignity, when a facility staff member used their foot to arouse Resident #1 who had lowered themselves to the floor and was not responding to staff's requests to get off the floor. This is evidenced: Resident #1: Resident #1 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS- an assessment tool) dated 9/20/2022, documented the resident had severe cognitive impairment. The facility policy and procedure (P&P) titled Resident Rights revised 1/2022, documented employees would treat all residents with kindness, respect, and dignity. The P&P documented that Federal and State laws guaranteed certain basic rights to all residents of the facility. Residents had the right to a dignified existence and to be treated with respect, kindness, and dignity. The P&P titled Quality of Life - Dignity revised/reviewed 1/2022, documented that each resident would be cared for in a manner that promoted and enhanced quality of life, dignity, respect, and individuality. The P&P documented residents would be treated with dignity and respect at all times. Review of the Comprehensive Care Plan (CCP) documented that the resident had difficulty understanding their surroundings related to cognitive impairment. Prior to admission, the family noted continuous cognitive decline including paranoid thoughts, wandering, and overall disorientation. The CCP interventions documented to provide support and ensure the resident was free from abuse. The facility investigation for date of incident 9/25/2022 at 2:15 PM, documented that at approximately 9:00 PM, the Director of Nursing (DON) received a call from the Licensed Practical Nurse (LPN). The LPN stated that Registered Nurse Manager (RNM) #1 was physically inappropriate towards a resident earlier in the shift. The LPN noted that RNM #1 kicked Resident #1, after the resident lowered themselves to the floor. The DON called the Administrator and started an investigation. During an interview on 10/28/2022 at 12:34 PM, RNM #1 stated that Resident #1 had attempted to elope from the facility and was being combative with staff. When the resident came to the unit, they put themselves on the floor and would not get up. RNM #1 stated that the resident was not responding to verbal instruction to get off the floor and after shaking the resident, the resident still did not move. RNM #1 stated that they then used their foot to nudge the resident on their shoulder. RNM #1 stated that it was wrong to use their foot and stated that they had been working a lot of hours and their back was hurting too much to be able to bend down. RNM #1 stated that they had slippers on at the time. RNM #1 stated they cared about the resident and should have asked other staff to intervene. During an interview on 10/28/2022 at 1:11 PM, Certified Nurse Aide (CNA) #1 stated that the resident tried to elope from the building. When the resident returned to the unit, the resident put their hands on the counter and gently lowered themselves to the floor. CNA #1 stated that they and other staff told the resident that they had to get off the floor and the resident did not respond. CNA #1 stated that RNM #1 went over to the resident and nudged the resident on their shoulder with their foot. CNA #1 stated that RNM #1 should not have used their foot to get the resident to respond. During an interview on 10/31/2022 at 11:57 AM, CNA #2 stated that they saw Resident #1 put themselves on the floor. CNA #2 stated that they went over to the resident, asked if they were okay and told the resident they should not be on the floor. CNA #2 stated that they left the resident so they could calm down because the resident had been combative a few minutes prior. CNA #2 stated that another resident started screaming that a resident was on the floor. CNA #2 stated that they and RNM #1 tried to get the resident off the floor by taking the resident's hands, but the resident would not move. CNA #2 stated that RNM #1 then used their foot and tapped the resident on their shoulder to get their attention. CNA #2 stated that RNM #1 should not have used their foot to arouse the resident. During an interview on 10/31/2022 at 3:51 PM, the Administrator (ADMIN) #1 stated that the expectation was for staff to always use their hands when arousing or providing care. ADMIN #1 stated that RNM #1 could have called someone else over to provide that arousal piece. The ADMIN #1 stated that RNM #1 was reeducated. 10 NYCRR 415.5(a)

Based on record review and interviews during an abbreviated survey (Case # NY 840), the facility did not ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse to the Administrator of the facility and to the State Agency for 1 (Resident #1) of 3 residents reviewed. Specifically, the facility did not ensure that an allegation of physical abuse observed by the Licensed Practical Nurse (LPN) on 9/25/2022, was reported to the Administrator and the New York State Department of Health (NYSDOH) within 2 hours after the allegation was made. The allegation was reported to the facility Administrator approximately 7 hours after the allegation was made and was not reported to the NYSDOH until approximately 5 weeks later on 11/2/2022. This is evidenced by: Resident #1: Resident #1 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS- an assessment tool) dated 9/20/2022, documented the resident had severe cognitive impairment. The policy and procedure (P&P) titled Abuse Prevention Program/Abuse and Neglect - Clinical Protocol/Abuse Investigation and Reporting revised 1/2022, documented residents had the right to be free from abuse. Any person who had knowledge or reason to believe that a resident had been the victim of mistreatment, abuse, neglect, or any criminal offense was to report or cause a report to be made of the mistreatment or offense. A person would not knowingly fail to report an incident of mistreatment or other offenses; screen reports or withhold information to reporting agencies. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property would be reported by the facility Administrator, or his/her designee to the named persons/agencies, including the State licensing/certification agency responsible for surveying/licensing the facility. Alleged violations would be reported immediately, but not later than 2 hours if the alleged violation involved abuse or had resulted in serious bodily injury, or within 24 hours if the alleged violation did not involve abuse and had not resulted in serious bodily injury. The facility investigation for date of incident 9/25/2022 at 2:15 PM, documented that at approximately 9:00 PM, the Director of Nursing (DON) received a call from the LPN. The LPN stated that Registered Nurse Manager (RNM) #1 was physically inappropriate towards a resident earlier in the shift. The LPN noted that RNM #1 kicked Resident #1, after the resident lowered themselves to the floor. The DON called the Administrator and started an investigation. The NYSDOH Intake Information form (Case # NY 840) dated 10/17/2022, documented an addendum dated 11/2/2022, for receipt of a facility reported incident that occurred on 9/25/2022 at 2:20 PM. During an interview on 10/28/2022 at 1:24 PM, LPN #1 stated that a resident yelled out that a resident was on the floor. LPN #1 went to check and saw Resident #1 on the floor, and they were not moving. LPN #1 shook the resident, and the resident still did not move. LPN #1 stated that RNM #1 went over to Resident #1 and kicked the resident. LPN #1 stated that they did not know why RNM #1 kicked the resident and stated that maybe they did that because the resident was not responding. LPN #1 then stated that the resident had shut her eyes tight and stated that they did not think that RNM #1 saw the resident do that before they kicked them. LPN #1 stated that they did not report the incident right away because they had talked to other staff about it and was told that if it was reported, no action would be taken. LPN #1 then stated that it was the weekend, and they did not have the Administrator (ADMIN) #1's phone number. LPN #1 stated that later that day, they went upstairs to another unit and talked to another nurse about it and was told that they needed to report it. During an interview on 10/31/2022 at 9:38 AM, the DON stated that LPN #1 reported an allegation of abuse to them, and it was not reported to the NYSDOH. The DON stated that they investigated the incident and determined there was no abuse, and therefore, determined that it was not reportable because of the outcome of the investigation. The DON stated they did not fully understand the regulation for reporting and stated that they could the see the importance of reporting the allegation right away. The ADMIN #1 was present and stated their understanding was to do the investigation and report as necessary. During an interview on 11/2/2022 at 11:25 AM, the ADMIN #1 stated that they were notified of the incident by the DON on 9/25/2022 at 9:15 PM. 10 NYCRR 415.4(b)(2)

Based on observation, record review, and interviews during an abbreviated complaints survey (Case #NY 129), the facility did not ensure a resident with an indwelling catheter (a tube inserted into the bladder to drain urine), received the appropriate care and services to prevent urinary tract infections ([CONDITION(S)]) to the extent possible for 1 (Resident #3) of 9 residents reviewed for urinary incontinence/urinary tract infection requiring an indwelling urinary catheter (tube placed in the bladder to allow urine to drain out of the body). Specifically, for Resident #3, the facility did not ensure the medical doctor orders were followed regarding the resident's Foley catheter and daily monitoring for patency, adequate intake, and output. Additionally, a method of monitoring was not put in place to observe changes in urine amount, color, and odor that would identify complications and needed treatment. This is evidenced by: Resident #3 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS- an assessment tool) dated 5/15/2022, documented the resident could be understood and could understand others. The Policy and Procedure (P&P) titled Catheter Care, Urinary, last updated 1/2022 documented to change catheter based on clinical indications and clean the peri area with routine hygiene during bathing and showering. Steps in the cleaning process included, washing the genitalia and perineum thoroughly with soap and water, rinsing and towel drying the area; cleansing around the urethral meatus (opening to the bladder) and use of a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward. It further documented the following: 1. Observe the resident's urine level for noticeable increases or decreases. If the level stays the same, or increases rapidly, report it to the physician or supervisor. 2. Observe the resident for complications associated with urinary catheters. 3. Check the urine for unusual appearance (i.e., color, blood, etc.) 4. Document the date and time catheter care was given and name and title of individual giving the catheter care. Character of urine such as color (straw colored, dark or red), clarity (cloudy, solid particles, or blood,) and odor. The Comprehensive Care Plan (CCP) for Urinary Incontinence, initiated on 6/24/2021 and last updated on 4/08/2022, did not address the placement of the indwelling catheter or monitoring of the catheter inserted on 6/02/2022. Resident #3 was not observed during survey from 6/29/2022 to 7/01/2022. Resident #3 was sent out to the hospital on 6/26/2022, prior to survey. A Nursing Progress Note dated 6/1/2022 at 2:24 PM, documented the resident was having problems with urinary retention. Seen by MD (medical doctor): ordered labs, Foley, medication, and urology consult. At 11:35 AM insertion of 14 fr. (French) Coude (type of catheter). Noted green/yellow drainage under foreskin. Urine clear yellow, Resident tolerated well. C&S (culture and sensitivity, test for urine infection) sent to lab. A Nursing Progress Note dated 6/2/2022 at 11:38 AM, documented resident has not voided this shift since 5:30 AM. Straight cathed with very small amount of urine returned. PO (by mouth) fluids encouraged and will monitor for voiding. A 24-hour Supervisor Report dated 6/2/2022 documented; Resident #3 was not voiding by self, if no voiding in 8 hours, straight cath and keep track of intake and output. Use #14 French coude, urine for C&S obtained and sent, Hematuria, output 300 mls. A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nursing Progress Note dated 6/3/2022 at 11:16 AM, urine in Foley has become bloody but with good output. A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Elevated PSA. A Nursing Progress Note dated 6/4/2022 at 4:08 PM, documented, resident remains with hematuria with good output. Urine C&S still pending. Denies any pain or discomfort. A Nursing Progress Note dated 6/4/2022 at 6:56 PM, documented resident remains with hematuria, Foley is running good at this time. A Lab Report dated 6/5/2022 at 8:01 AM, documented results of urine for C&S as follows: Urine Culture: >100,00 col/ml Proteus mirabilis (a gram-negative bacteria-infection) susceptible to [MEDICATION(S)]. A Nursing Progress Note dated 6/5/2022 at 3:35 PM, documented RN (Registered Nurse) assessed urine in Foley seems to be more urine color with bloody sediment. LPN (Licensed Practical Nurse) flushed Foley and removed large clots. An Electronic Treatment Administration Record (eTAR) dated June 2022 documented; irrigate Foley catheter with 60 ml. every shift if needed: NS started on 6/3/2022. Documentation demonstrated Resident #3's Foley was flushed twice on 6/5/2022. A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nursing Progress Note dated 6/6/2022 at 2:08 PM (RN Assessment), documented that Labs were reviewed with NP (nurse practitioner), urology consult ordered for elevated PSA and urine retention. Started on [MEDICATION(S)] DS for positive [CONDITION(S)]. Documentation on a 24-hour Supervisor Report dated 6/6, 6/7, 6/8, 6/9, and 6/10/2022 documented, Resident #3 was positive for a [CONDITION(S)]. Antibiotic until 6/13/2022. Documentation on a 24-hour Supervisor report dated 6/26/2022 documented; Resident #3 had a fall 6/26/2022 with head involvement. Mental status changes at 2:20 PM, sent to ER. No urine output. HCP notified. Vital signs B/P 125/65, temperature 97.7, respirations 18, pulse 104. A Nursing Progress Note dated 6/10/2022 at 9:00 AM (RN Assessment) documented, resident continues with hematuria via foley catheter. Bag drained approximately 350 cc urine. Awaiting urology appointment. Vital signs within normal limits. A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Continue antibiotic, monitor intake and output. A Nursing Progress Note dated 6/17/2022 at 6:16 PM, documented Resident #3 out for appointment with urology, returned with the following instructions: Please continue indwelling foley catheter, complete [MEDICATION(S)]. Continue [MEDICATION(S)] 0.4 mg nightly. Start [MEDICATION(S)] 5 mg daily. Please do passive voiding trial in AM on July 7th. Monitor urine output. If resident is in distress or adequate urine output is not noted, replace a new 16 French indwelling foley. Follow up 7/11/2022 at 2:30 PM. The Urology Physician Summary dated 6/17/2022 at 1:30 PM, documented the following, continue with indwelling foley catheter, Complete [MEDICATION(S)], Continue [MEDICATION(S)] 0.4 mg nightly, start [MEDICATION(S)] 5 mg, do voiding trial on 7/7/2022, monitor urine output. If in distress or if adequate urinary output is not noted replace with a new 16 fr indwelling catheter. Schedule a 1 to 2 week follow up after voiding trial. 7/11/2022 at 2:30 PM. Findings [CONDITION(S)], unspecified whether lower urinary tract symptoms present, Phimosis, and elevated prostate specific antigen (PSA), B/P 104/62, BMI 22.81, Weight 150 lbs., Temp. 97.7, Pulse 70, Respiration 18. A Nursing Progress Note dated 6/26/2022 at 11:32 AM, documented resident found on landing mat, doesn't appear to be hurt, foley intact. Assessment, family, and MD made aware. Neuros started. A Nursing Progress Note dated 6/26/2022 at 2:15 PM, documented resident transferred to hospital for mental status changes and B/P (blood pressure) 84/56. Urine is cloudy and scant. Family made aware. A Nursing Progress Note dated 6/26/2022 at 5:18 PM, documented resident diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Bed hold completed. An Electronic Treatment Administration Record (eTAR) dated June 2022, documented: irrigate foley catheter with 60 ml NS (normal saline, irrigating solution). every shift if needed: NS started on 6/3/2022. Documentation demonstrated Resident #3 Foley was flushed twice on 6/5/2022. During an interview on 6/29/2022 at 1:56 PM, the Certified Nursing Assistant (CNA) #2 stated the foley catheter collection bags are emptied every shift. There is a task in the CNA documentation to record the amount of output. If it is a different color or smells, we let the nurse know. During an interview on 6/29/2022 at 3:31 PM, CNA #3, stated Resident #3 was a resident they were familiar with. If the resident had poor output, they would inform the nurse. Foley collection bags were emptied on each shift or as needed. An unusual smell or color is reported to the nurse. The resident urine had been pink tinged sometimes and was good until the day of the fall on 5/26. Resident #3's urine was dark and very concentrated that day. The resident hadn't been drinking but the nurse was aware. We record Intake and Output in the CNA task on the computer. No documentation could be found by CNA#3 that this had been documented from the time the resident had the foley placed on 6/2/2022. CNA #3 indicated it had been done every shift, but not recorded in CNA task. During an interview on 6/29/2022 at 3:53 PM, the Admissions Registered Nurse stated Resident #3 was having problems voiding. The physician was notified on 6/2/2022 and an order to straight cath the resident was obtained. The residents I and O was to be monitored and a urine culture and sensitivity was obtained and sent out. A green/yellow drainage was noted around Resident #3 foreskin. The doctor was made aware and a consult for urology was done. This information was passed along to the RN in charge. RN #2 stated no adjustments were made to the CCP at that time and should have been. A task should have been put in place on the CNA documentation so intake and output would be monitored and recorded. During an interview on 6/29/2022 at 4:26 PM, Registered Nurse #1 stated there had been monitoring of the foley and the resident's intake and output from the time the foley was placed. It just got missed on the eMar/eTar and the CNA task. The RN #1 was the acting Unit Manager and the CCP for urinary incontinence had not been updated once the foley catheter was placed. During an interview on 6/30/2022 at 11:15 AM, the Assistant Director of Nursing (ADON) stated there was no documentation on Resident #3's Intake and Output on the CNA documentation. When the foley was placed according to the facility policy the CNA task that accomplishes this was not triggered. The resident should have been monitored as directed by the physician and the facility policy daily. The CCP for urinary incontinence had not been updated reflecting Resident #3 had a foley placed. If documentation is not done things can be missed and delivery of care can't be consistently reported to the physician. Staff will need to be reeducated. During an interview on 6/30/2022 at 1:27 PM, the Administrator stated the facilities policy on monitoring the foley catheter had not been done but should have been to ensure the best care was delivered to the resident. During an interview on 7/01/2022 at 10:45 AM, the Director of Nursing (DON) stated Resident #3 did have a CCP for urinary incontinence and this should have been updated documenting the placement of the foley and all goals and interventions. Education would be given to ensure monitoring and recording of intake and output was done as ordered by the physician. This had been missed. The CNA's reported color and decreased amount but without consistent documenting and monitoring we could not be sure if any problem existed prior to the resident's transfer to the hospital. 10NYCRR415.12(d)(1)

Based on record review and interviews during an abbreviated survey (Complaint #NY 753) the facility did not ensure the resident's right to be free from abuse for 1 (Resident #1) of 3 residents reviewed for abuse. Specifically, the facility did not ensure Resident #1 was free from abuse by a Certified Nursing Assistant on 11/17/2021 and 11/19/2021. This is evidenced by: The Policy and Procedure (P&P) for Abuse dated 10/1997 and last revised in 1/2021 documented every resident had the right to be free of abuse. All personnel were to attempt to immediately stop an abuse and promptly report the incident or suspected incident of resident abuse. Resident #1 was admitted to the facility on [DATE] with Alzheimer's disease, metabolic [CONDITION(S)] and alcoholic-induced [CONDITION(S)]. The Minimum Data Set (an assessment tool) dated 11/14/2021 documented the resident had severely impaired cognition, could usually make themself understood and had the ability to understand others. A Comprehensive Care Plan (CCP) dated 11/16/2021 documented Resident #1 exhibited inappropriate behavior, and staff were to identify triggers, provide a quiet area, provide diversional activities and administer [CONDITION(S)] medications as ordered. A Summary of Investigation dated 11/20/2021 at 9:00 PM documented that on 11/20/2021 at 9:00 PM Certified Nurse Aide (CNA) #2 reported to the Administrator on Duty (AOD) that they witnessed Certified Nursing Assistant (CNA) #1 being physically abusive to Resident #1. Incident 1: An undated statement from CNA #2, provided with the investigation dated 11/20/2021 documented that on Wednesday, 11/17/2021 they witnessed Resident #1 spit at CNA #1. CNA #1 swore at Resident #1 and dragged the resident into their room by the back of their neck with the resident's hair between their fingers. CNA #1 pushed the resident face-first onto the bed with the resident's knees on the floor. CNA #1 continued to push the resident's face into the mattress and yelled at them about not spitting again. When Licensed Practical Nurse (LPN) #2 got to the resident's room they told CNA #1 to stay away from the resident. A statement dated 11/22/2021 by LPN #1 documented that on Wednesday, 11/17/2021 they told CNA #1 to take Resident #1 to their room where they could give a medication. When they got to the resident's room and saw the resident laying across the bed with CNA #1 standing behind them holding the resident onto the bed by their shoulders. CNA #1 yelled at the resident and told them that it was disgusting and unacceptable behavior. The LPN told CNA #1 to let go of the resident and leave the room and to stop yelling at the resident. The LPN documented that they told the CNA a couple of times before they let go. The CNA was very angry that the resident had spit on them. Incident 2: A statement by CNA #4, dated Friday, 11/19/2021 documented that on Friday, 11/19/2021 at about 4:40 PM they witnessed CNA #1 very angry and stated the resident spit on them and right away grabbed the resident from their wheelchair, stood them up by the neck and dragged them to their room. CNA #4 followed them and witnessed CNA #1 pin the resident down on their bed. The resident screamed OK, OK. CNA #4 told CNA #1 I got it, please leave the room. After they got the resident to settle down, they told CNA #2 what happen and their response was Oh, I know they did that the other day. An undated statement from CNA #2, provided with the investigation dated 11/20/2021 documented that on Friday 11/19/2021, CNA #2 heard CNA #1 yelling at Resident #1 and bragging about his take down, of the resident. Residents were present and one resident stated, watch out for this one, he will kick your ass and CNA #1 laughed. During an interview on 12/7/2021 at 3:20 PM CNA #2 stated that on Wednesday, 11/17/2021 Resident #1 spat in CNA #1's face and CNA #1 became angry, swore at the resident and grabbed the resident's left arm and the back of the resident's neck and pulled them into their room. CNA #2 stated they were startled to see CNA #1 do this and followed them to the resident's room. From the doorway they witnessed CNA #1 throw the resident onto the bed face down with their knees on the floor and CNA #1 held the resident down with their hands on the resident's shoulders. During an interview on 12/8/2021 at 3:30 PM CNA #3 stated that on Wednesday, 11/17/2021 they were giving care to another resident but could hear a loud commotion. When they finished care, they went to Resident 1's room and witnessed CNA #1 holding Resident #1 face down on the bed with their hands on the resident's shoulders and the resident was yelling out. CNA #3 stated that they did not try to stop CNA #1. During an interview on 12/8/2021 at 1:50 PM LPN #1 stated that on the evening shift on Wednesday, 11/17/2021 Resident #1 had been combative and aggressive. The resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The LPN told CNA #1 to bring the resident to their room, and that they would administer an antipsychotic medication. When the LPN got to the resident's room the CNA had their hands on the resident's back holding them down and pushing the resident's face into the mattress. The LPN stated that they told the CNA several times you need to let (the resident) go, and the CNA did not release the resident right away. The LPN stated that once the CNA released the resident, they told the CNA to leave the room. During an interview on 12/7/2021 at 11:58 AM the Director of Nursing (DON) stated that, on 11/17/2021, CNA #1 had stated that he brought Resident #1 to their room due to behaviors. However, statements from other staff said CNA #1 had moved Resident #1 by the back of the neck. The two witnesses to the incident also stated CNA #1 had Resident #1 by the back of the neck and held the resident down on the bed. During a subsequent interview on 12/8/2021 at 12:58 PM the DON stated that Incident #2 occurred on 11/19/2021 at about 9:00 PM and was reported to them the next evening on 11/20/2021 at about 9:00 PM by the AOD. 10 NYCRR 415.4 (b)(1)(i)

Based on interviews and record review, during a COVID-19 Focused Infection Control Survey completed on 1/22/21, the facility did not ensure that it maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicated otherwise for 1 (Resident #1) of 3 residents reviewed for nutrition. Specifically, the facility did not ensure Resident #1, who had a documented decline in food intake, change in condition, and was newly diagnosed with [REDACTED]. This is evidenced by: Resident #1: Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had moderate cognitive impairment, could understand others and could make self understood. The MDS documented the resident weighed 220 pounds (lbs.). A Policy and Procedure (P&P) titled Weight Assessment and Intervention, last revised on 1/2021, documented nursing staff was to measure resident weights were to be measured monthly. A Comprehensive Care Plan (CCP) for Nutrition, last reviewed on 12/16/20, documented Resident #1 was at an increased nutrition risk related to type 2 diabetes, cerebral infarction and a history of dysphagia. Goals included the resident would be free from undesired significant weight changes and would be adequately nourished and hydrated via intake from meals and fluids. Interventions included: monitor meal consumption records, monitor weights as needed per facility protocol, and report significant weight loss to the Medical Doctor (MD) and Interdisciplinary Team for input. The care plan did not address the resident's decline in food intake, change in condition, or [DIAGNOSES REDACTED]. A facility COVID-19 line list documented Resident #1 tested positive for COVID-19 on 1/4/21 and exhibited symptoms of a cough on 1/5/21. A physician's orders [REDACTED]. A Nutrition Assessment completed on 12/9/20, documented the resident's weight was 220.2 lbs. and food intake was 50-75%. The assessment documented the resident's weight had been stable within 5 lbs. x 10 months and continued to be monitored monthly. The assessment documented the Registered Dietitian (RD) would continue to monitor intake/weight trends with changes made to plan of care as needed. A change in condition note dated 12/30/20, documented Resident #1 presented with the following change in condition: vomiting and flank pain on the left side. A change in condition note dated 12/31/20, documented the resident presented with uncontrolled pain. The noted documented the resident had intermittent recurrent nausea and vomiting. A progress note dated 1/4/21, documented the resident was rapid tested for the COVID-19 virus and the test returned a result of positive. A dietary note dated 1/6/21, documented the resident had a COVID-19 positive test and was noted to have flank pain and a cough. The resident was showing decreased intake over the last few days with episodes of emesis noted. The Registered Dietitian (RD) documented to further monitor symptoms inhibiting intake with interventions initiated as needed. A dietary note dated 1/19/21, documented the resident's intake had increased from initial COVID-19 diagnosis, however the resident's intake decreased again over the past week. The note documented the RD was to implement an intake study and supplementation and documented the resident's monthly weight was still not obtained. A review of meal intakes from 12/31/20 to 1/18/21 revealed there were 57 opportunities to document meal intakes (19 days x 3 meals per day = 57 opportunities); 26 meal entries documented the resident's intake was 0-50% and there was no documentation of intake for 15 meals during that time period. During a record review on 1/19/21 at 12:30 PM, Resident #1's weights were as follows: 10/5/20 = 217 lbs. 11/2/20 = 215.6 lbs. 12/3/20 = 220.2 lbs. 1/19/21 = 192.4 lbs. (obtained during survey on 1/19/21 at 3:45 PM, and revealed a 12.6% weight loss since 12/3/20). During an interview on 1/19/21 at 3:05 PM, the Registered Dietitian (RD) #1 stated she was aware a weight had not been obtained for Resident #1 for the month of January. She stated it had been difficult to get resident weights obtained because the residents were supposed to be in their rooms due to COVID-19. Resident #1 was on monthly weights and his/her weights had been stable. She stated the resident's intake had been declining based on the documentation, but she had not implemented any interventions. She did not know if the resident had lost weight related to the documented decline in intake and did not know the resident's overall nutritional status because she did not have a current weight to make that assessment. When she saw there was no weight for the month of January, she reported it during morning report where administration was made aware. RD #1 stated she had not gone over the resident's nutrition care plan since the documented decline in intake. Resident #1 was typically stable nutritionally and therefore, the nutrition care plan had been appropriate, but should have been updated to reflect the Resident's current changes. She stated an intake study and supplementation would start tomorrow, 1/20/21. During an interview on 1/19/21 at 3:10 PM, Director of Nursing (DON) stated Resident #1 should have had a monthly weight obtained during the first week of January. Resident #1's nutrition care plan should have been updated to reflect the resident's current status with the decrease in intake and COVID-19 diagnosis. The DON stated he had heard there were outstanding weights in morning report but he was not specifically aware that Resident #1 still needed to have a weight obtained for January. During an interview on 1/19/21 at 3:56 PM, the DON stated Resident #1 was weighed this afternoon (1/19/21) and weighed 192.4 lbs. He stated the policy for weighing residents did not change if the resident was positive for COVID-19 and the resident should have been weighed. He stated if the resident had been weighed during the first week of January, the facility could have intervened sooner and there could have been a different outcome regarding the amount of weight the resident lost. 10 NYCRR 415.12(i)(l)

Based on interviews and record review, during a COVID-19 Focused Infection Control Survey completed on 10/21/20, the facility did not ensure residents and facility staff providing services were tested and documented that testing was complete with the results of each test for COVID-19 that is consistent with current infection control measures during staff testing for COVID-19. Specifically, the facility failed to retest residents that tested negative every 3 to 7 days until testing identified no new cases of COVID-19 infection among residents for a period of at least 14 days since the most recent positive result. This is evidenced by: On 8/25/20, the Centers for Medicare & Medicaid Services (CMS) published Interim Final Rule number CMS3401-IFC, titled Medicare and Medicaid Programs, Clinical Laboratory Improvement Amendments of 1988 (CLIA), and Patient Protection and Affordable Care Act; Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency. This interim final rule provided, at 42 CFR section 483.80(h): The LTC (Long Term Care) facility must test residents and facility staff, including individuals providing services under arrangement and volunteers, for COVID-19. At a minimum, for all residents and facility staff, including individuals providing services under arrangement and volunteers, the LTC facility must: (1) Conduct testing based on parameters set forth by the Secretary (of Health and Human Services), including but not limited to: (i) Testing frequency. On 8/26/20, CMS's Center for Clinical Standards and Quality/Survey & Certification Group, issued guidance number QSO-20-38-NH, which set forth guidance relating to the 8/25/20 Interim Final Rule. The CMS guidance documented that upon identification of a single new case of COVID-19 infection in any staff or residents (i.e., an outbreak), 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 Facility Policy titled COVID-19 Testing Staff and Residents with a revised date of 8/28/20, documented under prioritizing testing, in the event of any new COVID -19 case in the facility, they will test all staff and resident that previously tested negative 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 facility received a positive COVID -19 result for Staff Member (SM) #1 on 8/26/20. Residents were tested on [DATE] and all tested negative (a time period of 7 days from the positive result). There was no further testing to ensure there were no new cases of COVID -19 infection among residents for a period of at least 14 days since the most recent positive result. The facility received a positive COVID -19 result for SM #2 on 9/15/20. Residents were tested [DATE] and 9/25/20 and all results were negative (a time period of 10 days from the positive result). There was no further COVID -19 testing done to ensure no new cases of COVID-19 for a period of at least 14 days. During an interview on 10/16/20 at 6:00 PM, the Director of Nursing stated they did not do a follow-up swab after the 9/2/20 swab because the staff member tested positive prior to effective date of QSO-20-38-NHs. He contacted NYS Epidemiology Division on 9/15/20. The facility did its initial test on all residents on 9/18/20 and a followup test the following week, on 9/25/20. The DON stated that the Epidemiolgy Division and he determined that testing frequency was acceptable. He must have misinterpreted what Epidemiology told him. He said he totally missed the next test date to get to the 14 days with no new cases. During an interveiw on 10/20/20 at 2:25 PM, the Administrator stated they did testing 7 days from the date of the positive staff test and then did one follow-up test. They recieved guidance from NYS Epidemiology and thought they were covered. Additionally, the positve result on 8/26/20 was prior to QSO-20-38-NH going into effect so they did not think it applied. 10 NYCRR 415.19(a)(1)

Based on record review and interview during a recertification survey, the facility did not esure that resident assessments accurately reflected the resident's status for 8 (Resident #'s 10, 43, 57, 70, 74, 85, 96, and #109) of 23 resident assessments reviewed. Specifically, for Resident #10, the facility did not ensure the Minimum Data Set (MDS) accurately reflected the resident's status related to pain management, for Resident #43, the facility did not ensure the Minimum Data Set (MDS) accurately documented the resident had a severe hearing impairment and did not utilize a hearing aid; for Resident #57, the facility did not ensure the MDS accurately reflected the resident was receiving [MEDICAL TREATMENT] care and services; for Resident #70, the facility did not ensure the MDS accurately reflected the resident had a fall with a major injury; for Resident #74, the facility did not ensure the MDS accurately reflected the resident had a vascular wound; for Resident #85, the facility did not ensure the MDS accurately reflected the resident's use of antibiotics [MEDICAL CONDITION] in his/her urine; for Resident #96, the facility did not ensure that the MDS accurately reflected the resident's status related to a recent fall and did not ensure the MDS accurately documented the resident's use of antidepressant and antianxiety medications; and for Resident #109, the facility did not ensure the resident's pressure ulcers were accurately reflected in the assessment. This is evidenced by: Resident #43: Resident #43 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-an assessment tool) dated 8/14/20, documented the resident had a minimal hearing impairment and used a hearing aid or other hearing appliance. During an observation on 10/16/20 at 12:10 PM, the resident was unable to hear normal conversation, or very loud speaking. Resident #43 requested to be spoken to loudly directly near his ear, and stated, I can't hear. A Comprehensive Care Plan for hearing loss to bilateral ears, documented that on 7/12/20 the resident placed his hearing aides in water and they were unfixable. During an interview on 10/16/20 at 12:22 PM, Certified Nursing Assistant #3 stated the resident is very hard of hearing and required the use of a white board or pen and paper to communicate with staff. CNA #3 stated the resident has not had a hearing aid in a long time, and he refused to use them when he did have them. During an interview on 10/19/20 at 4:23 PM, MDS Coordinator (MDSC) #2 stated Resident #43 could not understand normal or loud conversation secondary to the inability to hear. MDSC #2 stated she did not know how to code the MDS accurately when a resident previously had a device, and no longer did. MDSC #2 reviewed the MDS manual during this interview and stated she inaccurately coded Resident #43's MDS assessment. Resident #70: Resident #70 was admitted to the facility with the [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - an assessment tool) dated 9/4/2020, documented the resident had severely impaired cognition, could usually understand others and could usually make self understood. The Comprehensive Care Plan (CCP) for falls, revised on 9/2/20, documented the resident had a history of [REDACTED]. The CCP for Alteration in Physical Function, revised on 9/2/20, documented the resident had [MEDICAL CONDITION] and a left [MEDICAL CONDITION]. A progress note dated 7/15/20, documented the resident fell in his/her room and landed on his/her left side. The resident's sneakers were not laced or tied and (there was) no head involvement. He/she complained of left hip pain. A subsequent progress note dated 7/15/20, documented the resident complained of pain in his/her left hip and Tylenol was not helping the pain. The Nurse Practitioner was notified, and the provider said to send the resident out for possible fracture versus dislocation. A progress note dated 7/28/20, documented the resident was admitted to the facility with a [MEDICAL CONDITION] hip and had a hemiarthroplasty (surgical procedure that involves replacing half of the hip joint) of the left hip. The MDS dated [DATE] did not reflect that the resident had a fall with a major injury. During an interview on 10/20/20 at 9:33 AM, the MDS Coordinator stated Section J in the MDS dated [DATE] should have been coded as a fall with a major injury when the resident returned from the hospital. She stated the resident had fallen in the facility and fractured his/her hip. She stated section J did not reflect that the resident had a fall with a major injury, and it should have. During an interview on 10/20/20 at 9:56 AM, the Director of Nursing stated the resident's MDS should have been coded as a fall with a major injury considering the resident fell and fractured his/her hip. Resident #96: Resident #96 was admitted with the [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-an assessment tool) dated 9/28/20, documented the resident had moderately impaired cognition, could sometimes understand others and make self-understood. The MDS documented the resident had no falls since the previous assessment and the resident received an antidepressant and antianxiety medication on 7 out of 7 days during the look back period. The Centers for Medicare & Medicaid Services' RAI 3.0 Instruction Manual documented that the review period for any fall is from the day after the last MDS assessment to the current assessment. All available sources for any fall since the last assessment are to be rereviewed, including nursing home incident reports, fall logs, and the medical record progress notes. The RAI manual documents that certain medication classifications include a seven day look back to record the number of days a resident received a class of medications. The resident's medical record included a nursing progress note dated 9/10/20 that documented the resident was found on the floor in his room and complained of hitting his head. The resident's comprehensive care plan (CCP) for falls documented a fall on 9/10/20. The resident's Medication Administration Record [REDACTED]. During an interview on 10/20/20 at 11:38AM, the MDS Coordinator Registered Nurse #2, stated that she obtained the information for the MDS through a review of the resident's clinical records and by visiting the resident on the unit. She stated that she sometimes missed things and had recently been reviewing the previously submitted MDS assessments to make modifications and correct errors. She stated the antidepressant was entered inaccurately and did not believe the antianxiety medication had been coded inaccurately. The information regarding the resident's fall was corrected by the MDS Coordinator on 10/19/20. 10NYCRR415.11(b)

Based on observation, record review and interviews during the recertification survey the facility did not develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 9 (Resident #'s 10, 57, 74, 75, 85, 100, 103, 104 and #313) of 23 residents reviewed for comprehensive care plans (CCPs). Specifically, for Resident #10, the facility did not ensure the CCP included resident specific and non-pharmacological interventions to address the resident's pain; for Resident #'s 100 and 104, did not ensure nutrition CCP's included resident specific information or interventions; for Resident #57, did not ensure the intervention to monitor labs on the CCP for Fluid/Electrolyte Imbalance was implemented; for Resident #313, did not ensure the intervention for off loading boots on the CCP for risk for pressure ulcers was implemented; for Resident #103, did not ensure the development and implementation of a comprehensive person- centered care plan to meet the needs of the resident with the [DIAGNOSES REDACTED].#74, did not ensure a care plan for the management of pain was resident specific and included non-pharmacological interventions for pain management; for Resident #75, did not ensure a CCP was developed and implemented for the management of weight loss; for Resident #109, the facility did not ensure a care plan was developed for the care and treatment of [REDACTED].#85 the facility did not ensure there was a CCP to [MEDICAL CONDITION] (multidrug resistant organism) in the resident's urine and that the resident was on isolation for it. This is evidenced by: The facility policy titled Care Plan, Comprehensive Person-Centered, last revised 3/2020 documented; A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The facility policy titled Care Planning- Interdisciplinary Team, last revised 3/2020 documented; A comprehensive care plan for each resident will be developed within seven (7) days of completion of the resident's assessment (MDS). Resident #10: Resident #10 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-an assessment tool) dated 7/22/20 documented the resident was without cognitive impairment. physician's orders [REDACTED]. The Medication Administration Record [REDACTED]. The above MAR indicated [REDACTED]. During an interview on 10/14/20 at 11:26 AM, the resident stated I'm in too much pain to talk. During an interview on 10/14/20 at 11:35 AM, LPN #3 stated she had already administered the resident's pain medication and was not aware of any other interventions that were specific to alleviating this resident's pain. LPN #3 also reported the resident had refused routine medications yesterday (including those to manage pain) which may be the cause of increased pain today. All medications have been accepted today and LPN #3 expects the resident's pain to be relieved soon. The CCP titled Alteration in Comfort related to Diabetic [MEDICAL CONDITION] was initiated on 3/27/20 and last updated on 10/20/20. The CCP documented interventions to; administer medications as ordered, assess pain, evaluate effectiveness of pain interventions, monitor for signs of pain and utilize appropriate non-pharmacological (pharm) interventions, and monitor for probable cause of pain. During an interview on 10/20/20 at 01:29 PM, the Director of Nursing (DON) stated he initiated the CCP for [MEDICAL CONDITION] and did not review it for thoroughness as he should have. It does not have non-pharm interventions as it should and is not person-centered as it should be. Resident #103: The resident was admitted with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - an assessment tool) dated 9/28/20 documented the resident had moderate cognitive impairment. The medical record did not include a comprehensive person-centered care plan for the resident's dementia diagnosis. On 10/20/20 at 11:00 AM, Registered Nurse (RN) #1 stated all care plans are resolved in the computer when a resident is discharged . Resident #103 was discharged to the hospital on [DATE] and readmitted on [DATE]. A new care plan for dementia should have been developed upon readmission. On 10/20/20 at 11:30 AM, the Admissions Registered Nurse #3 stated a dementia care plan should have been developed. On 10/20/20 at 12:10 PM, RN #4 (Unit Manager) stated the Interdisciplinary Team (IDT) reviews and revises the baseline care plans and a person-centered dementia care plan should have been implemented. On 10/20/20 at 2:00 PM, the Director of Nursing (DON) stated that a care plan for the resident's [DIAGNOSES REDACTED]. Resident #74: Resident #74 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-an assessment tool) dated 9/11/20, documented the resident received as needed pain medication for pain, and that the resident's pain was frequent. The resident did not have cognitive impairment. The Comprehensive Care Plan (CC) titled Resident has an Alteration in Comfort related to Wound Status and [MEDICAL CONDITION], last revised on 6/23/20, included interventions to administer medications as ordered and give pain medication prior to treatments and therapy sessions. The Medication Administration Record [REDACTED]. The result of the medication for pain was documented as effective or unknown. During an interview on 10/19/20 at 2:03 PM, Licensed Practical Nurse (LPN) #5 stated the resident did not receive non-pharmacological interventions for pain. LPN #5 stated the care plan did not reflect nonpharmacological interventions for the management of pain. During an interview on 10/20/20 at 12:40 PM, the Director of Nursing (DON) stated a resident receiving narcotic pain medication should have a comprehensive person-centered care plan that included non-pharmacological interventions for the management of pain. The DON stated the resident should have a note in the medical record reflecting if the narcotic pain medication given was effective or not effective. 10 NYCRR 415.11(c)(1)

Based on record review and interviews during a recertification survey, the facility did not ensure (i) A resident received care, consistent with professional standards of practice, to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable; and (ii) A resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (Resident #109) of 3 residents reviewed for pressures ulcers. Specifically, for Resident #109, the facility did not ensure professional standards of practice for infection control were followed during a pressure ulcer dressing change; did not ensure the intervention on the Comprehensive Care Plan (CCP) for turning and positioning the resident from side to side every 2 hours while in bed was implemented and monitored; and did not ensure a physician's orders [REDACTED]. This is evidenced by: Resident #109: The resident was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had three stage 3 pressure ulcers (localized areas of tissue necrosis (dead) that typically develop when soft tissue is compressed between a bony prominence and an external surface for a long period of time, involves full-thickness skin loss potentially extending into the subcutaneous tissue layer) and 3 stage 4 pressure ulcers (full thickness tissue loss with exposed bone, tendon or muscle) that developed while a resident at the facility. The Minimum Data Set (MDS-an assessment tool) documented the resident had severe cognitive impairment and required extensive assist with the physical support of 2 persons for bed mobility. A document titled RN: Weekly wound assessment dated [DATE], documented an unstageable pressure ulcer to the right buttock, an unstageable pressure ulcer to the left buttock, and a suspected deep tissue injury (a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) to the right and left heel were present. A document titled RN: Weekly wound assessment dated [DATE], documented the resident had a stage 3 pressure ulcer on the right buttock, an unstageable pressure ulcer (pressure ulcers where the base of the sore is not visible to determine the stage) to the left buttock with undermining and tunnel areas not visible from the opening in the skin, a right heel unstageable pressure ulcer and a left heel unstageable pressure ulcer. Finding #1: The facility did not ensure infection control practices were maintained according to acceptable standards of practice during the observation of a dressing change. The Policy and Procedure (P&P) for wound care date 3/20 documented gloves should be removed and hand hygiene should be performed after removing a soiled dressing, use gauze to catch irrigation solution that is poured directly over the wound, to wear sterile gloves when holding a moist surface over the wound or physically touching the wound. A physician's orders [REDACTED].), and cover with [MEDICATION NAME] (a wound dressing designed for wounds with heavy drainage) adhesive every day shift for wound care. A physician's orders [REDACTED]. During an observation on 10/16/20 at 9:27 AM, LPN #4 was observed performing wound care to the resident's right and left buttock. LPN #4 removed the outer layer of a dressing to the left upper buttock and removed the dressing covering the right upper buttock wound. LPN #4 did not change gloves or perform hand hygiene between removal of the dressings from both wounds. LPN #4 removed a dressing saturated in tan colored drainage from the base of the wound to the left upper buttock and a dressing saturated in tan colored drainage from the base of the wound on the right buttock. LPN #4 did not change gloves or perform hand hygiene between the removal of the dressings from the right and left buttock wounds. LPN #4 picked up a bottle of wound cleanser and sprayed the cleanser oonto the left buttock wound and right buttock wound. LPN #4 did not change gloves or perform hand hygiene prior to picking up the wound cleanser. Additionally, the wound cleanser liquid with wound debris from the left buttock wound drained into the right buttock wound. The Assistant Director of Nursing/ Wound Care Certified (ADON/WCC) Nurse was present during the dressing change. The ADON/WCC told LPN #4 to wash her hands. LPN #4 removed gloves, applied hand sanitizer, and put clean gloves on. The left and right buttock wounds were patted dry. LPN #4 then removed her gloves, and applied hand sanitizer and applied clean gloves. Each wound was packed with Maxsorb AG with gloves changed and hand hygiene performed between application of dressings. During an interview on 10/16/20 at 9:45 AM, LPN # 4 stated wound care to the left and right buttock was regularly performed together, despite the wounds being separate wounds and having separate MD orders for wound care. LPN #4 stated she was told by the ADON/WCC this morning that the wound care for each wound on the resident's buttocks were to be performed separately while the Department of Health was observing. LPN #4 stated she thought it was acceptable practice to remove both dressings and irrigate both wounds at the same time. LPN #4 stated she was unsure how to prevent the irrigation debris from the wound on the left upper buttock to not drip into the right upper buttock wound. LPN #4 stated she did forget to remove her gloves and perform hand hygiene on several occasions during the wound care, until she was instructed to do so by the ADON/WCC. During an interview on 10/16/20 at 10:01 AM, the Director of Nursing (DON) stated he would expect the removal of gloves, hand hygiene performed, and new gloves applied after removing a contaminated dressing, after irrigating a wound and before providing care from one wound to another. The DON stated the left and right buttock wound care should have been completed separately, the irrigation solution with debris from the left upper buttock wound should have been prevented from draining into the right upper buttock wound to prevent cross contamination of the wounds. The DON stated the facility recently had a mock survey and wound care was an area identified as needing improvement. The DON stated in mid-September 2020 education was provided to all licensed staff and performance evaluations were completed. Finding #2 The facility did not ensure the intervention on the Comprehensive Care Plan (CCP) for repositioning (turn and position the resident from side to side every 2 hours) while in bed was implemented and monitored. The P&P for repositioning revised 3/19, documented repositioning of the resident is a common, effective intervention for preventing skin breakdown, promoting circulation and providing pressure relief. Additionally, it documented positioning the resident on an existing pressure ulcer should be avoided since it puts additional pressure on tissue that is already compromised and may impede healing. The P&P instructs the use of two people to prevent shearing (occurs when layers of skin rub against each other or when the skin remains stationary & the underlying tissue moves & stretches & angulates or tears the underlying capillaries & blood vessels causing tissue damage) while turning and moving the resident in bed. The P&P for Pressure Ulcer Prevention revised on 3/20, documented the resident would frequently be repositioned when dependent on staff for positioning, and the care plan interventions and strategies would be reviewed for effectiveness on an ongoing basis. An at Risk for Impaired Dkin Integrity CCP, last revised on 8/4/20, documented the resident would be turned and positioned every 2 hours. A document titled Documentation Survey Report dated October 2020, documented an intervention/ task of turn and re-position at least every 2 hours to be documented every shift. On 10/15/20 and 10/16/20 for the 11 PM -7 AM shift, NA was placed in the signature box with a staff member's initials. The system response key noted on this document that NA indicated Not Applicable. Resident #109 was observed lying on his/her back in bed, with a pillow under her lower legs on a pillow on the following dates and times: 10/14/20 at 11:22 AM; 10/15/20 at 9:34 AM; 10/15/20 at 11:53 AM; 10/16/20 at 8:11 AM; 10/16/20 at 9:15 AM; 10/16/20 at 11:46 AM; 10/16/20 at 2:29 PM; 10/19/20 at 9:38 AM; and 10/19/20 at 11:34 AM. During an interview on 10/16/20 at 2:32 PM, CNA #2 stated tried to reposition the resident approximately every 2 hours. CNA #2 stated the resident required two persons and extensive assistance for bed mobility, however she completed the task by herself, as there wasn't enough staff to assist her. CNA #2 stated she did the best she could to reposition the resident. CNA #2 stated she isn't sure why the resident was laying on her back during each observation today. During an interview on 10/16/20 at 4:58 PM, Registered Nurse Unit Manager (RNUM) #4 stated she expected the resident to be repositioned every two hours with two staff assistance as the resident was care planned for. RNUM #4 stated the resident was unable to assist in repositioning him/herself. RNUM #4 stated she would expect a resident have his/her position alternated to side and back with each position change. RNUM #4 stated she was not aware the resident's position was not being changed or that staff were not available to reposition him/her effectively. RNUM #4 stated she would not expect the CNA's to document not applicable (NA) on the treatment record for turning and positioning of this resident. During an interview on 10/20/20 at 12:40 PM, the DON stated he expected the resident's care plan to be followed. He expected the resident to have a position change, alternating side to back to side, and not just laying on his/her back. The DON stated he would expect two staff members to turn and reposition the resident as he/she is care planned for. The DON stated he would not expect a staff member to document NA for the intervention of turn and position every 2 hours. Finding #3: The facility did not ensure a physician's orders [REDACTED]. A physician's orders [REDACTED]. An At Risk for Impaired Skin Integrity CCP, last revised on 8/4/20, documented the resident would have an air mattress applied to the bed, and it would be set at 150 pounds. Resident #109 was observed lying on his/her back in bed on an air mattress. The air mattress was set to 100 pounds on the following dates and times: 10/14/20 at 11:22 AM; 10/15/20 at 9:34 AM; 10/16/20 at 11:46 AM; 10/16/20 at 2:29 PM; 10/16/20 at 4:34 PM10/19/20 at 9:38 AM; and 10/19/20 at 11:34 AM. During an observation on 10/20/20 at 11:35 AM, Resident #109 was observed lying on his/her back in bed on an air mattress. The air mattress was set to 100 pounds. During an interview on 10/19/20 at 4:42 PM, LPN #5 stated she documented on the Treatment Assistance Record (TAR), the air mattress was set to 150 pounds today for the 7:00AM-3:00PM shift. LPN #5 stated she did not physically check the setting on the air mattress and just assumed it was accurate. LPN #5 checked the setting of the air mattress during this interview and noted it to be set at 100 pounds. During an interview on 10/19/20 at 4:50 PM, Registered Nurse Unit Manager (RNUM) #4 stated she would expect staff to confirm the air mattress was set per the MD orders to 150 pounds and as noted on the TAR prior to signing off that it was accurate. During an interview on 10/20/20 at 11:37 AM, RNUM #4 reviewed Resident #109's TAR and confirmed it should be set at 150 pounds, per the MD orders. RNUM #4 entered Resident #109's room with this surveyor and observed the resident laying in bed on an air mattress that was set to 100 pounds. RNUM #4 stated this should have been changed yesterday and set the air mattress to 150 pounds. During an interview on 10/20/20 at 12:40 PM, the DON stated he would expect the TAR to accurately reflect the care and services the resident received. The DON stated he would not expect staff to sign the TAR if the task was not performed. He stated he would expect Resident #109's air mattress to be set per the MD orders, and the staff should have corrected this on 10/19/20 when visualized by LPN #5 and brought to the attention of RNUM #5 as inaccurately set to 100 pounds. 10NYCRR415.12(c)(2)

Based on record review and interviews during a recertification survey the facility did not ensure that it maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for one (Resident #75) of five residents reviewed for nutrition. Specifically for Resident #75, the facility did not identify and address an ongoing weight loss, and the Medical Doctor (MD) was informed of the resident's weight loss. This is evidenced by: Resident #75: The resident was admitted to the nursing home with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having severely impaired cognitive skills for daily decision making. It documented the resident had no difficulty chewing or swallowing and weighed 129 pounds. A Policy and Procedure (P&P) titled Weight Assessment and Intervention, last revised on 03/2020, documented any weight change of 5 % or more since the last weight assessment will be retaken the next day for confirmation; the dietician will respond within 24 hours of receipt of written notification of significant weight change; the threshold for significant unplanned and undesired weight loss will be based on 1 month of a 5% weight loss is significant and greater than a 5% weight loss is severe. The P&P documented assessment information shall be analyzed by the multidisciplinary team and physician to assist in identifying conditions, clinical situation and or medications that may be causing the weight loss. A Patient Review Instrument (PRI), dated 9/7/20, completed at the hospital prior to the resident's admission documented the resident weighed 119 pounds. A physician's orders [REDACTED]. A Nutrition Assessment was completed on 9/15/20 and documented the resident's most recent body weight was 128.8 pounds on 9/9/20. It assessed the resident as not having difficulty chewing or swallowing. The goals assessed were to maintain weight. The resident's reported usual body weight was 130-150 pounds and the resident would be on weekly weights until a baseline weight was established. A Comprehensive Care Plan (CCP), with a revised date of 9/15/20, documented the resident would be adequately nourished and hydrated and the resident would maintain her weight. The CCP included interventions to monitor weights as needed per facility protocol and to report significant weight loss to the Medical Doctor (MD) and Interdisciplinary Team for input. A dietary note dated 9/18/20 documented the resident had a weight loss of 14.8 pounds, her intake was at goal and weights were varied. A dietary note dated 9/25/20 documented the resident had a 10-pound weight loss from last week and the resident's intake had been at goal since admission. It documented weekly weights would be until a true weight can be assessed and the resident had not lost 24 pounds since admission. A dietary note dated 9/29/20, documented the resident's first 2 weeks of weights were most likely incorrect and her PO intake was at goal. Weights were as follows: 09/09/20 = 128.8 lbs. 09/17/20 = 114 lbs. - weight loss of 11.5% since 9/9/20 09/25/20 = 104.2 lbs. - weight loss of 8.6% since 9/17 and weight loss of 19.1 % since 9/9/20 10/05/20 = 106 lbs. - weight loss of 17.7% since 9/9/20 During an interview on 10/20/20 at 1:14 PM, the Director of Nursing (DON) stated he would expect a resident with a weight loss of greater than 5 % to have daily weights implemented and an intake study completed. The DON stated he would expect the weight loss to be further investigated. During an interview on 10/20/20 at 1:18 PM, Registered Dietician (RD) #5 stated the facility policy was that a resident admitted to the facility would be weighed for three consecutive days and then weekly for four weeks. The facility policy is if there was a weight change, the resident would be added to weekly weights for 4 weeks, an intake study would be completed, supplements may be added, to notify the physician as soon as practicable if significant weight changes, and a CCP would be implemented specific to the significant weight change. RD #5 stated she did not follow the facility policy for weight loss and is not sure why. RD #5 stated the resident had a good appetite and intake of food and fluids, and therefore felt the resident could not have lost a significant amount of weight as noted by the weights obtained. RD #5 stated she did not discuss the resident's significant weight loss with the interdisciplinary team, or with the physician. 10NYCRR 415.12(i)(l)

Based on record review, and interviews during a recertification survey the facility did not ensure that residents who require [MEDICAL TREATMENT] receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences, for one (Resident #57) of one resident reviewed for [MEDICAL TREATMENT]. Specifically, for Resident #57, the facility did not consistently provide ongoing monitoring for complications before and after [MEDICAL TREATMENT] treatments provided at a certified [MEDICAL TREATMENT] facility and did not consistently review the resident's [MEDICAL TREATMENT] communication book to provide ongoing communication and collaboration with the [MEDICAL TREATMENT] facility regarding [MEDICAL TREATMENT] care and services. This is evidenced by: Resident #57: The resident was admitted to the facility with the [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - an assessment tool) dated 8/31/2020 documented the resident was cognitively intact, could understand others and could make self understood. The Policy and Procedure titled [MEDICAL TREATMENT] dated 3/2020, documented a Communications Log would be used for each resident who left the building for [MEDICAL TREATMENT] in order to communicate the resident's needs and response to the [MEDICAL TREATMENT] treatments. The inter-facility communications would be tracked and followed up on. A Comprehensive Care Plan for [MEDICAL TREATMENT] last revised 9/3/2020, documented the resident required [MEDICAL TREATMENT] ([MEDICAL TREATMENT] (HD) off site) related to [MEDICAL CONDITION] every Tuesday, Thursday and Saturday and had a double lumen CVC (Central Venous Catheter) (28 cm) located to the right chest wall. Interventions included; to check HD port dressing daily and document the condition and report any complications to the Medical Doctor (MD) and [MEDICAL TREATMENT] center and to use the communication book to relay information to and from [MEDICAL TREATMENT] staff regarding plan of care. A Physician order [REDACTED]. [MEDICAL TREATMENT] completed via double lumen CVC (28 cm) located to the right chest wall. The [MEDICAL TREATMENT] Communication Book documented: 10/03/20 - did not include documentation of monitoring for complications after [MEDICAL TREATMENT] treatment provided at a certified [MEDICAL TREATMENT] facility. 10/06/20 - did not include documentation of the resident's pre and post weight and vital signs while at the [MEDICAL TREATMENT] facility and did not include documentation of monitoring for complications after the [MEDICAL TREATMENT] treatment provided at a certified [MEDICAL TREATMENT] facility. 10/08/20 - did not include documentation of the resident's pre and post weight and vital signs while at the [MEDICAL TREATMENT] facility and did not include documentation of monitoring for complications after the [MEDICAL TREATMENT] treatment provided at a certified [MEDICAL TREATMENT] facility. 10/10/20 - did not include documentation of monitoring for complications after [MEDICAL TREATMENT] treatment provided at a certified [MEDICAL TREATMENT] facility and did not include documentation that the facility reviewed a question documented by the [MEDICAL TREATMENT] center asking if the resident was being administered blood pressure medications on HD days and if so, to hold the medications due to the resident's low blood pressure. The [MEDICAL TREATMENT] center documented they were unable to pull the required fluid from the resident. 10/13/20 - did not include documentation of monitoring for complications before and after [MEDICAL TREATMENT] treatment provided at a certified [MEDICAL TREATMENT] facility. 10/15/20 - did not include documentation of monitoring for complications after [MEDICAL TREATMENT] treatment provided at a certified [MEDICAL TREATMENT] facility and did not include documentation that the [MEDICAL TREATMENT] communication book was reviewed when the [MEDICAL TREATMENT] facility documented to please watch the resident's fluid consumption before treatments due to large gains. During a medical record review on 10/20/20, there was no documented evidence from 10/3/20 - 10/15/20 of ongoing communication and collaboration with the [MEDICAL TREATMENT] facility regarding [MEDICAL TREATMENT] care and services. During an interview on 10/19/20 at 10:59 AM, Licensed Practical Nurse (LPN) #1 stated the resident's weight and vital signs were obtained in the facility prior to the resident leaving for [MEDICAL TREATMENT] and were documented in the [MEDICAL TREATMENT] communication book. She stated weights and vital signs were not obtained when the resident returned from [MEDICAL TREATMENT]. She stated the communication book was reviewed prior to the resident leaving for [MEDICAL TREATMENT] but was not reviewed upon the resident's return from [MEDICAL TREATMENT]. She stated [MEDICAL TREATMENT] usually documented the resident's post [MEDICAL TREATMENT] information and did not document anything more. The LPN stated the communication book was not used to document how the [MEDICAL TREATMENT] treatment went or how the resident was feeling before or after a [MEDICAL TREATMENT] treatment. During an interview on 10/19/20 at 3:39 PM, LPN #2 stated when the resident returned from [MEDICAL TREATMENT] on the evening shift, she would give the resident's [MEDICAL TREATMENT] communication book to the Registered Nurse (RN) to review. She stated LPNs did not review the communication book. LPN #2 stated the resident's weight and vital signs were not taken when the resident returned from [MEDICAL TREATMENT]. During an interview on 10/20/20 09:05 AM, RN Unit Manager #1 stated an RN was supposed to review and initial the resident's [MEDICAL TREATMENT] communication book when the resident returned to the facility after a [MEDICAL TREATMENT] treatment. She stated if the communication book was not initialed, then it was not reviewed by the RN. She stated sometimes the communication book was reviewed but not always. She stated the RN was supposed to review the book and call the on-call provider if the [MEDICAL TREATMENT] facility recommended new orders. She stated she was not aware of the 10/10/20 entry in the communication book regarding the resident's blood pressure medication or the 10/15/20 entry regarding the resident's fluid consumption. The RN stated the resident was weighed and had vital signs taken before he/she went to [MEDICAL TREATMENT] but not when he/she returned. During an interview on 10/20/20 at 9:48 AM, the Director of Nursing stated the RN should be reviewing the [MEDICAL TREATMENT] communication book and then initialing or signing that it was reviewed. The RN should report any changes to the provider. He stated the 10/10/20 entry regarding the resident's blood pressure medication should have been reviewed with the physician to change the medication times to prevent a decrease in blood pressure at [MEDICAL TREATMENT]. He stated there should have been a progress note written to document the [MEDICAL TREATMENT] communication book was reviewed with physician. The DON stated the communication book should be reviewed every time the resident came back from [MEDICAL TREATMENT] but stated the signatures indicating the book was reviewed were scant. He stated there could be closer monitoring being done of the resident who received [MEDICAL TREATMENT] care and services. During an interview on 10/20/20 at 12:48 PM, the Registered Dietician stated the resident was weighed monthly at the facility, but got weighed regularly at [MEDICAL TREATMENT]. She stated she was not made aware of [MEDICAL TREATMENT] communication regarding the resident's fluid consumption on 10/15/20. She stated she did not review the [MEDICAL TREATMENT] communication book, but she should have been made aware of that communication book entry from the nursing unit so that she could address it. 10NYCRR415.12

Based on observation, record review and resident and staff interviews, the facility failed to ensure that the resident environment remained as free of accident hazards as possible, and each resident received adequate supervision and assistance devices to prevent accidents for four (4) (Resident #s 37, 42, 86 and #99) of five residents reviewed for smoking. Specifically, the facility failed to have an effective system in place to monitor and supervise residents who smoke. Resident #99 had been assessed as not requiring supervision for smoking, but was observed to have burn holes on multiple articles of clothing, and had maintained possession of her cigarettes and lighter. Additionally, 3 residents (Resident #s 37, 42, and #86) who had been assessed as needing supervision for smoking, were observed to have smoking materials (cigarettes and lighter) on their person and in their rooms. This resulted in no actual harm with the potential for more than minimal harm, which is Immediate Jeopardy to resident health or safety, and Substandard Quality of Care. This was evidenced by: The Health and Safety Policy for Smoking last updated 1/2016, documented that residents' cigarettes and lighters were to be kept in the medication rooms. Residents were not permitted to have cigarettes, lighters or matches on their person or in their room at any time. Additionally, if there was any evidence of dropped ashes, burning of clothing, fires or dangerous situations, the resident was to be re-evaluated for safe smoking. Compliance with this policy was the responsibility of all staff members. All violations of this policy were to be reported to the Administrator or their designee. Resident #99: This resident was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was cognitively intact. A Smoking assessment dated [DATE], documented the resident was not required to wear a smoking apron. A Comprehensive Care Plan (CCP) for Smoking dated 9/1/11, with a review date of 10/15/15, documented the resident was alert and oriented to person, place and time, and required assistance for safety. The resident had been provided with a copy of the smoking policy, and was not required to wear a smoking apron when smoking. All smoking materials were to be kept with the nursing staff and locked in the medication cart. The CCP included the need for an ongoing evaluation of the resident's status and abilities by the Interdisciplinary Team (IDT). A Safety and Risk Education - Smoking Education Form was signed by the resident but was undated. During an observation on 1/14/16 at 2:00 pm on Mountain View (MV) unit, Resident #99 was sitting in a chair by the main nursing station wearing a black coat and hat. While waiting for a staff member to take her out to the smoking hut, the resident pulled a pack of cigarettes and blue lighter from her coat pocket in full view of several Certified Nurse Assistants (CNA's) and the Registered Nurse Manager (RNM) #2. A staff member approached the resident and stated that the staff were running late, but someone would take the resident out to smoke shortly. This resident continued to hold her lighter and cigarettes, and counted her cigarettes, until being taken outside for scheduled smoking break at 2:22 PM. During an observation on 1/14/16 at 3:15 pm on MV unit, Resident #99 was sitting in a hall across from the main nursing station and had a lighter in her hand, which she pulled out of her coat. Housekeeping, three CNAs, RNM #2, and another RN were standing in front of and/or walking past the resident. RNM #2 was at the nurses station, in front of the resident. During an observation on 1/15/16 at 9:15 am, Resident #99 was sitting on MV unit in the area around the nursing station wearing her black coat and hat. The resident pulled her blue lighter out of her right coat pocket. During the observation, five CNAs, RNM #2, an LPN and the Resident Aide (RA) walked past this resident while she had her lighter out. During an observation on 1/15/16 at 11:15 am, Resident #99 was sitting in the hallway on the MV unit wearing a black coat and had her blue lighter in her hand, and was repeatedly putting the lighter in and out of her pocket. Five CNAs, RNM #2, an LPN, and the Housekeeper walked past this resident. During an observation on 1/15/16 at 1:15 pm, Resident #99 was wandering around the MV unit in front and behind the nurses station, and in the hallway. The resident's black coat had four burn marks on the front, which were clearly visible, and there were ashes on the front of the coat from the chest to her lap area. Additionally, the residents's walker had a plastic carrying tray on it and had significant amount of ashes piled in the corners and seams of the tray. During this observation, the resident also took her lighter out of her coat pocket. During an observation and interview on 1/15/16 at 2:45 pm, a CNA was asked to help this surveyor examine Resident #99's room for signs of smoking and clothing for burn marks. The CNA identified four shirts that had burn marks on them. During an observation at 2:55 pm, Resident #99 was in the outdoor smoking hut with RNM #2 and another staff member. Resident #99 was wearing her black coat with burn marks on it. During an interview on 1/14/16 at 3:15 pm, a CNA on MV unit stated that no residents are allowed to have cigarettes or lighters on their person. This CNA identified Resident #99 and #86 as smokers who were taken out at 10 am, 2 pm, 4 pm and 6 pm to smoke with a staff member present. The CNA stated during the day a resident aide (RA) was responsible for taking residents out to smoke and if that staff member was not available that a CNA would take the residents out to smoke. Cigarettes and lighters were kept locked up in the medication room and that they were given to resident just before going out to smoke. During an interview on 1/15/16 at 9:15 am, Resident #99 stated she had her lighter with her all the time, but that her cigarettes were locked up by the nurses. During an interview on 1/15/16 at 1:00 pm, Resident #99 was on the MV unit sitting alone by the nursing station. Resident #99 stated she burned her jacket when smoking outside in the smoking area, because it was windy out there. She stated that other residents who smoke wore a smoking bib, but stated she did not wear one to protect her clothing. She stated that she got ashes on her coat and in her tray on her walker because it was windy outside, and that sometimes the cigarette sparks landed on her coat while she was smoking. During an interview on 1/15/15 at 2:45 pm, a CNA from MV unit stated Resident #99 had noticeable burn marks on her clothing, but they were old from previous times when resident was having behavioral issues. The CNA stated the resident went out with friends and family and sometimes returned with lighters. Also, she frequently sneaked lighters when taken out to smoke by staff and would not give the lighter back to the staff. During an interview on 1/15/16 at 3:00 pm, RNM #2 was at the smoking hut with residents smoking and stated that Resident #99 was alert, oriented and appropriate to be smoking. She further stated that Resident #99 comes back from visits with family and friends with burns on clothing and that the facility can't control this. RNM #2 stated Resident #99 frequently came back from family visits with lighters, but the facility could not search the residents because they have rights. Resident #86: This resident was originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was cognitively intact. A Smoking assessment dated [DATE], documented the resident was required to wear a smoking apron. A Comprehensive Care Plan (CCP) for Smoking dated 6/25/13, with a review date of 12/17/15, documented the resident was alert and oriented to person, place and time, and required assistance for safety. The resident had been provided with a copy of the smoking policy, and was required to wear a smoking apron when smoking. All smoking materials were to be kept with the nursing staff and locked in the medication cart. A Safety and Risk Education - Smoking Education Form was signed by the resident but was undated. During an observation on 1/15/16 at 1:45 pm, Resident #86 was sitting in her room in her wheelchair with oxygen on and showed the state surveyor her lighter that was in the right pocket of her coat. During an interview on 1/15/16 at 1:15 pm, the RA from MV unit stated Resident #86 and Resident #99 were the two smokers on MV unit. The RA further stated designated resident smoking times were 10 am, 2 pm, 4 pm, and 6 pm. She stated the nurses had resident cigarettes and Resident #86's pipe locked in the medication room, but Resident #99 and Resident #86 have their own lighters, so she only had to retrieve the cigarettes from the medication cart because the residents always had their own lighter with them. RA stated that cigarettes are returned to the nurse to lock in medication cart or medication room, and since 10/2015, the residents kept their own lighters. During an interview on 1/15/16 at 1:45 pm, Resident #86 stated she kept her lighter with her at all times and that it was a gift from a dear friend and she would not want to give it to the nurses to be stored. She stated the tobacco in her room was used to roll cigarettes but she was no longer able to do this, so she now smoked a pipe. Various staff members take the smokers out to the smoking hut, and said the hut was in disrepair and was cold and windy. Resident #37: This resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was cognitively intact. A Smoking assessment dated [DATE], documented the resident was not required to wear a smoking apron. A Comprehensive Care Plan (CCP) for smoking dated 11/19/14, documented the resident was alert and oriented to person, place and time, and required assistance for safety. The resident had been provided with a copy of the smoking policy, and was to utilize a smoking apron as necessary. All smoking materials were to be kept with the nursing staff and locked in the medication cart. A Safety and Risk Education - Smoking Education Form was signed by the resident but was undated. During an observation and interview on 1/15/16 at 11:40 am, this resident was sitting in a chair in his room. On the overbed table next to his chair was a cigarette lighter. The resident stated that he keeps his cigarettes and lighter in his room, but knows not to smoke inside the facility or when he was wearing oxygen. He also stated that staff knew he had his smoking materials that was why staff did not have to give him a lighter or cigarettes, they just had to go outside with him. During an interview on 1/15/16 at 12:23 pm, RNM #1 stated that this resident kept his cigarettes and lighter with him, although he should not have. She stated that these residents know the rules, and should have given their lighters and cigarettes back to staff when they were done. During an interview on 1/15/16 at 2:05 pm, the LPN passing medication on the Courtyard unit stated, cigarettes, lighters and other smoking material were kept locked in medication room until a resident was ready to smoke. The LPN stated that the only resident she knew that kept his own lighter was Resident #37, who kept it on his overbed table next to his chair. Resident #42: This resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented that the resident was cognitively intact. A Smoking assessment dated [DATE], documented the resident was required to wear a smoking apron. A Comprehensive Care Plan (CCP) for smoking dated 1/21/15, documented that the resident was alert and oriented and requires assistance for safety. The resident had been provided a copy of the smoking policy and was to wear a smoking apron as necessary. The resident also signed a Safety and Risk Education - Smoking Education Form dated 1/21/15. All smoking materials were to be kept with the nursing staff and locked in the medication cart. During an interview on 1/14/16 at 12:57 pm, the resident was sitting in her wheelchair in her room. She stated that she smokes and keeps her lighter and cigarettes in the pocket on the left side of her wheelchair. During an interview on 1/15/16 at 2:35 pm, the Resident Assistant (RA) stated she took the resident outside to smoke every day at 10:00 am and 2:00 pm, and that she gave Resident #42 her lighter which the resident would returned to her after smoking. The RA would then give the lighter to the LPN to lock in the medication cart. The RA stated that this morning she was one hour late in taking the resident out to smoke. When they returned to the unit, the LPN was not available so she (the RA) did not collect the lighter and cigarettes. During an interview on 1/15/16 at 11:40 am, the RNM stated that the resident was initially assessed by the social worker and RNM for safety while smoking. The resident smokes at every break; 10:00 am, 12:00 pm, 2:00 pm, 4:00 pm and 8:00 pm. The RA brings the resident to the smoking hut and gives resident her cigarettes and lighter. The facility did not document when the lighters and cigarettes were returned to the LPNs. During an interview on 1/15/16 at 12:05 pm, the RNM stated the resident should not have had the smoking materials because she knew the rules and had signed an agreement. Additional Interviews: During an interview on 1/15/16 at 12:05 pm, RNM #2 stated, for residents who smoke, their cigarettes and lighters were locked in the medication room. Staff members who take the residents out to smoke were to get their lighters and cigarettes from the nurse. No residents are allowed to have lighters on their person or in their rooms. During an interview on 1/15/16 at 12:25 pm, the Director of Nursing (DON) stated all lighters and cigarettes were to be kept in the medication carts, but the facility had problems with a couple of residents who wanted to hold their cigarettes. If a staff member sees that a resident has cigarettes or lighters on their person, they should tell the resident the items need to be in the medication cart and report to the supervisor. If a staff member notices burn marks on a residents clothing, it should be reported to a supervisor and the resident should immediately be reassessed for smoking and a smoking apron. During an interview on 1/15/16 at 12:55 pm, the Administrator stated that no residents were allowed to have cigarettes or lighters on their person. If ashes drop on a resident while smoking the RA should report it and the resident should be reassessed for a smoking apron. If a resident is noted to have burn marks on their clothing it should be reported and resident should be reassessed for safety. 10 NYCRR 415.12(h)(2)

Based on observation, record review and resident and staff interviews during a recertification survey, it was determined that the facility policy failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Specifically, the facility failed to have an effective system in place to monitor and supervise residents who smoke. Resident #99 had been assessed as not requiring supervision for smoking, but was observed to have burn holes on multiple articles of clothing, and had maintained possession of her cigarettes and lighter. Additionally, three (3) residents (Resident #s 37, 42 and #86), who had been assessed as needing supervision for smoking, were observed to have smoking materials (cigarettes and lighter) on their person and in their rooms. This resulted in no actual harm with the potential for more than minimal harm, which is Immediate Jeopardy to resident health or safety. This was evidenced by: Refer to F 323 - Quality of Care - Scope/Severity K Finding: The Health and Safety Policy for Smoking dated 1/2016, documented that residents' cigarettes and lighters were to be kept in the medication rooms. Residents were not permitted to have cigarettes, lighters or matches in their room at any time. Additionally, if there was any evidence of dropped ashes, burning of clothing, fires or dangerous situations, the resident was to be re-evaluated for safe smoking. Compliance with this policy was the responsibility of all staff members. All violations of this policy were to be reported to the Administrator or their designee. During an interview on 1/15/16 at 12:25 pm, the Director of Nursing (DON) stated an assessment is done on any resident who smokes to determine their safety. There are scheduled times set up on the units for smoking. The Residents are not allowed to smoke alone so are accompanied outside to smoke by the Resident Assistants (RA). All lighters and cigarettes are kept in the medication carts. The facility does have problems with a few residents who want to hold their cigarettes, but the cigarettes and lighters must be kept in the medication carts. If a staff member sees that a resident has cigarettes or lighters on their person they should tell the resident the items need to be in the medication cart and report to the supervisor. If a staff members notices burn marks on a residents clothing it should be reported to a supervisor and the resident should be reassessed for smoking and a smoking apron. During an interview on 1/15/16 at 12:55 PM the Administrator (Adm) stated that residents smoke in designated areas, and residents cigarettes and lighters are kept with the nurses. No residents are allowed to have cigarettes or lighters on their person. If ashes drop on a resident while smoking the RA should report it and the resident should be reassessed for a smoking apron. If a resident is noted to have burn marks on their clothing it should be reported and the resident should be reassessed for safety. 10 NYCRR 415.26

Based on observation, record review and resident and staff interviews during a recertification survey, it was determined that the facility Quality Assurance (QA) Program did not have a process that readily identified issues that had the potential to cause serious harm to residents. Specifically, the facility failed to have an effective system in place to monitor and supervise residents who smoke. Resident #99 had been assessed as not requiring supervision for smoking, but was observed to have burn holes on multiple articles of clothing, and had maintained possession of her cigarettes and lighter. Additionally, 3 residents (Resident #s 37, 42, and #86 ) who had been assessed as needing supervision for smoking, were observed to have smoking materials (cigarettes and lighter) on their person and in their rooms. This resulted in no actual harm with the potential for more than minimal harm, which is Immediate Jeopardy to resident health or safety, and Substandard Quality of Care. This was evidenced by: The Health and Safety Policy for Smoking dated 1/2016, documented that residents' cigarettes and lighters were to be kept in the medication rooms. Residents were not permitted to have cigarettes, lighters or matches in their room at any time. Additionally, if there was any evidence of dropped ashes, burning of clothing, fires or dangerous situations, the resident was to be re-evaluated for safe smoking. Compliance with this policy was the responsibility of all staff members. All violations of this policy were to be reported to the Administrator or their designee. Refer to F-323, Scope and Severity-L During an interview on 1/15/16 at 12:25 pm, the Director of Nursing (DON) stated an assessment is done on any resident who smoke to determine the safety. There are scheduled times set up on the units for smoking. The Resident Assistants (RA) take the residents out to smoke, no resident is allowed to go outside to smoke alone. All lighters and cigarettes are kept in the medication carts. The facility does have problems with a couple of residents who want to hold their cigarettes, but the cigarettes and lighters must be kept in the medication carts. If a staff member sees that a resident has cigarettes or lighters on their person they should tell the resident the items need to be in the medication cart and report to the supervisor. If a staff members notices burn marks on a residents clothing it should be reported to a supervisor and the resident should be reassessed for smoking and a smoking apron. During an interview on 1/15/16 at 12:55 PM the Administrator stated that residents smoke in designated areas, and residents ' cigarettes and lighters are kept with the nurses. No residents are allowed to have cigarettes or lighters on their person. If ashes drop on a resident while smoking the RA should report it and the resident should be reassessed for a smoking apron. If a resident is noted to have burn marks on their clothing it should be reported and the resident should be reassessed for safety. 10 NYCRR 415.27(a-c)

Based on medical record review and staff interview during a complaint investigation (Case #NY 042), the facility failed to notify the physician of a change in the resident's condition which caused a delay in treatment during an extended abbreviated survey. Specifically, for one (Resident #1) of two residents reviewed, after a resident with a history of frequently falling, and who received a medication to prevent clotting, fell and struck her head, the facility failed to notify the physician for further direction and care. Subsequently, the resident was found unresponsive and was transferred to the hospital where she expired from a bleed in the brain. This resulted in actual harm that is Immediate Jeopardy and Substandard Quality of Care to resident's health & safety. This was evidenced by following: Resident #1: The resident was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) dated [DATE] assessed the resident as having moderately impaired cognition. The Policy and Procedure (P&P) for Falls Prevention Assessment and Plan of Care issued ,[DATE] and revised ,[DATE], documented that if a resident fell , the physician was to be notified as appropriate. The Comprehensive Care Plan (CCP) for Risk for Falls dated [DATE], documented that the resident had a history of [REDACTED]. The resident was on hourly safety checks. The resident was observed for adverse side effects/toxicity of medications in the current drug regimen. A physician progress notes [REDACTED]. The resident was on [MEDICATION NAME] (an anticoagulation medication used to prevent the blood from clotting), and the physician documented that she had "great concern that with these falls she (the resident) was going to have a serious injury and possible irreversible damage." The resident had a recent fall that had resulted in an arm fracture. A Psychiatry Consult Note: Initial Evaluation dated [DATE], documented that the resident was receiving [MEDICATION NAME] and had a history of [REDACTED]. It was documented that the resident's present medication regimen seemed "OK". "Why her (the resident) frequent falls haven't led to more serious problems is a mystery given the presence of [MEDICATION NAME] ([MEDICATION NAME])." A physician's orders [REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. It was documented that the resident received the [MEDICATION NAME] daily from [DATE] through [DATE]. A physician progress notes [REDACTED]. The resident had hit the right side of her head and there was a laceration on the right brow which was bleeding and required compression, which stopped the bleeding after five minutes. The resident was fully evaluated for decreased cognition, imbalance or slurred speech. The resident recovered well without "any so-called neurological deficits." Although the resident was "on [MEDICATION NAME] and multiple falls, risk versus benefits, will continue with the [MEDICATION NAME] at this point." The resident's multiple falls situation and right sided weakness would be discussed with the physician and whether or not the resident should continue on [MEDICATION NAME] therapy in the future. The note was not countersigned by the supervising physician. A Nurses Note dated [DATE] at 10:30 am and signed by a Registered Nurse (RN), documented that the resident was observed sitting on the floor in her room. A skin tear was noted above the resident's right eye with a moderate amount of blood and there was a bruise around the area of the skin tear. Direct pressure and an ice pack were applied to the eye. The resident's vital signs were checked and were within normal limits. Neurological checks were completed and were within normal limits. The resident stated that the area (surrounding the skin tear) was sore. The Physician's Assistant (PA) evaluated the resident and advised the RN to monitor the resident for mental status changes and increased discomfort. A Neurological Flow Sheet dated [DATE] at 10:30 am, documented that the fall was unobserved, the resident hit her head, and an injury was sustained. The Neurological Flow Sheet further documented the resident's eyes opened spontaneously to verbal command and that she was able to move on command. The resident was oriented and conversed and her motor strength was normal for her. The resident's pupils were measured to be 3 millimeters (mm), and were reactive to light. It was not documented if the pupil reaction was at the resident's baseline or if they were sluggish, as was indicated on the form. The resident's vital signs were within normal range for the resident. There were no other neurological assessments documented on the flow sheet. A Nurses Note dated [DATE] at 6:45 pm, documented that at 5:00 pm, an LPN found the resident to be unresponsive. Her heart rate was 44 beats a minute (normal range is 60 to 100 beats a minute), her blood pressure was ,[DATE] (normal range is ,[DATE] mm of mercury to ,[DATE]). The resident's respirations were shallow, she was "yellowish" in color and her skin was cool to the touch. The pupils were unresponsive and the resident did not respond to a sternal rub (a technique used to induce reaction to a painful stimulus) or to pinching and there was no motor strength noted in the resident. The ambulance was called and the resident was transported to the hospital. It was also documented that the resident had her vital signs taken at 3:00 pm by a Certified Nursing Assistant (CNA) and that the vital signs were within normal limits. An untimed Nurses Note dated [DATE], documented that the hospital physician notified the Registered Nurse Supervisor (RNS) that the resident had died at 8:44 pm. The resident had a Computerized Tomography test (CT Scan) done when she arrived at the hospital which had revealed a large right sided subdural hematoma (a [MEDICAL CONDITION] which results in bleeding between layers of tissue surrounding the brain. The accumulation of blood between these layers cause compression of the brain.). A breathing tube was placed in the resident, and the resident subsequently died at 8:44 pm. An Incident Report dated [DATE] documented that the resident had a fall at 10:15 am. She was found on the floor at the foot of her bed. There was a superficial skin tear above the right eye with some bruises surrounding the area. An ice pack was applied to the skin tear and the resident's vital signs were within normal limits. An Incident Report - QA (Quality Assurance) Form dated [DATE] at 11:00 am, documented that the resident had a fall at 10:15 am. The resident had been last seen in bed watching television at 9:45 am, and at that time she was alert and oriented. The Investigation Results/Root Cause section of the form documented that the resident had been attempting to self-transfer to the bathroom. The resident stated that she fell and hit her head. An Investigative Summary Form dated [DATE], and signed by the Director of Nursing (DON), documented that the resident's fall had been unobserved, however the resident had stated that she fell and hit her head. Due to the resident's clinical presentation, the PA did not feel it was necessary to send the resident to the hospital at that time. The resident's vital signs remained stable until the unit RN left for the day. An addendum dated [DATE] was written on the form and documented that the resident had been transferred to the hospital and subsequently expired from a right subdural hematoma. During an interview on [DATE] at 10:03 am, the DON stated that this resident was a frequent faller and was also receiving anticoagulant therapy ([MEDICATION NAME]). After her fall on [DATE], the resident was assessed by an RN and the PA and staff monitored the resident's vital signs and neurological status. During an interview on [DATE] at 1:21 pm, RN#1 stated that she was the acting nurse manager on this resident's unit on [DATE]. She stated that when she arrived in the resident's room, the resident was bleeding from a skin tear above the right eye, and the vital signs were within normal limits. The PA arrived and performed a neurological assessment on the resident. RN#1 also asked the DON to come to the room because she was concerned about the resident because she was on [MEDICATION NAME] and she had a head injury. The DON asked the PA if the resident should go to the hospital for evaluation and the PA responded that she did not and that the resident should be monitored. The PA did not say how often the resident's neurological status should be monitored and did not write an order. She also stated that she thought the facility policy was for neurological checks after a fall were to be performed once a shift, but that she performed a second check at 1:30 pm because she was concerned for the resident due to her [MEDICATION NAME] use and because she had hit her head in the fall. RN#1 reviewed the P&P and stated that the P&P did not specifically mention how often neurological checks were to be done and that she must have learned that in her orientation to the facility. During an interview on [DATE] at 1:38 pm, the DON stated that on [DATE], RN#1 called her to come to this resident's room because this resident was a frequent faller, was on [MEDICATION NAME] and had hit her head in this fall. She stated that when she arrived in the resident's room, the resident was bleeding from a skin tear above the right eye. Within minutes the PA arrived and performed a neurological assessment on the resident. She asked the PA if the resident should go to the hospital for evaluation and the PA responded that she did not and that the resident should be monitored. The PA did not say how often the resident's neurological status should be monitored and did not write an order. She also stated that the facility policy was for neurological checks after a fall were to be performed once a shift. The DON reviewed the P&P and stated that the P&P did not specifically mention how often neurological checks were to be done. If the physician or the PA wanted neurological checks to be done on a resident more frequently than once a shift, then they would have ordered it. The DON stated that the PA did not make the correct decision in this case because the resident should have been sent to the hospital for evaluation because she was high risk for injury because she was taking [MEDICATION NAME] and had fallen and hit her head. She stated that the physician was in the building on [DATE] but was not notified of the resident's fall until [DATE]. During an interview on [DATE] at 10:24 am, the PA stated that on [DATE], she was called to this resident's room. When she entered the room it was very apparent that the resident had hit her head in the fall, and that she was bleeding a moderate amount of blood from a laceration over her right eye. The resident seemed okay at the time and her neurological signs were within the norm for this resident. She instructed staff to monitor her but did not instruct them as to how often to perform neurological checks and she did not write an order for [REDACTED]. She stated that she had the same concern when she came into this resident's room, but she was nervous about the situation and made a poor decision not to send the resident to the hospital for evaluation. In the hospital they could have ensured that her vital signs remained stable and supported until tests cold have been performed and a decision made on how best to treat the head injury. She stated that she should have immediately sent the resident to the hospital, or at the very least she should have ensured that the staff monitored the resident's neurological status every hour. She stated that she was very uncomfortable with the situation and that she felt this was due to her lack of experience. The physician was in the facility at the time of the resident's fall, but she did not notify the physician until the next day ([DATE]). During an interview on [DATE] at 10:40 am, the resident's physician stated that she was in the facility on [DATE] but was not notified of the resident's fall until [DATE]. The physician stated that this resident was very high risk for injury due to her frequent falls and because she was receiving [MEDICATION NAME] daily. She would have expected the resident to have hourly neurological checks by an RN after falling and hitting her head and that checking neurological status once a shift was not sufficient. She also stated that the PA should have ordered neurological checks for every hour, should have ordered the resident's blood be tested for the level of clotting as affected by the [MEDICATION NAME], and that the resident should have been immediately sent to the hospital for evaluation because she was such a high risk for injury. She stated that the decision not to send the resident for evaluation was poor judgment on the PA's part. She stated that she did not counter-sign the PA's note dated [DATE] at 9:03 am because she had concerns over the PA's judgment in this situation. During an interview on [DATE] at 4:10 pm, the Medical Director stated that the resident had been receiving [MEDICATION NAME]. Because of the [MEDICATION NAME] the resident had blood drawn 17 days prior to the resident falling and they showed that the resident's clotting factors ([MEDICATION NAME] Time (PT) and International Normalized Ratio (INR), expressed as PT/INR) were high. Because of the high PT/INR, after the fall, a repeat test should have been done to evaluate the potential for bleeding. The Medical Director also stated that there had been no baseline neurological assessment on this resident and that neurological monitoring should have been done more frequently than once a shift on this resident after her fall due to the increased risk of bleeding and because she had struck her head. The Medical Director also stated that in hind sight, there were many red flags for this resident because of her [MEDICATION NAME] use and her history of falling, and that [MEDICATION NAME] use with this resident should have been discontinued. The immediacy was removed [DATE], which was prior to the investigation exit, as the facility had implemented the following interventions: The facility contracted with experienced consultants to assist in addressing the issues identified by the Department of Health. A thorough Quality Assurance (QA) review of the supervisor report book and I&As for monitoring of changes in the residents' conditions and timely notification of the medical providers was conducted on [DATE] and [DATE] by the DON. The P&P for Falls was reviewed and revised. The Medical Director and the Attending Physicians developed a new policy to address head injury and implemented a Neurological Status protocol. An enhanced CCP was developed for residents receiving [MEDICATION NAME] who were at risk for injury. A new P&P for Notification of Physician for changes in condition was implemented. The facility provided evidence that 100% of the nursing department staff were educated and in-serviced on the new P&Ps and protocols. A plan was for future interventions including QA reviews for monitoring of residents and notification of physicians of changes in condition were outlined to the surveyor. 10NYCRR 415.3(e)(2)(ii)(a)

Based on medical record review and staff interview during a complaint investigation (Case #NY 042), the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Specifically, for 1 (Resident #1) of 2 residents reviewed, after a resident with a history of frequently falling, and who received a medication to prevent clotting, fell and struck her head, the facility failed to adequately assess and monitor the resident. Subsequently, the resident was found unresponsive and was transferred to the hospital where she expired from a bleed in the brain. This resulted in actual harm that is Immediate Jeopardy and Substandard Quality of Care to resident's health and safety. This was evidenced by following: Resident #1: The resident was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) dated [DATE] assessed the resident as having moderately impaired cognition. The Policy and Procedure (P&P) for Falls Prevention Assessment and Plan of Care issued ,[DATE] and revised ,[DATE], documented that if a resident fall was not witnessed, or if the resident was noted to have hit their head, vital signs and neurological status was to be monitored for 72 hours. A Falls Assessment/Screening form dated [DATE], documented that the resident had falls within the past six months, a history of prior fractures, altered mobility, dementia, confusion, and inability to follow directions. The resident was assessed to be at risk for falls. The Comprehensive Care Plan (CCP) for Risk for Falls dated [DATE], documented that the resident had a history of [REDACTED]. The resident was on hourly safety checks. The resident was observed for adverse side effects/toxicity of medications in the current drug regimen. A physician progress notes [REDACTED]. The resident was on [MEDICATION NAME] (an anticoagulation medication used to prevent the blood from clotting), and the physician documented that she had "great concern that with these falls she (the resident) was going to have a serious injury and possible irreversible damage." The resident had a recent fall that had resulted in an arm fracture. A Psychiatry Consult Note: Initial Evaluation dated [DATE], documented that the resident was receiving [MEDICATION NAME] and had a history of [REDACTED]. It was documented that the resident's present medication regimen seemed "OK". "Why her (the resident) frequent falls haven't led to more serious problems is a mystery given the presence of [MEDICATION NAME] ([MEDICATION NAME])." A physician's orders [REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. It was documented that the resident received the [MEDICATION NAME] daily from [DATE] through [DATE]. A physician progress notes [REDACTED]. The resident had hit the right side of her head and there was a laceration on the right brow which was bleeding and required compression, which stopped the bleeding after five minutes. The resident was fully evaluated for decreased cognition, imbalance or slurred speech. The resident recovered well without "any so-called neurological deficits." Although the resident was "on [MEDICATION NAME] and multiple falls, risk versus benefits, will continue with the [MEDICATION NAME] at this point." The resident's multiple falls situation and right sided weakness would be discussed with the physician and whether or not the resident should continue on [MEDICATION NAME] therapy in the future. The note was not countersigned by the supervising physician. A Nurses Note dated [DATE] at 10:30 am and signed by a Registered Nurse (RN), documented that the resident was observed sitting on the floor in her room. A skin tear was noted above the resident's right eye with a moderate amount of blood and there was a bruise around the area of the skin tear. Direct pressure and an ice pack were applied to the eye. The resident's vital signs were checked and were within normal limits. Neurological checks were completed and were within normal limits. The resident stated that the area (surrounding the skin tear) was sore. The Physician's Assistant (PA) evaluated the resident and advised the RN to monitor the resident for mental status changes and increased discomfort. A Neurological Flow Sheet dated [DATE] at 10:30 am, documented that the fall was unobserved, the resident hit her head, and an injury was sustained. The Neurological Flow Sheet further documented the resident's eyes opened spontaneously to verbal command and that she was able to move on command. The resident was oriented and conversed and her motor strength was normal for her. The resident's pupils were measured to be 3 millimeters (mm), and were reactive to light. It was not documented if the pupil reaction was at the resident's baseline or if they were sluggish, as was indicated on the form. The resident's vital signs were within normal range for the resident. There were no other neurological assessments documented on the flow sheet. A Nurses Note dated [DATE] at 3:30 PM, documented that the resident had fallen at 10:15 am. At 11:00 am, the resident complained of a headache and was given [MEDICATION NAME] (a narcotic pain relief medication). The note was signed by a Licensed Practical Nurse (LPN). An RN Assessment for Acute Monitoring dated [DATE] at 1:30 pm, documented that the resident's neurological signs were at her baseline. She was alert and oriented and her pupils were equal in size and reactive to light. Her heart rate was 72 beat a minute, respirations were 18 breaths a minute and here blood pressure was normal at ,[DATE]. The resident stated that the skin tear above her right eye was sore and that she had received [MEDICATION NAME] at 11:00 am. A Nurses Note dated [DATE] at 6:45 pm, documented that at 5:00 pm, an LPN found the resident to be unresponsive. Here heart rate was 44 beats a minute (normal range is 60 to 100 beats a minute), her blood pressure was ,[DATE] (normal range is ,[DATE] mm of mercury to ,[DATE]). The resident's respirations were shallow, she was "yellowish" in color and her skin was cool to the touch. The pupils were unresponsive and the resident did not respond to a sternal rub (a technique used to induce reaction to a painful stimulus) or to pinching and there was no motor strength noted in the resident. The ambulance was called and the resident was transported to the hospital. It was also documented that the resident had her vital signs taken at 3:00 pm by a Certified Nursing Assistant (CNA) and that the vital signs were within normal limits. An untimed Nurses Note dated [DATE], documented that the hospital physician notified the Registered Nurse Supervisor (RNS) that the resident had died at 8:44 pm. The resident had a Computerized Tomography test (CT Scan) done when she arrived at the hospital which had revealed a large right sided subdural hematoma (a [MEDICAL CONDITION] which results in bleeding between layers of tissue surrounding the brain. The accumulation of blood between these layers cause compression of the brain.). A breathing tube was placed in the resident, and the resident subsequently died at 8:44 pm. The 24 Hour Supervisor's Report dated [DATE], documented that the resident had a fall at 10:15 am, with head injury and a skin tear above the right eye. Under the day, evening and night shift columns "Neuro" was written in with a check box next to it. The "Neuro" box for the day shift was checked. Next to the "Neuro" box for the evening shift was written that the resident went to the emergency room . It was also documented on the evening portion of the form that the resident was found unresponsive at dinner time and was sent to the hospital. An Incident Report dated [DATE] documented that the resident had a fall at 10:15 am. She was found on the floor at the foot of her bed. There was a superficial skin tear above the right eye with some bruises surrounding the area. An ice pack was applied to the skin tear and the resident's vital signs were within normal limits. An Incident Report - QA (Quality Assurance) Form dated [DATE] at 11:00 am, documented that the resident had a fall at 10:15 am. The resident had been last seen in bed watching television at 9:45 am, and the at that time she was alert and oriented. The Investigation Results/Root Cause section of the form documented that the resident had been attempting to self-transfer to the bathroom. The resident stated that she fell and hit her head. An Investigative Summary Form dated [DATE], and signed by the Director of Nursing (DON), documented that the resident's fall had been unobserved, however the resident had stated that she fell and hit her head. Due to the resident's clinical presentation, the PA did not feel it was necessary to send the resident to the hospital at that time. The resident's vital signs remained stable until the unit RN left for the day. An addendum dated [DATE] was written on the form and documented that the resident had been transferred to the hospital and subsequently expired from a right subdural hematoma. During an interview on [DATE] at 10:03 am, the DON stated that this resident was a frequent faller and was also receiving anticoagulant therapy ([MEDICATION NAME]). After her fall on [DATE], the resident was assessed by an RN and the PA and staff monitored the resident's vital signs and neurological status. She also stated that staff were to monitor a resident's neurological status every shift after falling and hitting the head. She stated that this was the facility's policy. During an interview on [DATE] at 1:21 pm, RN#1 stated that she was the acting nurse manager on this resident's unit on [DATE]. She stated that when she arrived in the resident's room, the resident was bleeding from a skin tear above the right eye, and the vital signs were within normal limits. The PA arrived and performed a neurological assessment on the resident. RN#1 also asked the DON to come to the room because she was concerned about the resident because she was on [MEDICATION NAME] and she had a head injury. The DON asked the PA if the resident should go to the hospital for evaluation and the PA responded that she did not and that the resident should be monitored. The PA did not say how often the resident's neurological status should be monitored and did not write an order. She also stated that she thought the facility policy was for neurological checks after a fall were to be performed once a shift, but that she performed a second check at 1:30 pm because she was concerned for the resident due to her [MEDICATION NAME] use and because she had hit her head in the fall. RN#1 reviewed the P&P and stated that the P&P did not specifically mention how often neurological checks were to be done and that she must have learned that in her orientation to the facility. During an interview on [DATE] at 1:38 pm, the DON stated that on [DATE], RN#1 called her to come to this resident's room because this resident was a frequent faller, was on [MEDICATION NAME] and had hit her head in this fall. She stated that when she arrived in the resident's room, the resident was bleeding from a skin tear above the right eye. Within minutes the PA arrived and performed a neurological assessment on the resident. She asked the PA if the resident should go to the hospital for evaluation and the PA responded that she did not and that the resident should be monitored. The PA did not say how often the resident's neurological status should be monitored and did not write an order. She also stated that the facility policy was for neurological checks after a fall were to be performed once a shift. The DON reviewed the P&P and stated that the P&P did not specifically mention how often neurological checks were to be done. If the physician or the PA wanted neurological checks to be done on a resident more frequently than once a shift, then they would have ordered it. The DON stated that the PA did not make the correct decision in this case because the resident should have been sent to the hospital for evaluation because she was high risk for injury because she was taking [MEDICATION NAME] and had fallen and hit her head. She stated that the physician was in the building on [DATE] but was not notified of the resident's fall until [DATE]. The DON also stated that when the resident complained of a headache at 11:00 am, the LPN should have reported this to an RN and the resident should not have received [MEDICATION NAME] at that time. During an interview on [DATE] at 3:01 pm, the RNS stated that on [DATE], she came on duty at 3:00 pm. She received report that the resident had fallen and hit her head, and she peaked in the resident's room and she looked okay. She stated that she did not do a neurological assessment on the resident at that time because she was busy getting report on the facility. She did not assess the resident until she was found unresponsive at 5:00 pm. During an interview on [DATE] at 10:24 am, the PA stated that on [DATE], she was called to this resident's room. When she entered the room it was very apparent that the resident had hit her head in the fall, and that she was bleeding a moderate amount of blood from a laceration over her right eye. The resident seemed okay at the time and her neurological signs were within the norm for this resident. She instructed staff to monitor her but did not instruct them as to how often to perform neurological checks and she did not write an order for [REDACTED]. She stated that she had the same concern when she came into this resident's room, but she was nervous about the situation and made a poor decision not to send the resident to the hospital for evaluation. In the hospital they could have ensured that her vital signs remained stable and supported until tests cold have been performed and a decision made on how best to treat the head injury. She stated that she should have immediately sent the resident to the hospital, or at the very least she should have ensured that the staff monitored the resident's neurological status every hour. She stated that she was very uncomfortable with the situation and that she felt this was due to her lack of experience. The physician was in the facility at the time of the resident's fall, but she did not notify the physician until the next day ([DATE]). During an interview on [DATE] at 10:40 am, the resident's physician stated that she was in the facility on [DATE] but was not notified of the resident's fall until [DATE]. The physician stated that this resident was very high risk for injury due to her frequent falls and because she was receiving [MEDICATION NAME] daily. She would have expected the resident to have hourly neurological checks by an RN after falling and hitting her head and that checking neurological status once a shift was not sufficient. When the resident complained of a headache at 11:00 am, the LPN should not have given the [MEDICATION NAME] and an RN should have been notified to assess the resident at that time. She also stated that the PA should have ordered neurological checks for every hour, should have ordered the resident's blood be tested for the level of clotting as affected by the [MEDICATION NAME], and that the resident should have been immediately sent to the hospital for evaluation because she was such a high risk for injury. She stated that the decision not to send the resident for evaluation was poor judgment on the PA's part. She stated that she did not counter-sign the PA's note dated [DATE] at 9:03 am because she had concerns over the PA's judgment in this situation. During an interview on [DATE] at 10:01 am, the DON stated that there was no CCP for the resident receiving anticoagulation therapy and that the facility did not have such a CCP. She also stated that the facility did not have a P&P that addressed anticoagulation therapy. During an interview on [DATE] at 4:10 pm, the Medical Director stated that the resident had been receiving [MEDICATION NAME]. Because of the [MEDICATION NAME] the resident had blood drawn 17 days prior to the resident falling and they showed that the resident's clotting factors ([MEDICATION NAME] Time (PT) and International Normalized Ratio (INR), expressed as PT/INR) were high. Because of the high PT/INR, after the fall, a repeat test should have been done to evaluate the potential for bleeding. The Medical Director also stated that there had been no baseline neurological assessment on this resident and that neurological monitoring should have been done more frequently than once a shift on this resident after her fall due to the increased risk of bleeding and because she had struck her head. The Medical Director also stated in hind sight, that there were many red flags for this resident because of her [MEDICATION NAME] use and her history of falling, and that [MEDICATION NAME] use with this resident should have been discontinued. The immediacy was removed [DATE], which was prior to the investigation exit, as the facility had implemented the following interventions: The facility contracted with experienced consultants to assist in addressing the issues identified by the Department of Health. A thorough Quality Assurance (QA) review of the supervisor report book and I&As for monitoring of changes in the residents' conditions and timely notification of the medical providers was conducted on [DATE] and [DATE] by the DON. The P&P for Falls was reviewed and revised. The Medical Director and the Attending Physicians developed a new policy to address head injury and implemented a Neurological Status protocol. An enhanced CCP was developed for residents receiving [MEDICATION NAME] who were at risk for injury. A new P&P for Notification of Physician for changes in condition was implemented. The facility provided evidence that 100% of the nursing department staff were educated and in-serviced on the new P&Ps and protocols. A plan was for future interventions including QA reviews for monitoring of residents and notification of physicians of changes in condition were outlined to the surveyor. 10NYCRR 415.12

Based on medical record review and staff interview during an extended abbreviated investigation (Case #NY 042), the facility failed to ensure it was administrated in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the Administration failed to ensure that the facility poilicy and procedure for neurological checks included parameters for neuro checks following a head injury, that the physician was notified for further direction and care (F157), and the facility failed to adequately assess and monitor (F309) one (Resident #1) of two residents reviewed, after the resident with a history of frequently falling, and who received a medication to prevent clotting, fell and struck her head. Subsequently, the resident was found unresponsive and was transferred to the hospital where she expired from a bleed in the brain. This resulted in actual harm and Immediate Jeopardy to the health and safety and Substandard Quality of Care for this resident. This was evidenced by: Refer to Quality of Care, F-157- scope and severity - J Refer to Quality Assurance, F- 309- scope and severity-J Resident #1: The resident was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) dated [DATE] assessed the resident as having moderately impaired cognition. A physician progress notes [REDACTED]. The resident was on [MEDICATION NAME] (an anticoagulation medication used to prevent the blood from clotting), and the physician documented that she had "great concern that with these falls she (the resident) was going to have a serious injury and possible irreversible damage." The resident had a recent fall that had resulted in an arm fracture. A physician progress notes [REDACTED]. The resident had hit the right side of her head and there was a laceration on the right brow which was bleeding and required compression, which stopped the bleeding after five minutes. The resident was fully evaluated for decreased cognition, imbalance or slurred speech. The resident recovered well without "any so-called neurological deficits." Although the resident was "on [MEDICATION NAME] and multiple falls, risk versus benefits, will continue with the [MEDICATION NAME] at this point." The resident's multiple falls situation and right sided weakness would be discussed with the physician and whether or not the resident should continue on [MEDICATION NAME] therapy in the future. The note was not countersigned by the supervising physician. An Incident Report dated [DATE] documented that the resident had a fall at 10:15 am. She was found on the floor at the foot of her bed. There was a superficial skin tear above the right eye with some bruises surrounding the area. An ice pack was applied to the skin tear and the resident's vital signs were within normal limits. An Investigative Summary Form dated [DATE], and signed by the Director of Nursing (DON), documented that the resident's fall had been unobserved, however the resident had stated that she fell and hit her head. Due to the resident's clinical presentation, the PA did not feel it was necessary to send the resident to the hospital at that time. The resident's vital signs remained stable until the unit RN left for the day. An addendum dated [DATE] was written on the form and documented that the resident had been transferred to the hospital and subsequently expired from a right subdural hematoma. A Nurses Note dated [DATE] at 6:45 pm, documented that at 5:00 pm, an LPN found the resident to be unresponsive. Here heart rate was 44 beats a minute (normal range is 60 to 100 beats a minute), her blood pressure was ,[DATE] (normal range is ,[DATE] mm of mercury to ,[DATE]). The resident's respirations were shallow, she was "yellowish" in color and her skin was cool to the touch. The pupils were unresponsive and the resident did not respond to a sternal rub (a technique used to induce reaction to a painful stimulus) or to pinching and there was no motor strength noted in the resident. The ambulance was called and the resident was transported to the hospital. It was also documented that the resident had her vital signs taken at 3:00 pm by a Certified Nursing Assistant (CNA) and that the vital signs were within normal limits. An untimed Nurses Note dated [DATE], documented that the hospital physician notified the Registered Nurse Supervisor (RNS) that the resident had died at 8:44 pm. The resident had a Computerized Tomography test (CT Scan) done when she arrived at the hospital which had revealed a large right sided subdural hematoma (a [MEDICAL CONDITION] which results in bleeding between layers of tissue surrounding the brain. The accumulation of blood between these layers cause compression of the brain.). A breathing tube was placed in the resident, and the resident subsequently died at 8:44 pm. During an interview on [DATE] at 10:03 am, the DON stated that this resident was a frequent faller and was also receiving anticoagulant therapy ([MEDICATION NAME]). After her fall on [DATE], the resident was assessed by an RN and the PA and staff monitored the resident's vital signs and neurological status. During an interview on [DATE] at 1:38 pm, the DON stated that on [DATE], RN#1 called her to come to this resident's room because this resident was a frequent faller, was on [MEDICATION NAME] and had hit her head in this fall. She stated that when she arrived in the resident's room, the resident was bleeding from a skin tear above the right eye. Within minutes the PA arrived and performed a neurological assessment on the resident. She asked the PA if the resident should go to the hospital for evaluation and the PA responded that she did not and that the resident should be monitored. The PA did not say how often the resident's neurological status should be monitored and did not write an order. She also stated that the facility policy was for neurological checks after a fall were to be performed once a shift. The DON reviewed the P&P and stated that the P&P did not specifically mention how often neurological checks were to be done. If the physician or the PA wanted neurological checks to be done on a resident more frequently than once a shift, then they would have ordered it. The DON stated that the PA did not make the correct decision in this case because the resident should have been sent to the hospital for evaluation because she was high risk for injury because she was taking [MEDICATION NAME] and had fallen and hit her head. She stated that the physician was in the building on [DATE] but was not notified of the resident's fall until [DATE]. During an interview on [DATE] at 10:24 am, the PA stated that on [DATE], she was called to this resident's room. When she entered the room it was very apparent that the resident had hit her head in the fall, and that she was bleeding a moderate amount of blood from a laceration over her right eye. The resident seemed okay at the time and her neurological signs were within the norm for this resident. She instructed staff to monitor her but did not instruct them as to how often to perform neurological checks and she did not write an order for [REDACTED]. She stated that she had the same concern when she came into this resident's room, but she was nervous about the situation and made a poor decision not to send the resident to the hospital for evaluation. In the hospital they could have ensured that her vital signs remained stable and supported until tests cold have been performed and a decision made on how best to treat the head injury. She stated that she should have immediately sent the resident to the hospital, or at the very least she should have ensured that the staff monitored the resident's neurological status every hour. She stated that she was very uncomfortable with the situation and that she felt this was due to her lack of experience. The physician was in the facility at the time of the resident's fall, but she did not notify the physician until the next day ([DATE]). During an interview on [DATE] at 10:40 am, the resident's physician stated that she was in the facility on [DATE] but was not notified of the resident's fall until [DATE]. The physician stated that this resident was very high risk for injury due to her frequent falls and because she was receiving [MEDICATION NAME] daily. She would have expected the resident to have hourly neurological checks by an RN after falling and hitting her head and that checking neurological status once a shift was not sufficient. She also stated that the PA should have ordered neurological checks for every hour, should have ordered the resident's blood be tested for the level of clotting as affected by the [MEDICATION NAME], and that the resident should have been immediately sent to the hospital for evaluation because she was such a high risk for injury. She stated that the decision not to send the resident for evaluation was poor judgment on the PA's part. She stated that she did not counter-sign the PA's note dated [DATE] at 9:03 am because she had concerns over the PA's judgment in this situation. During an interview on [DATE] at 4:10 pm, the Medical Director stated that the resident had been receiving [MEDICATION NAME]. Because of the [MEDICATION NAME] the resident had blood drawn 17 days prior to the resident falling and they showed that the resident's clotting factors ([MEDICATION NAME] Time (PT) and International Normalized Ratio (INR), expressed as PT/INR) were high. Because of the high PT/INR, after the fall, a repeat test should have been done to evaluate the potential for bleeding. The Medical Director also stated that there had been no baseline neurological assessment on this resident and that neurological monitoring should have been done more frequently than once a shift on this resident after her fall due to the increased risk of bleeding and because she had struck her head. The Medical Director also stated that in hind sight, there was many red flags for this resident because of her [MEDICATION NAME] use and her history of falling, and that [MEDICATION NAME] use with this resident should have been discontinued. The immediacy was removed [DATE], which was prior to the investigation exit, as the facility had implemented the following interventions: The facility contracted with experienced consultants to assist in addressing the issues identified by the Department of Health. A thorough Quality Assurance (QA) review of the supervisor report book and I&As for monitoring of changes in the residents' conditions and timely notification of the medical providers was conducted on [DATE] and [DATE] by the DON. The P&P for Falls was reviewed and revised. The Medical Director and the Attending Physicians developed a new policy to address head injury and implemented a Neurological Status protocol. An enhanced CCP was developed for residents receiving [MEDICATION NAME] who were at risk for injury. A new P&P for Notification of Physician for changes in condition was implemented. The facility provided evidence that 100% of the nursing department staff were educated and in-serviced on the new P&Ps and protocols. A plan was for future interventions including QA reviews for monitoring of residents and notification of physicians of changes in condition were outlined to the surveyor. 10NYCRR 415.26

Based on observation and staff interview, the facility did not ensure that the the resident environment remained as free of accident hazards as possible for one of three residents reviewed during a complaint investigation (Case #NY 751). Specifically, the facility did not ensure that the care planned safety device for one (Resident #1) of three residents reviewed was activated, monitored and checked for functionality. Resident #1 has a history of multiple falls due to non-compliance and self transferring behavior and was care planned for a sensor beam to be placed facing the residents bed and on at all times. The sensor beam was not turned on for at least two shifts and went unnoticed by at least four staff members, until Resident #1 self transferred, fell and sustained a fracture to the left humerus. This is a repeat deficiency from 7/25/12. This resulted in actual harm that is not immediate jeopardy. This is evidenced by: Resident #1 The resident was admitted to the facility on [DATE] diagnosed with [REDACTED]. The Minimum Data Set, dated dated dated 5/31/12 assessed the resident had moderately impaired cognition. The Comprehensive Care Plan for Falls last reviewed and rewritten on 2/29/12 documented that the resident had 24 falls between 3/2/12 and 8/20/12. It documented approaches to prevent falls that included numerous safety devices including a sensor beam added to the resident's room on 5/4/12. The sensor beam was then moved to the wall facing the bed on 6/25/12. Resident #1's Kardex (instruction to staff on how to care for a resident, including the use of safety devices)documented the sensor beam facing the bed was initiated on 5/4/11. The Alarm monitor log for the period of August 2012 was signed by Licensed Practical Nurse (LPN) #1 as checked and functioning correctly on 8/24/12 at 5:00 pm. An Incident Report dated 8/25/12 at 2:15 am documented that Certified Nursing Assistant (CNA) heard doors bang and found Resident #1 lying face down on the floor near the bathroom. Resident #1 was assessed by the Registered Nurse (RN) and noted with a bump on the left side of her forehead, complaint of pain in the left shoulder with a gross deformity noted, was cool to the touch with slight swelling. The Incident Report documented that the resident was transferred to the hospital for evaluation of her shoulder. An X-ray report dated 8/25/12 revealed Resident #1 had a fracture of the left humerus. An Employee Disciplinary Action dated 8/27/12 documented that Licensed Practical Nurse (LPN) #2 failed to follow the Care Plan/Kardex when LPN #2 did not correctly check the resident's sensor beam for functionality despite entering the resident's room and failed to ensure the alarm was operational. An Employee Disciplinary Action dated 8/28/12 documented that CNA #1 failed to follow the Care Plan/Kardex which documented that the resident should have her sensor beam on at all times and the sensor beam was not on the evening shift of 8/24/12. An Employee Disciplinary Action dated 8/28/12 documented that CNA #2 failed to follow the Care Plan/Kardex which documented that the resident should have her sensor beam on at all times and the sensor beam was not on the night the incident occurred and the resident fell and injured herself. An Employee Disciplinary Action dated 8/29/12 documented that LPN #1 failed to follow the Care Plan/Kardex when LPN #1 did not correctly check the resident's sensor beam for functionality upon the resident's return from an activity. The Investigative Summary Conclusion dated 8/28/12 signed by the Director of Nursing (DON) documented that the investigation team concluded that Resident #1 "should have had her sensor beam on but the sensor beam was not turned on and she was injured as a result of this fall." The conclusion further documented that the staff members responsible for this resident were disciplined. During an interview on 9/12/12 at 3:00 pm, CNA #1 stated that she is the regular caregiver for Resident #1. CNA #1 stated that the resident has a bed alarm but removes it so a sensor beam was added to her room to alert staff when Resident #1 gets up. CNA #1 stated that Resident #1 became very annoyed and agitated at the sensor beam because it would activate at her slightest movement and so she spoke with RN #1. CNA #1 stated that she reported Resident #1's increased agitation at the sensor beam about a week prior to the incident, and the RN agreed that "we should keep it off while she was awake and activate it when she was sleeping at night." CNA #1 stated from that point forward, she would not activate the alarm until after Resident #1 had fallen asleep and she would advise the night CNA if the Resident was not yet asleep before change of shift so that the night CNA could activate the sensor beam when the resident fell asleep. CNA #1 stated that the change to the activation came from a conversation with RN #1, however, the Kardex was not changed and stated that the sensor beam should be on at all times. During an interview on 9/12/12 at 3:30 pm, LPN #1 stated that she is regularly assigned to Resident #1's unit and is very familiar with Resident #1's history of falls due to non-compliance and self transferring behavior. LPN #1 stated that some time ago, a sensor beam was placed in Resident #1's room and has been moved to different locations throughout the room because Resident #1 had turned the beam off in the past. LPN #1 stated that the sensor beam was affixed to the wall facing the residents bed at least a couple of months ago. LPN #1 stated that a week or so prior to the incident, she noticed that the sensor beam didn't alarm as much and would go off more frequently toward the end of the night. LPN #1 stated that she signed the alarm monitoring log on 8/24/12 that the sensor beam was checked and functioning however, she did not actually check the sensor beam because the resident was at an activity and not in her room. LPN #1 stated that she did not check the sensor beam when Resident #1 returned to her room, nor did she notice that the sensor beam did not alarm when she entered the resident's room to give her evening medications. During an interview on 9/12/12 at 4:00 pm, the DON stated that after the incident, the investigation team determined that Resident #1's sensor beam had not been turned on or checked for functionality by two CNAs and 2 LPNs prior to the incident. The DON stated there may have been some miscommunication between CNA #1 and RN #1 about the continued use of the sensor beam, but that the sensor beam was on the Kardex, should have been on at all times, and staff should have followed the plan of care as noted on the Kardex. 10NYCRR 415.12(h)(1)

Based on record review and staff interview, the administrator failed to ensure that the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well being for each resident, during a partial extended abbreviated survey (#NY 32). Specifically, a resident with dementia, severe cognitive impairment, and who was identified as a high elopement risk, exited the facility undetected on 2/19/12 at approximately 6:40 p.m. and was found at approximately 7:10 p.m. by a community member driving past the facility who noticed the resident lying on the ground next to the road. The community member notified the facility staff immediately. The resident was transported to the hospital and treated for [REDACTED]. This had the potential to affect 22 residents at high risk for elopement. This is evidenced by: Accidents and Supervision - F323 Scope/Severity KDuring an interview on 2/22/12 at 11:50 am, the DON stated that she did not realize until 2/22/12 at 9:00 am that alarm monitoring was not being conducted. In a follow-up interview at 3:00 pm, the DON stated that she was involved in the investigation of the elopement and that all nursing staff insisted that an alarm didn't sound but that it was her assumption that staff had turned off the alarm without knowing the cause of the alarm. The DON stated that the resident was also observed by two dietary workers yet no one intervened and she believed that the resident walked the doors off of the kitchen hallway that are not alarmed. The DON stated that it concerned her that when the resident was seen coming off the elevator by the kitchen that it didn't concern the staff members. The DON stated that our alarm systems are the problem and will effect a lot more people if the facility continues to accept residents with wandering behaviors. The DON stated that she was not aware that the alarm function checks were not being conducted until 2/22/12 and that the RNs on the Units were responsible to make sure that they were done. The DON stated that she was aware that codes to disalarm Wanderguard alarms were being given to visitors on one unit however, had not realized that by giving the alarm codes to visitors it would cause "the whole system to fail." The DON stated "several systems failed." During an interview on 2/22/12 at 4:15 pm, the Administrator stated that she was appointed as the Administrator on 2/9/12. The Administrator stated that all wanderguarded doors use one code to deactivate the alarm system and the stairwells have another code. The Administrator stated that she was aware that the codes to disalarm the wanderguarded exits were given to visitors. The Administrator stated that only those who were visiting residents on the Bathgate Unit needed the codes and the facility had asked that they not share the code. The Administrator stated that she did not know how many people were aware of the code at the time of this interview. The Administrator stated that she and the Board of Directors had recently identified concerns that someone could either access the building or exit the building without being detected, however, they had not been able to pull all of the pieces together yet. The Administrator stated that she believed, with the alarm system, no one should be able to get out of the building without an alarm activating. The Administrator reviewed several Alarm Monitoring Log sheets, including Resident #1's, identified that they were not complete and stated that the situation was unacceptable. The Administrator stated that the DON or her designee was responsible for making sure the alarms were checked. The Administrator stated that she was unaware that the nursing staff were not conducting reliability testing of the wanderguard bracelets in accordance with established policies and procedures and manufacturer's instructions. The Administrator stated that she was unsure of exactly how nursing staff responded to alarms and had previously seen that the alarms were deactivated without head counts being done. The Administrator stated that there was no policy or procedure in place to direct the response to the activation of the alarms. During an interview on 2/24/12 at 12:00 pm, the Chief Financial Officer (CFO) stated that prior to 2/9/12, she was the Administrator of Record. The CFO stated that she knew for sure that codes were given to the visitors of the Bathgate Unit but was unsure if the other units provided the codes to their visitors. The CFO stated that she did not realize until the time of the interview that visitors with the exit door codes could potentially disalarm a legitimate Wanderguard alarm. The CFO stated that nursing staff was responsible for checking the batteries on the bracelets nightly and functionality of the bracelets at the alarmed exits weekly. The CFO stated that it was the responsibility of the DON to insure that the checks were being done and stated "I don't know if it was being done, I assumed it was." The CFO stated that she recalled that the Director of Engineering had met with the DON when the recommendations to check the functionality weekly were received by the manufacturer in August of 2011. The CFO stated that she was not auditing the systems because she assumed it was being done. The CFO stated that periodically she would hear that the alarms didn't work, but when tested , the alarms were functional. The CFO stated "the alarm is not a fail safe system, you rely on people to do what they are suppose to do."10 NYCRR 415.26

Based on record review and staff interview, the facility failed to have a Quality Assurance(QA) program that readily identified issues that have the potential to cause serious harm to residents reviewed during a partial extended abbreviated survey (Case #NY 432). Specifically, for 7 (#'s 1, 2, 3, 4, 5, 6 and 7) of 22 residents reviewed, the facility failed to ensure that effective Quality Assurance systems were in place to monitor the effectiveness of facility policies and practices related to unsafe wandering. This resulted in Immediate Jeopardy and Substandard Quality of Care to the health and safety of residents and had the potential to effect all 22 residents assessed to be at high risk for elopement. The findings were as follows: Accidents and Supervision F 323 Scope and Severity KThe facility policy titled Lost Resident/Elopement last revised 4/2011 documented preventative measures for the necessary care and supervision of residents who wander to avert potential elopement and to provide instruction to staff regarding a lost resident and how to conduct a thorough search for the lost resident. The policy documented that those residents identified at high risk for wandering will have their photograph added to the Elopement Risk book located at the desk in the lobby. The policy outlined prevention of incidents for residents at risk to wander/elope to include assessment and care plans, frequent observations of the resident by nursing staff, recognition of those residents at risk by all staff including housekeeping and dietary and the ability for all staff to intervene per the care plan, and operational monitoring devices (Wanderguard bracelets). The policy documented that a review of the incident/assessment of behaviors will be conducted in any instance of elopement to determine root cause. The policy documented that all incidents will be reviewed at Quality Assurance meetings for review of systems, and that staff would be educated as to their role and in their responsibilities. During an interview on 2/22/12 at 4:15 pm, the Administrator stated that she was appointed as the Administrator on 2/9/12. The Administrator stated that all wanderguarded doors use one code to deactivate the alarm system and the stairwells have another code. The Administrator stated that she was aware that the codes to disalarm the wanderguarded exits were given to visitors. The Administrator stated that only those who were visiting residents on the Bathgate Unit needed the codes and the facility had asked that they not share the code. The Administrator stated that she did not know how many people were aware of the code at the time of this interview. The Administrator stated that she and the Board of Directors had recently identified concerns that someone could either access the building or exit the building without being detected, however, they had not been able to pull all of the pieces together yet. The Administrator stated that she believed, with the alarm system, no one should be able to get out of the building without an alarm activating. The Administrator reviewed several Alarm Monitoring Log sheets, including Resident #1's, identified that they were not complete and stated that the situation was unacceptable. The Administrator stated that the DON or her designee was responsible for making sure the alarms were checked. The Administrator stated that she was unaware that the nursing staff were not conducting reliability testing of the wanderguard bracelets in accordance with established policies and procedures and manufacturer's instructions. The Administrator stated that she was unsure of exactly how nursing staff responded to alarms and had previously seen that the alarms were deactivated without head counts being done. The Administrator stated that there was no policy or procedure in place to direct the response to the activation of the alarms. During an interview on 2/24/12 at 12:00 pm, the Chief Financial Officer (CFO) stated that prior to 2/9/12, she was the Administrator of Record. The CFO stated that she knew for sure that codes were given to the visitors of the Bathgate Unit but was unsure if the other units provided the codes to their visitors. The CFO stated that she did not realize until the time of the interview that visitors with the exit door codes could potentially disalarm a legitimate Wanderguard alarm. The CFO stated that nursing staff was responsible for checking the batteries on the bracelets nightly and functionality of the bracelets at the alarmed exits weekly. The CFO stated that it was the responsibility of the DON to insure that the checks were being done and stated "I don't know if it was being done, I assumed it was." The CFO stated that she recalled that the Director of Engineering had met with the DON when the recommendations to check the functionality weekly were received by the manufacturer in August of 2011. The CFO stated that she was not auditing the systems because she assumed it was being done. The CFO stated that periodically she would hear that the alarms didn't work, but when tested , the alarms were functional. The CFO stated "the alarm is not a fail safe system, you rely on people to do what they are suppose to do." During a follow-up interview on 2/24/12 at 12:30 pm, the Administrator stated that she was the head of the QA Committee prior to her appointment to Administrator and had not yet transitioned out of the QA role. She stated that QA issues were usually issues identified in Statements of Deficiency and other than that, department heads determined their own issues to bring to QA. The Administrator stated these issues had not be revealed by the QA committee and the DON had not included alarm testing, staff response to alarms, or the accessibility of the codes to visitors as an area of concern that required monitoring. 10 NYCRR 415.27(a-c)

Based on staff interviews, family interviews and medical record review during a partial extended abbreviated survey (Case #NY 32), the facility did not ensure that the residents environment remained as free of accident hazards as possible; and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 7 (Resident #'s 1, 2, 3, 4, 5, 6 and 7) of 22 residents reviewed the facility failed to have systems in place to adequately monitor and supervise residents with unsafe wandering behaviors who had been identified as at high risk for elopement. The facility failed to ensure that policies and procedures were developed and implemented to investigate the cause of alarms sounding and to account for all residents after the alarms sounded. Battery and functionality tests of Wanderguards were not conducted at recommended intervals. The disarming codes for alarms were well known by visitors. In addition, staff allowed residents to wander in non-resident areas of the building without ensuring adequate supervision. A resident with dementia, severe cognitive impairment, and who was identified as a high elopement risk exited the facility undetected on 2/19/12 at approximately 6:40 p.m. and was found at approximately 7:10 p.m. by a community member driving past the facility who noticed the resident lying on the ground next to the road. The community member notified the facility staff immediately. The resident was transported to the hospital and treated for [REDACTED]. This was evidenced by:The facility policy titled Lost Resident/Elopement last revised 4/2011 documented preventative measures for the necessary care and supervision of residents who wander to avert potential elopement and to provide instruction to staff regarding a lost resident and how to conduct a thorough search for the lost resident. The policy documented that those residents identified at high risk for wandering will have their photograph added to the Elopement Risk book located at the desk in the lobby. The policy outlined prevention of incidents for residents at risk to wander/elope to include assessment and care plans, frequent observations of the resident by nursing staff, recognition of those residents at risk by all staff including housekeeping and dietary and the ability for all staff to intervene per the care plan, and operational monitoring devices (Wanderguard bracelets). The policy documented that a review of the incident/assessment of behaviors will be conducted in any instance of elopement to determine root cause. The policy documented that all incidents will be reviewed at Quality Assurance meetings for review of systems, and that staff would be educated as to their role and in their responsibilities. The facility policy titled "Alarm Policy/ Wanderguards, Sensor Beams and Tab Alarms" dated 8/2011 documented that when a resident is issued a Wanderguard, the Registered Nurse (RN) will add the resident's name to the Alarm Monitoring Book and the Wanderguard will be checked daily for proper use and functioning by the RN or Licensed Practical Nurse (LPN). The policy documented that the day, evening and night shift will be responsible for checking alarms and the results of the check will be documented in the alarm monitoring book. If an alarm is found not functioning, it will have its battery replaced or the alarm will be replaced. The policy further documented that the Wanderguard transmitters (bracelets) will be checked everyday and it is the responsibility of the supervisor on each shift to ensure compliance. The policy documented that each week, every resident who has a Wanderguard on their person or personal devices must be physically assisted through a door protected by a watchmate door monitor and if the bracelet passes, that documentation must be made on the weekly alarm check sheets. Finding #1The facility failed to ensure supervision of all residents assessed at high risk of wandering with Wanderguards, when the code to disarm the Wanderguard alarm at all exit doors was provided to an undetermined number of visitors.During an interview on 2/22/12 at 11:45 am on Bathgate Unit, Visitor #1 stated that he was given the exit door access code by nursing staff.During an interview on 2/22/12 at 1:30 pm, Visitor #2 was walking with a resident from the Courtyard Unit who had a Wanderguard. Visitor #2 stated that she had the code to disarm the exit doors and it was written down in her pocketbook.During an interview on 2/22/12 at 1:45 pm, Visitor #3 on Mountainview Unit stated that he was given the code to the exit doors by nursing staff.During an interview on 2/22/12 at 3:00 pm, the Director of Nursing (DON) stated that for at least the last six years, visitors of the Bathgate Unit have been given the code to the exit doors with Wanderguard alarms and stairwells. The DON stated that all Wanderguard doors throughout the facility are deactivated using the same code and stairwell door alarms have a different code, but all stairwell alarms are deactivated by the same code. The DON stated that only those visitors on Bathgate, the locked unit, should have the exit door codes so that they can get off the unit. The DON stated that she was unaware that other visitors of residents on other units had the code but "if that were the case, that would make the entire Wanderguard alert system fail because it would mean that anyone could shut off an active alarm." The DON stated that there was no way to ensure that visitors with a door code did not deactivate a Wanderguard alarm.During an interview on 2/22/12 at 4:15 pm, the Administrator stated that all wanderguarded doors use one code to deactivate the alarm system and the stairwells have another code. The Administrator stated that she was aware that the codes were given to visitors. The Administrator stated that only those who were visiting residents on the Bathgate Unit needed the codes and the facility had asked that they not share the code. The Administrator stated that she did not know how many people were aware of the code at the time of this interview. The Administrator stated that she and the Board of Directors had recently identified concerns that someone could either access the building or exit the building without being detected, however, they had not been able to pull all of the pieces together yet. During an interview on 2/24/12 at 12:00 pm, the Chief Financial Officer (CFO) stated that prior to 2/9/12, she was the Administrator of Record. The CFO stated that she knew for sure that codes were given to the visitors of the Bathgate Unit but was unsure if the other units provided the codes to their visitors. The CFO stated that she did not realize until the time of the interview that visitors with the exit door codes could potentially disalarm a legitimate Wanderguard alarm. Resident #1 The resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident with severely impaired cognition.The revised Bracelet Test Procedures dated December 10, 2010 issued by the manufacturer documented that all bracelets must be tested weekly at a monitored exit to confirm that they are being properly detected. The manufacturer documented that when preforming the required maintenance testing the end user will test the bracelet at an exit protected by the door monitor, clear the area of all other bracelets, arm the monitor and open the door, bring the bracelet within the detection area, confirm that the door monitor detected the bracelet by generating an alarm and if the bracelet passed the test, record the bracelet ID and date and time of the successful test. If the bracelet failed the test, the manufacturer documented that the bracelet should be removed from service and replaced with a new bracelet that passed the test.The facility policy titled Lost Resident/Elopement last revised 4/2011 documented preventative measures for the necessary care and supervision of residents who wander to avert potential elopement and to provide instruction to staff regarding a lost resident and how to conduct a thorough search for the lost resident. The policy documented that those residents identified at high risk for wandering will have their photograph added to the Elopement Risk book located at the desk in the lobby. The policy outlined prevention of incidents for residents at risk to wander/elope to include assessment and care plans, frequent observations of the resident by nursing staff, recognition of those residents at risk by all staff including housekeeping and dietary and the ability for all staff to intervene per the care plan, and to insure monitoring devices (Wanderguard bracelets) were operational. The policy documented that a review of the incident/assessment of behaviors will be conducted in any instance of elopement to determine root cause. The policy documented that all incidents will be reviewed at Quality Assurance meetings for review of systems, and that staff would be educated as to their role and in their responsibilities. The facility Policy titled "Alarm Policy/ Wanderguards, Sensor Beams and Tab Alarms" dated 8/2011 documented that when a resident is issued a Wanderguard, the Registered Nurse (RN) will add the resident's name to the Alarm Monitoring Book and the Wanderguard will be checked daily for proper use and functioning by the RN or Licensed Practical Nurse (LPN). The policy documented that the day, evening and night shift will be responsible for checking alarms and the results of the check will be documented in the alarm monitoring book. If an alarm is found to be not functioning, it will have its battery replaced or the alarm will be replaced. The policy further documented that the Wanderguard transmitters (bracelets) will be checked every day and it is the responsibility of the supervisor on each shift to ensure compliance. The policy documented that each week, every resident who has a Wanderguard on their person or personal devices must be physically assisted through a door protected by a watchmate door monitor and if the bracelet passes, that documentation must be made on the weekly alarm check sheets. The Comprehensive Care Plan (CCP) initiated on 12/5/11 documented that Resident #1 was at risk to wander due to cognitive impairment, was noted to be "trailing" staff off the unit and approaches implemented included, placing a monitoring device on the resident that sounds alarms when the resident leaves the unit, place resident in area where observation is possible and not to allow resident to leave the facility or unit unattended. The CCP documented that on 12/15/11 the resident exited the double doors off the unit and was found standing by the elevators, Wanderguard was working properly. On 12/20/11, the resident was noted to be trailing a volunteer with pets to the double doors, the Wanderguard was working. On 1/15/12, resident wandered out of unit doors, attempted elopement without injury and on 2/19/12 resident eloped out of the building and was sent to the emergency room for evaluation. The Alarm Monitoring Log dated December 2011 documented that the Wanderguard was checked 16 out of 26 days.The Alarm Monitoring Log dated January 2012 documented that the Wanderguard was checked 11 out of 31 days. The Alarm Monitor Log (undated) documented that Wanderguard Battery Checks are to be completed nightly and Wanderguard door monitor checks are to be completed weekly by bringing the resident through the alarmed door. The log documented that the Wanderguard battery check was completed on 2/3, 2/10 and 2/18/12 and the Wanderguard door monitor checks were blank for 2/1/12 - 2/22/12.The Alarm Monitor Log for Resident #1 (undated) initiated on 2/20/12 documented the Wanderguard battery check on 2/20/12 and 2/21/12 and was blank for 2/22/12.Nurse's Note dated 12/5/11 at 12:50 pm documented that the resident was noted to be trailing staff wanting to go to the lobby and was difficult to redirect. The note further documented that Resident and Family Services (RFS) was aware and a Wanderguard had been placed.Nurse's Note dated 12/15/11 at 11:50 am documented that the resident was found standing next to the elevator after exiting through the double doors off the unit. The note documented that the Wanderguard was working and the Certified Nurses Assistant (CNA) had a difficult time redirecting the resident as she wanted to visit her sister.Nurse's note dated 12/20/11 at 1:45 pm documented that the resident was noted to follow a visitor with dogs to the double doors, was approached and monitored by the RN, became angry and opened the double doors, saw the dogs were not there and came back onto the unit.Nurse's note dated 2/5/12 at 12:30 pm documented that the Wanderguard was sounding and the resident was standing outside of the unit doors attempting to call the elevator. The note further documented that the resident was mad at her sister and wanted to leave the facility. Resident was redirected back to the unit without injury and placed on one hour safety checks. Nurse's note dated 2/19/12 at 8:50 pm documented that at 7:08 pm, RN Supervisor was notified via page that an unidentified resident was found by a motorist driving by the facility. The unidentified resident was identified as Resident #1, was assessed and transported to the hospital for evaluation. The note further documented that there was a high visitors traffic and the resident is noted to "trail" members of families. An RN documented that the Wanderguard was cut off of the resident prior to transport to the hospital and it was functioning properly. Nurse's note dated 2/20/12 at 7:45 am documented that the resident was returned to the facility with bruising and complaints of soreness to both her knees but all x-rays were negative for fractures. During an interview on 2/22/12 at 11:00 am, the Director of Engineering stated that the Wanderguard system was checked by maintenance staff weekly to ensure that the exit door receivers are functioning properly, battery checks of the wanderguards are checked nightly and since August of 2011 when he received the Revised Bracelet Test Procedures dated December 10, 2010 issued by the manufacturer, nursing staff were checking the bracelets at the door weekly. During an interview on 2/22/12 at 11:45 am, the DON stated that she realized at 9:00 am on 2/22/12 after a review of several alarm monitoring books that alarm monitoring was not being conducted and that the RNs were not checking the alarm books to insure that the alarm checks were being completed. During an interview on 2/22/12 at 11:50 am, the RN Manager (RNM) stated that the system of checking the Wanderguards had changed in the last two months based on the manufacturer's recommendations and the night staff would check the battery function of the Wanderguard bracelets during the 11:00 pm - 7:00 am shift and the 7:00 am to 3:00 pm shift would walk the residents through the exit doors weekly. The RNM stated that she would then review the monitoring book on a weekly basis to ensure that the checks were done, however, stated she had not done so for a least a month due to being out of the facility a few times a week or covering other units. The RNM stated not checking the alarm book was an oversight.During an interview on 2/22/12 at 12:10 pm, LPN #1 stated that she was unaware that the Wanderguard monitor checks were her responsibility. LPN #1 stated that she thought that the night shift was responsible to check the Wanderguard functionality and was only informed earlier on this date, that she was responsible.During an interview on 2/22/12 at 3:00 pm, the DON stated that she was involved in the investigation of the elopement and that all nursing staff insisted that an alarm didn't sound but that it was her assumption that staff had turned off the alarm without knowing the cause of the alarm. The DON stated that the resident was also observed by two dietary workers yet no one intervened and she believed that the resident walked the doors off of the kitchen hallway that are not alarmed. The DON stated that it concerned her that when the resident was seen coming off the elevator by the kitchen that it didn't concern the staff members. The DON stated that our alarm systems are the problem and will effect a lot more people if the facility continues to accept residents with wandering behaviors. The DON stated that she was not aware that the alarm function checks were not being conducted until 2/22/12 and that the RNs on the Units were responsible to make sure that they were done. The DON stated "several systems failed". During an interview on 2/22/12 at 3:30 pm, Certified Nurse's Assistant (CNA) #1 stated that on 2/19/12 Resident #1 was agitated and placed at the nurse's station at approximately 6:15 pm when the CNA went to provide care to another resident. CNA #1 stated that she was not aware that Resident #1 was missing until the RN Supervisor reported that a resident was found outside. CNA #1 stated that she did not hear any alarms that evening and is unsure how the resident got off of the unit. CNA #1 stated that there have been times that the Wanderguard alarm has be activated and staff look through the door and if the area is clear, then the alarm is disabled, with the belief that the alarm is malfunctioning. CNA #1 stated that if it is believed that the Wanderguard alarm is malfunctioning, head counts are not conducted.During an interview on 2/22/12 at 3:45 pm, CNA #2 stated that on the evening shift of 2/19/12, she did not hear any Wanderguard alarms during the shift. CNA #2 stated that she was advised of a missing resident by the RN Supervisor who called to the unit at approximately 7:00 pm to report that a resident was on the ground outside.During an interview on 2/22/12 at 4:00 pm, LPN #2 stated that Resident #1 has a history of wanting to go to the main floor of the facility to visit with someone she knows and that is why she repeatedly tries to leave the unit. LPN #2 stated that the alarm activated earlier in the day on 2/19/12 however the staff were unable to determine the cause of the alarm. LPN #2 stated that a staff member had reset the alarm without a determination of the cause of the alarm and head counts were not conducted. LPN #2 stated to her knowledge there are a few families that visit who have the codes to disalarm the exit door. During an interview on 2/22/12 at 4:15 pm, the Administrator stated that she and the Board of Directors were aware that there were problems with the security related to the Wanderguard alarm system. The Administrator stated that she was appointed to her position two weeks ago and wasn't able to put all of the pieces in place but believed that with the alarm system, no one should be able to get out of the building without an alarm activating. The Administrator reviewed several Alarm Monitoring Log sheets, including Resident #1's, identified that they were not complete and stated that the situation was unacceptable. The Administrator stated that the DON or her designee was responsible for making sure the alarms were checked. The Administrator stated that she was unsure of how nursing staff responded to alarms, had previously seen that the alarms were deactivated without head counts being done but that there was no policy or procedure in place to direct the response to the activation of the alarms. During an interview on 2/22/12 at 4:45 pm, RN Supervisor #1 stated that at approximately 6:40 pm, a page was called for Supervisor needed. The RN Supervisor stated that she was informed that a resident was on the ground outside. The RN Supervisor stated that she left the facility through the main doors, searched the parking lot and then located a community member with the unidentified resident between the facility and the highway. The RN Supervisor stated that when she got to the resident, she identified Resident #1, assessed her for injuries and contacted 911. The RN Supervisor stated that prior to being transported to the hospital, she cut the Wanderguard bracelet from Resident #1 and when she returned to the unit, the Wanderguard alarm activated and appeared to be functioning properly.During an interview on 2/23/12 at 12:00 pm, the maintenance technician stated that after a review of the last three months of maintenance requests, there were no reports of concern from nursing staff that the Wanderguard alarm system was malfunctioning. The maintenance technician stated that he has received verbal reports from nursing that the alarm system had malfunctioned but when immediately tested , he found the system in working order. During an interview on 2/23/12 at 1:30 pm, Dietary Worker #1 stated that on 2/19/12, while working in the kitchen, Dietary Worker #2 reported that a resident was seen exiting the elevator by the kitchen. Dietary Worker #1 stated that he directed Dietary Worker #2 to report the incident to the Dietary Supervisor. Dietary Worker #1 stated that he also told the Dietary Supervisor to call upstairs to the nursing staff to report the incident. Dietary Worker #1 stated, to his knowledge, the Dietary Supervisor did not make the call to the nursing staff. Dietary Worker #1 stated that when he received the report of a resident coming off of the elevator, he thought is was one of the residents allowed to use the vending machines. During an interview on 2/23/12 at 1:45 pm, the Dietary Supervisor stated that Dietary Worker #2 caught her in passing and stated that a resident was in the elevator. The Dietary Supervisor stated that she thought the dietary worker was talking about a resident on the unit and did not think twice about it. When asked by the surveyor if Dietary Worker #1 told her to call upstairs to report the incident to nursing staff, the Dietary Supervisor stated, "if he did, I didn't hear him, the dishmachine was going"During an interview on 2/23/12 at 2:00 pm, Dietary Worker #2 stated that she and Dietary Worker #3 were getting ready to collect dining carts from the units at approximately 6:30 pm on 2/19/12 when they saw a resident coming off the elevator. Dietary Worker #2 stated that they asked the resident if she needed help, to which the resident responded "no" and they asked her if she was going to the vending machines, to which the resident responded "yes". The Dietary Worker #2 stated they proceeded to the units and then reported to Dietary Worker #1 that they had seen the resident getting off the elevator and was instructed by Dietary Worker #1 to call upstairs to nursing staff. Dietary worker #2 stated that she told Dietary Worker #1 to call as she did not know who to call. Dietary Worker #2 stated she did say something to the Dietary Supervisor but does not know if she heard her.In a follow-up interview with LPN #1 on 2/23/12 at 2:45 pm, LPN #1 stated that about a month ago the system of checking wanderguards at the exit doors changed to being done during her shift and the battery checks were completed by the night shift. LPN #1 reviewed the Alarm Monitoring Log and thought that the check marks that were placed in the check battery section on 2/3, 2/10 and 2/18/12 were actually for when the alarm was checked at the exit door.Resident #2 The resident was admitted to the facility on [DATE] diagnosed with [REDACTED]. The MDS dated [DATE] assessed the resident had severely impaired cognition.The CCP initiated on 1/25/12 documented that Resident #2 was at risk to wander due to cognitive impairment and on 1/25/12 the resident wandered off of the unit when the door was held open by a visitor.The Alarm Monitoring Log dated January 2012 documented that Wanderguard Battery Checks are to be completed nightly and Wanderguard door monitor checks are to be completed weekly by bringing the resident through the alarmed door. The alarm monitor log documented that a Wanderguard was placed to the left ankle of Resident #2 on 1/25/12. Wanderguard battery checks are blank on 1/26/12 and 1/30 and 1/31/12. Weekly door monitor check was documented as completed on 1/25/12. The Alarm Monitoring Log dated February 2012 documented that Wanderguard Battery Checks are to be completed nightly and Wanderguard door monitor checks are to be completed weekly by bringing the resident through the alarmed door. The Wanderguard Battery Check and the Weekly Door monitor checks are blank from 2/1/12 through 2/22/12.During an interview on 2/22/12 at 11:50 am, the RN Manager (RNM) stated that the system of checking the Wanderguard had changed in the last two months based on the manufacturer's recommendations and the night staff would check the battery function of the Wanderguard bracelets during the 11 pm - 7 am shift and the 7 am to 3 pm shift would walk the residents through the exit doors weekly. The RNM stated that she would then review the monitoring book on a weekly basis to ensure that the checks were done, however, had not done so for a least a month due to being out of the facility a few times a week or covering other units. The RNM stated not checking the alarm book was just an oversight. The RNM stated that she became aware at 9:00 am, this date, that Resident #2's checks had not been completed. The RNM was asked why, at the time of the interview, the checks still were not done, the RNM stated that she would need to check with LPN #1.During an interview on 2/22/12 at 12:10 pm, LPN #1 stated that she was unaware that the Wanderguard monitor checks were her responsibility. LPN #1 stated that she thought that the night shift was responsible to check the Wanderguard functionality and was only informed earlier on this date, that she was responsible. LPN #1 stated that she was not directed to check the functionality of Resident #2's Wanderguard on this date and that she had not done so as of this interview.Resident #3 The resident was admitted to the facility on [DATE] diagnosed with [REDACTED].The Alarm Monitoring Log dated February 2012 documented that Wanderguard Battery Checks are to be completed nightly and Wanderguard door monitor checks are to be completed weekly by bringing the resident through the alarmed door. The Weekly Door monitor check was blank on 2/21/12.During an interview on 2/22/12 at 11:30 am, the RNM reviewed the Alarm Monitoring Log for Resident #3 and stated the weekly check of the Wanderguard should have been completed on 2/21/12, however, it does not appear as though it was tested .10 NYCRR 415.12(h)(1)(2)