Every finding on record at Rome Memorial Hospital, Inc - R H C F

The facility failed to provide needed care and services that are resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice. Specifically, Resident #1's advanced directives were Do Not Resuscitate (allow natural death) and when they became unresponsive, the staff did not verify the Resident #1's advance directives per facility policy, and initiated cardiopulmonary resuscitation for approximately three minutes. Findings include:The 12/2025 revised facility policy, [Cardiopulmonary Resuscitation] Identification, documented All residents would have a [Medical Order for Life Sustaining Treatment] form completed upon admission. The [Medical Order for Life Sustaining Treatment] was the only identifier for code status ([Do Not Resuscitate] or Full Code). The [Medical Order for Life Sustaining Treatment] form should be located in the front of the resident's hard chart. Resident #1 had diagnoses including Parkinson's Disease and metabolic encephalopathy. The [DATE] Minimum Data Set assessment documented Resident #1 had severe cognitive impairment and was dependent for all activities of daily living and mobility. Resident #1's comprehensive care plan initiated on [DATE], and revised on [DATE] documented they had advance directives and a new [Medical Order for Life Sustaining Treatment] form was completed on [DATE]. Interventions included do not resuscitate and comfort measures only, and respect their wishes for advanced directives. The [DATE] Physician #3's order documented do not resuscitate and comfort measures. The Medical Order for Life Sustaining Treatment form, signed by the Health Care Proxy on [DATE], documented do not resuscitate, do not intubate, comfort measures only, do not send to the hospital, no feeding tube, no intravenous fluids, do not use dialysis, and determine the use of antibiotics when infection occurs. The Medical Order for Life Sustaining Treatment form was witnessed by the Director of Nursing and Licensed Practical Nurse #6. The [DATE] facility investigation, completed by the Administrator, documented on [DATE] at approximately 9:04 PM, Resident #1's Health Care Proxy reported to Licensed Practical Nurse #4 that Resident #1 was not breathing and did not have a pulse. Licensed Practical Nurse #4 responded immediately, and entered the room to assist the resident. They were not familiar with Resident #1's current plan of care. They activated the emergency call system and initiated cardiopulmonary resuscitation on Resident #1. Additional staff responded to the room, Licensed Practical Nurse #5 notified the facility supervisor and the attached hospital's emergency response team responded. During the resuscitative efforts, Resident #1's Health Care Proxy expressed they did not want Resident #1 to receive cardiopulmonary resuscitation or any other life sustaining interventions. Physician #7 (from the attached hospital's emergency response team) terminated resuscitative efforts, and Resident #1 was pronounced deceased at 9:08 PM with family at the bedside. During an interview on [DATE] at 3:28 PM, Licensed Practical Nurse #4 stated on [DATE], Resident #1's Health Care Proxy (resident's spouse) grabbed them and was quite frantic that Resident #1 stopped breathing, and to do whatever they could to save them. They did not know the resident's code status at the time. They went to the room and activated the emergency alert. They asked Resident #1's Health Care Proxy if the resident was a do not resuscitation or a full code. The Health Care Proxy stated they wanted the resident to be a full code and wanted everything done for them. Licensed Practical Nurse #4 stated the instinct to save a life kicked in and they initiated cardiopulmonary resuscitation. They know they made a mistake and should have verified the advanced directives on the Medical Order for Life Sustaining Treatment form before initiating any treatment of this resident. They have been re-educated and will ensure they check the Medical Order for Life Sustaining Treatment in the future. During an interview on [DATE] at 9:44 AM, Physician #3 stated Resident #1's Medical Order for Life Sustaining Treatment form should have been reviewed prior to starting cardiopulmonary resuscitation. 10 New York Codes, Rules, and Regulations 415.12 Past non-compliance was identified. The Administrator was notified the facility's compliance date was [DATE]. The facility provided verification the following corrective actions were completed:- On [DATE], a complete and thorough investigation of Resident #1's death was completed. An audit of Resident #1's chart was completed to include verification of the Medical Order for Life Sustaining Treatment form, comprehensive care plan, and physician orders. - On [DATE], all nursing staff were educated on the process for advanced directives and code status. The training included verification of the Medical Order for Life Sustaining Treatment form, how to initiate the emergency response, and documentation post incident.- On [DATE], a full house audit was completed to verify all Medical Order for Life Sustaining Treatment forms were completed, that orders were entered correctly, and they had corresponding care plans with appropriate interventions. Continued audits occurred for new admission and re-admissions daily until [DATE].- On [DATE], a full house audit was conducted of all staff with current cardiopulmonary resuscitation certifications.- The facility planned to conduct code drills monthly for the next six months to monitor compliance.- Medical Order for Life Sustaining Treatment audits to be completed monthly for the next six months to ensure continued compliance.

Based on record review and interviews during the recertification and abbreviated (NY00362429) surveys conducted 1/2/2025-1/8/2025 the facility did not ensure the resident's physician was consulted and the resident's representative was notified when there was a need to alter treatment significantly for 1 of 1 resident (Resident #61) reviewed. Specifically, Resident #61 did not receive 5 doses of their Parkinson's disease (a progressive neurological disorder) medication (pramipexole dihydrochloride) and there was no documented evidence the physician or resident's representative were notified of the omission. Findings include: The facility policy, Notification of Medical Condition Changes, reviewed 6/2022, documented the nurse immediately reported specific changes in a resident's condition or treatment to their attending physician and shared with the resident and/or the resident's representative. The notification was documented in the resident's medical record. The pharmacy policy Provider Pharmacy Requirements, effective 9/2018, documented the provider pharmacy agreed to provide routine and timely pharmacy services, as well as emergency pharmacy service 24 hours per day, seven days per week. New medication orders were available for administration on the next routine delivery, unless otherwise requested by facility staff. Medications would be delivered by the primary pharmacy or back-up pharmacy or were available from the emergency medication kit/back-up medication supply. Resident #61 had diagnoses including Parkinson's disease and dementia. The 12/3/2024 Minimum Data Set assessment (a health status assessment tool) documented the resident had severe cognitive impairment. The 11/29/2024 physician order documented pramipexole dihydrochloride oral tablet 1.5 milligrams three times a day for Parkinson's disease. The 12/2/2024 History and Physical completed by the Medical Director documented the resident's plan was to continue Sinemet 25/100 (Parkinson's medication) two tabs four times a day, benztropine (Parkinson's medication) 0.5 milligrams a day, and pramipexole 1.5 milligrams three times per day for Parkinson's disease. The resident was also on Sinemet extended release 50/200 one tab once a day. The Comprehensive Care Plan initiated 12/19/2024 documented the resident had impaired cognition related to diagnoses of dementia and Parkinson's disease. Interventions included their family was involved in decision making. The 12/30/2024 at 8:48 PM pharmacy alert message documented the pramipexole dihydrochloride refill was rejected and could not be filled because it was too soon and needed to be resubmitted for refill on or after 1/1/2025. The 12/2024 and 1/2025 Medication Administration Record documented the pramipexole dihydrochloride oral tablet 1.5 milligrams, give one tablet by mouth three times a day for Parkinson's with a start date of 11/29/2024. The pramipexole dihydrochloride was signed off as a 9 chart code which indicated other/ see progress notes, at the following times: - On 12/31/2024 at 9:00 AM by Licensed Practical Nurse #6 and at 3:00 PM and 9:00 PM by Licensed Practical Nurse #7. - On 1/1/2025 at 9:00 AM and 3:00 PM by Licensed Practical Nurse #8. The nursing administration progress notes documented the pramipexole dihydrochloride medication: - Was on order on 12/31/2024 at 9:08 AM by Licensed Practical Nurse #6. - Was on order on 12/31/2024 at 3:56 PM and 8:04 PM by Licensed Practical Nurse #7 - On 1/1/2025 at 9:20 AM Licensed Practical Nurse #8 documented Registered Nurse #5 called the pharmacy and the medication would be delivered on the second pharmacy run that day. - On 1/1/2025 at 3:50 PM Licensed Practical Nurse #8 documented they were waiting on pharmacy to deliver the medication. There was no documented evidence in the nursing progress notes the medical provider was notified of missed doses of pramipexole dihydrochloride or that the medication was unavailable, or the resident's representative was notified of the missed medication doses. During an interview on 1/2/2025 at 11:13 AM, Resident #61's family member stated the resident did not receive doses of their Parkinson's medication on 12/31/2024 and 1/1/2025. They were not notified by the facility and was only made aware of this while visiting during a medication administration. When they questioned the nurse why the resident was not given the medication, they were told the facility was waiting on pharmacy for delivery of the medication. They were upset the medication was not given because it was a vital medication. They could have brought the medication from home, so the resident did not go without it. During an interview on 1/7/2025 at 10:57 AM, Licensed Practical Nurse #6 stated they thought they reported to Registered Nurse #4 (charge nurse) the resident's pramipexole dihydrochloride medication was not available on 12/31/2024. They did not notify the provider or the family. Missed doses meant the body's medication levels were not as they should be and therefore was less effective. During a telephone interview on 1/7/2025 at 2:53 PM, Licensed Practical Nurse #7 stated there was often a delay in medications getting to the facility from the pharmacy and it was not uncommon for residents to miss a day or two of their ordered medications. On 12/31/2024 they stated they called the pharmacy, was not sure who they talked to, and was told the medication was on its way. It was not delivered before the end of their shift. They did not report the missed doses, or that the medication was unavailable. The resident got the pramipexole dihydrochloride for their tremors and the tremors could get worse if it was not given as ordered. During an interview on 1/8/2025 at 10:15 AM, the Charge Registered Nurse #4 stated they had not been notified the pramipexole dihydrochloride for Resident #61 was unavailable and doses were missed. They would have called the pharmacy directly and the provider and the family would have been notified. It was important the provider was informed of missed medication doses as it was a delay in treatment that could cause negative effects. During an interview on 1/8/2025 at 11:01 AM, Medical Director/ Physician #3 stated they were supposed to be notified of any medications not given regardless of the reason why. They did not recall being notified of missed doses of the pramipexole dihydrochloride for Resident #61, but they should have been. The resident should have received all ordered doses for their safety and to treat their Parkinson's disease. Either the licensed practical nurse that administered medications, or the registered nurse should have called. If there was a pharmacy issue, they could have changed the treatment plan if they were made aware. During an interview on 1/8/2025 at 11:15 AM, the Director of Nursing stated nurses were responsible for physician notification of missed medications. The nurse that was supposed to administer the medication should have reported to the registered nurse the medication was unavailable. The registered nurse would then notify the resident or the family as well as the provider. They were made aware yesterday of Resident #61's missed pramipexole dihydrochloride doses and the provider should have been notified at that time. The resident and or family should have been made aware the treatment plan was not followed as ordered. 10NYCRR 415.3(2)(ii)(a)

Based on record review and interviews during the recertification survey conducted 1/2/2025-1/8/2025, the facility did not ensure they assessed residents using the quarterly review instrument specified by the State and approved by the Centers for Medicare and Medicaid Services not less frequently than once every 3 months for 3 of 3 residents (Residents #28, #46, and #53) reviewed. Specifically, Residents #28's, #46's, and #53's Minimum Data Set assessments were completed later than 14 days after the Assessment Reference Date (the final day of the observation period to gathering information about a resident's condition when completing the assessment). Findings include: The facility policy, Interdisciplinary Minimum Data Set 3.0 Completion, revised 1/2023, documented to complete an accurate Minimum Data Set on all residents based on New York State Department of Health and Centers for Medicare and Medicaid Services guidelines. Assessments would be completed based on the Minimum Data Set 3.0 Manual. The Minimum Data Set Coordinator was responsible for setting up timely assessments within the guidelines as defined in the Minimum Data Set 3.0 Manual. The Centers for Medicare and Medicaid Service's, Minimum Data Set Resident Assessment Instrument Version 3.0 Manual documented An Omnibus Budget Reconciliation Act assessment (comprehensive or quarterly) is due every quarter unless the resident is no longer in the facility. There must be no more than 92 days between Omnibus Budget Reconciliation Act assessments. 1) Resident #53 had diagnoses including epilepsy (a seizure disorder), cognitive communication deficit, and adult failure to thrive. The quarterly Minimum Data Set assessment document an Assessment Reference Date of 11/13/2024 and the assessment was completed on 1/4/2025. 2) Resident #28 had diagnoses including hemiplegia and hemiparesis (weakness and paralysis on one side) following cerebral infarction (stroke), and difficulty walking. The quarterly Minimum Data Set assessment documented an Assessment Reference Date of 11/22/2024 and the assessment was completed on 1/4/2025. 3) Resident #46 had diagnoses including Parkinson's disease (a progressive neurological disorder) and dementia. The quarterly Minimum Data Set assessment documented an Assessment Reference Date of 12/14/2024 and the assessment was not completed as of 1/7/2025. During a telephone interview on 1/7/2025 at 12:56 PM, Minimum Data Set Consultant #9 stated they created the schedule to complete the Minimum Data Set assessments. The Minimum Data Set was completed by the various departments, if they were not done on time, they would reach out to the department to have them completed. They had 14 days from the Assessment Reference Date to complete the assessment. It was important to complete the Minimum Data Set assessment for the resident as it was part of their plan of care. It tracked their progress and helped direct their care. Resident #53 should have had their assessment completed by 11/27/2024 and submitted by 12/4/2025. It was not completed until 1/4/2025. Resident #28 should have had their assessment completed by 12/6/2024 and submitted by 12/13/2024. It was not completed until 1/4/2025. Resident #46 should have had their assessment completed by 12/17/2024 and submitted by 1/3/2025. It was not completed and would be completed on 1/7/2025, and they would submit it after completion. They stated they usually only submitted the Minimum Data Set assessments once a week. The Minimum Data Set assessments for Residents #28, #46, and #53 were not completed timely because section GG (Functional Abilities and Goals) was not completed, all other sections were completed. During an interview on 1/8/2025 at 11:01 AM, the Administrator stated it was the responsibility of the Minimum Data Set Consultant to ensure Minimum Data Set assessments were completed, and they did the audits for those assessments. 10NYCRR 415.11(a)(4)

Based on observation, record review, and interview during the recertification survey conducted 4/11/23-4/14/23, the facility failed to assess residents for risk of entrapment from bed rails prior to installation, review the risks and benefits of bed rails with the resident or resident representative, and obtain informed consent prior to the installation of bed rails for 10 of 10 residents (Residents #9, 11, 14, 15, 16, 29, 32, 36, 37, and 38) reviewed. Specifically, for Residents #9, 11, 14, 15, 16, 29, 32, 36, 37, and 38 there was no documented evidence bed rail assessments were completed, and consents were obtained prior to bed rail installation; there was no documented evidence the risks and benefits of bed rails were explained to the residents or their representatives prior to bed rail use; and there were no care plans that included the use and monitoring of bed rails. Findings include: The facility policy Bedrail Safety last reviewed 8/2021, documented it was the facility's policy to prevent entrapment and other safety hazards associated with bed rail use. Staff would be educated on bed rail safety at orientation and annually and would include entrapment, risks and benefits pertaining to bed rails, and the need to report actual or potential risk to their immediate supervisor. 1)Resident #16 had diagnoses including unspecified dementia, cervical spinal stenosis (narrowing of the spinal canal in the neck), and osteoarthritis. The 1/25/23 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, was totally dependent on 2 for bed mobility and transfers and did not use a bed rail restraint. The following observations were made of Resident #16: -on 4/13/23 at 2:04 PM the resident was transferred to bed using a mechanical lift. The bed had bilateral upper 1/2 bed rails in the raised position. -on 4/13/23 at 4:06 PM the resident was in bed with bilateral upper 1/2 bed rails in the raised position. The comprehensive care plan (CCP) last revised 6/8/2020 documented the resident had an activity of daily living (ADL)/mobility self performance deficit due to dementia and limited range of motion due to spine fractures. Interventions included total assistance of 2 for bed mobility and to boost in bed. There was no documentation the resident required the bed rails. The care instructions (Kardex) active on 4/13/23 did not document the resident had bed rails in place. There was no documented evidence the risks and benefits of bed rails were reviewed with the resident or resident representative, or informed consent was obtained prior to the installation of bed rails. 2) Resident #29 had diagnoses including Alzheimer's disease, osteoarthritis, and a history of falls. The 3/3/23 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, required extensive assistance of 2 for bed mobility, and did not use a bed rail restraint. The following observations were made of Resident #29: - on 4/12/23 at 8:48 AM the resident was in bed with their eyes closed. The bed had bilateral 1/2 bed rails in the raised position. - on 4/13/23 at 9:16 AM the resident was in bed with their eyes closed. The bed was in the low position with fall mats on the floor and bilateral 1/2 bed rails in the up position. - on 4/14/23 at 9:35 AM the resident was in bed with their eyes closed. The bed was in the low position with fall mats on the floor and bilateral 1/2 bed rails in the up position. The comprehensive care plan initiated 10/15/2019 and last revised 6/14/22 documented the resident had an ADL self-care deficit and limited mobility due to left upper extremity contracture and peripheral nerve injury. Interventions included extensive assistance of 2 for bed mobility. The resident was combative and resistive at times. The care instructions dated 4/14/23 documented the resident was dependent on 2 for bed mobility and transfers and did not include the use of bed rails. There was no documented evidence the risks and benefits of bed rails were reviewed with the resident or resident representative, or informed consent was obtained prior to the installation of bed rails. 3) Resident #11 had diagnoses including Alzheimer's disease, osteoarthritis, and history of falls. The 4/4/23 Minimum Data Set assessment documented the resident had severely impaired cognition, required extensive assistance of 2 for bed mobility, was totally dependent for transfers, and did not use bed rails. The following observations were made of Resident # 11: - on 4/11/23 at 2:15 PM the resident was in bed with their eyes closed. The bed was at knee height and had bilateral 1/2 bed rails in the raised position. - on 4/12/23 at 1:13 PM staff assisted the resident back to bed with a mechanical lift. The bed had bilateral 1/2 bed rails in the raised position. The care instructions dated 4/14/23 resident did not include the use of bed rails. There was no documented evidence the risks and benefits of bed rails were reviewed with the resident or resident representative, or informed consent was obtained prior to the installation of bed rails. During an interview on 4/12/23 at 9:00 AM, the Director of Plant Operations stated bed rails were original manufacturer's equipment and could be removed if needed. Bed rail use would be a nursing area. Bed rails or positioning bars were checked on a semiannual basis using the FDA (Food and Drug Administration) device. They were not sure if all residents used them, but all beds had them and all the beds were measured for entrapment. During an interview on 4/12/23 at 9:10 AM, the Director of Nursing (DON) stated all resident beds were equipped with the bed rails that were original equipment. All the beds had them and if a resident needed to use them, they were available. The DON stated if residents did not need them, they could be left in the down position. The facility did not remove the bed rails. All beds were checked for entrapment. During an interview on 4/12/23 at 1:52 PM certified nurse aide (CNA) #10 stated bed rails were present on all the beds, and some of the residents used bed rails for turning and sitting up. The CNA stated they had just assisted Resident #11 to bed using a mechanical lift and the bed rails were raised after putting the resident to bed. The CNA was not aware of any resident that did not have bed rails and was not aware of potential dangers of bed rail use. During an interview on 4/12/23 at 1:56 PM, CNA # 18 stated all residents were able to have their bed rails up. The CNA was not aware of anybody who was not supposed to have bed rails. The CNA stated they raised resident bed rails after care was complete. They were not aware of any risks associated with bed rail use. During a follow-up interview on 4/13/23 at 8:48 AM, the DON stated the facility did not perform bed rail assessments to determine a resident's ability to use them. All resident beds included bed rails. Their policy contained a statement that upper bed rails used for bed mobility and transfers were not considered a restraint. All of the beds in the facility were equipped with original bed rails that came with the beds. The policy did not address other possible bed rail dangers, or reasons bed rails may not be safe to use. The DON stated maintenance performed entrapment assessments every 6 months on all beds. The DON did not feel there was a danger to the residents from bed rail use. They felt staff would notify the charge nurse if any resident was in danger from bed rail use. During an interview 4/14/23 at 1:18 PM, physician #3 stated bed rail use should be individualized and assessed for each resident's safety. 10NYCRR 415.12(h)(1)(2)

Based on observation, record review, and interview during the recertification and abbreviated (NY00307214) surveys conducted 4/11/23-4/14/23, the facility failed to ensure residents were free from abuse for 1 of 1 resident (Resident #38) reviewed. Specifically Resident #15 was witnessed by facility staff making inappropriate sexual contact with Resident #38 on 10/10/22, 11/18/22, and 12/16/22 and the facility did not have a plan in place to protect Resident #38 from Resident #15's advances. Additionally, the incidents on 10/7/22 and 11/18/22 were not reported to the New York State Department of Health (NYS DOH) as required. Findings include: The facility policy Abuse and Adverse Incident Prevention and Reporting reviewed 3/2023 documented the facility did not permit verbal, mental, sexual, or physical abuse. The facility provided initial and ongoing education for all employees which addressed abuse identification and prevention. Prevention included analysis completed on a continued basis of assessment, care planning, and monitoring of residents with needs and behaviors which might lead to conflict. The 8/2016 NYS DOH Incident Reporting Manual documented that sexual abuse can be resident to resident, staff to resident, family/visitor to resident. At least one of the following elements must be present for an incident to be reportable to the NYS DOH: - Non-consensual sexual intrusion or penetration. - Touching intimate body parts or the clothing covering intimate body parts. - Examination or treatment of the resident for other than [NAME] fide medical purposes. - Observation or photographs of another person's intimate body parts. Resident #38 was admitted to the facility with diagnoses including Alzheimer's disease, generalized anxiety disorder, and depression. The 9/30/22 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment and required limited to extensive assistance with most activities of daily living (ADLs). Resident #38's comprehensive care plan (CCP) revised 7/15/22 documented the resident had impaired cognition related to dementia with impaired short-term and long-term memory. The resident did not recognize staff or know that they were in a skilled nursing facility. Interventions included encourage to make daily decisions, provide aides to assist with orientation, reorient when able or needed, and include family in care planning. Resident #15 had diagnosis including hemiplegia and hemiparesis (weakness and paralysis on one side) following cerebral infarction (stroke), anxiety, and legal blindness. The 11/1/22 MDS documented the resident had intact cognition, did not exhibit behavioral symptoms directed toward others, did not walk, and required supervision with locomotion on the unit. Resident #15's CCP initiated 5/13/21 documented the resident self-propelled around the unit during the day and approached other residents without regard for personal space or privacy. The resident's intentions were to help other's and the resident needed reminders to respect other's privacy and personal space. Interventions included to remind resident of social distancing, staff were to complete 15 minute checks when out of bed to monitor where the resident was, and nursing was following with the physician on the resident behavior of respecting other resident's personal space. There was no documented evidence of 15 minute checks completed for Resident #15. A Behavior assessment dated [DATE] by licensed practical nurse (LPN) #13 documented that Resident #15 was observed to be hovering around a female resident, poking at the female resident, and holding the female resident's hand. LPN #13 educated Resident #15 that they were not supposed to be having physical contact with any of the female residents as discussed with them in the past. LPN #13 documented that Resident #15 confirmed understanding of the education and stated that it would not happen again. LPN #13 documented the supervisor was immediately notified of the behavior. A behavior progress note dated 10/7/22 by LPN #12 documented Resident #15 was observed by a CNA reaching into the shirt of Resident #38, while Resident #38 licked the arm of Resident #15. The incident happened between rooms [ROOM NUMBERS] in front of the nurse's station. The behavior was immediately stopped upon request by the reporting CNA. The Summary of Investigation dated 10/10/22 and signed by the Director of Nursing (DON) included: - a witness statement by certified nurse aide (CNA) #11 untimed and dated 10/10/22 documented on 10/7/22 (no time documented) they observed Resident #38 licking Resident #15's arm and Resident #15's hand was inside the shirt and on the breast of Resident #38. CNA #11 asked the residents what they were doing, and Resident #38 replied, do you see what [they] are doing to me? CNA #11 told Resident #15 they were not supposed to be close to Resident #38. Resident #15 freaked out and removed their hand from Resident #38's shirt and tried to give excuses. CNA #11 told Resident #15 to get away from Resident #38 and the behavior was unacceptable because Resident #38 did not know what they were doing. The CNA reported the incident to the nurse. - a statement by Resident #15 untimed and dated 10/10/22 documented they went by Resident #38 a few times that day and Resident #38 grabbed their arm. The second time Resident #38 kissed their arm. The third time Resident #38 took Resident #15's hand and placed it on their breast. Resident #15 told Resident #38 no several times and pulled their arm back. The resident documented they knew they were doing nothing wrong and was surprised Resident #38 placed Resident #15's hand on their breast. - a statement by Resident #38 dated 10/10/22 at 1:25 PM documented no one did anything to them and they would have said something. They would have kicked their butt all the way to the door. - the DON documented that it was determined abuse did not occur and the incident was not reportable according to nursing home incident reporting standards. There was no documented evidence why the incident was not investigated until 3 days after the observed interaction between Residents #15 and #38. There was no documented evidence Resident #15's and #38's CCPs were reviewed to determine if interventions remained appropriate The Summary of Investigation dated 11/18/22 and signed by the Assistant Director of Nursing (ADON) included: - a witness statement by CNA #14 untimed with an obscured date documented on 11/17/22 they witnessed Resident #15 sitting very close to Resident #38. CNA #14 sat at the nursing desk and heard Resident #38 swat Resident #15 away while yelling at Resident #15 for touching them. Resident #15 asked Resident #38 to go to their room with them to watch TV. CNA #14 told the nurse and separated the residents. Resident #15 denied the incident. - a statement from Resident #15 dated 10/18/22 documented they did not touch Resident #38 or ask them to watch TV in their room the previous evening. The resident stated sometimes Resident #38 would reach for Resident #15's arm when they went by. - a statement from Resident #38 dated 11/18/23 documented they did not know what happened on 11/17/22, they did not want to answer the questions, and said to leave them alone. - On 11/18/22 the ADON documented after interviewing staff and residents the incident was not deemed reportable according to the Nursing Home Incident Reporting Manual. There was no documented evidence Residents #38's and #15's care plans were reviewed to determine if appropriate interventions were in place to protect Resident #38 from abuse by Resident #15. The Nursing Home Facility Incident Report documented on 12/16/22 at 4:33 PM Resident #38 was in the hallway near the nurse's desk when Resident #15 passed by in their wheelchair and was observed touching Resident #38's breast. - an undated witness statement by CNA #11 documented on 12/16/22 they were approaching the nurse's station and saw Resident #15 close to Resident #38. Resident #15 grabbed Resident #15's breast. Resident #38 tried to move Resident #15's hands away and Resident #15 touched them again. Resident #38 said I'm going to slap your face. Resident #38 tried to touch Resident #15, and CNA #11 told Resident #15 to get away from Resident #38. Resident #15 asked CNA #11 not to tell anyone and they would not do it again. Another nurse heard the conversation and told Resident #15 to move away from Resident #38 and took care of the situation. - a witness statement dated 12/16/22 by LPN #7 documented on 12/16/22 at 4:20 PM they heard CNA #11 telling Resident #15 to stop touching Resident #15 and Resident #15 said they would not do it again and asked the CNA not to tell on them. LPN #7 called the DON immediately who said they would be in as soon as possible. The DON arrived at 5:00 PM. - a statement from Resident #38 dated 12/16/22 at 5:15 PM by the DON documented Resident #38 stated no one had touched them and they felt safe. - a statement from Resident #15 dated 12/16/22 at 5:45 PM by the DON documented Resident #15 stated they were going towards the dining room at 4:15 PM to watch TV. When they stopped, Resident #38 was sitting in the hallway at the nurse's desk. Resident #38 grabbed their arm and started kissing it. Resident #15 pulled back and Resident #38 grabbed their arm again. Resident #15 stated they did place their hand on Resident #38's left breast. Resident #38 told Resident #15 they were going to slap them, and Resident #15 pulled their hand back and was confronted by staff. There was no documented evidence Residents #38's and #15's care plans were reviewed to determine if appropriate interventions were in place to protect Resident #38 from abuse by Resident #15. Resident #38's CCP was updated 1/3/23 to include observe for all male residents around the resident and remind for social distancing at all times. Resident #15's CCP was updated on 2/3/23 to include the resident was to be a minimum of 6 feet away from any female resident when participating in an activity, and the resident was not to stop in the hallways to have conversations with any female residents. During an interview on 4/14/23 at 1:46 PM, CNA #11 stated that on 12/16/22 Resident #15 started touching Resident #38's feet with their feet and Resident #15 reached out to touch the breast of Resident #38. CNA #11 stated that Resident #38 was pushing Resident #15 away but Resident #15 kept reaching and CNA #11 intervened. CNA #11 stated Resident #38 did not remember or know what they were doing but Resident #15 was alert and oriented. CNA #11 stated that they had reported to the nurse two similar behaviors by Resident #15 toward Resident #38 prior to the 12/16/22 incident and had also told Resident #15 not to touch Resident #38. CNA #11 stated that before 12/16/22, the facility had only spoken to Resident #15 about their behavior with the two previous incidents, to give them a chance. CNA #11 stated that the facility did not increase supervision of Resident #15 or tell them not to go near female residents until after 12/16/22 incident. CNA #11 stated that the facility had provided abuse and neglect training to them. During an interview on 4/13/23 at 3:16 PM, CNA #16 stated that Resident #15 has displayed some inappropriate behaviors toward female staff members, but they have not seen it toward female residents. CNA #16 stated that they had been instructed to monitor where Resident #15 was. During an interview on 4/13/23 at 3:16 PM, CNA #14 stated that they were supposed to watch Resident #15 around female residents as Resident #15 had been caught inappropriately touching other residents. CNA #14 stated they should closely monitor Resident #15 and if they paused too long, they should encourage Resident #15 to move along. During an interview on 04/14/23 at 1:57 PM LPN #12 stated they were trained on abuse and neglect and if they witnessed an inappropriate interaction between two residents they should intervene, make sure both residents were safe, and notify a supervisor. They stated that they knew of the incident on 12/16/22 between Resident #15 and Resident #38. LPN #12 did not think anything happened between the two residents prior to 12/16/22. LPN #12 stated staff should monitor the residents for any future incidents and keep them apart. They stated if a cognitively intact resident inappropriately touched a cognitively impaired resident there was a lack of capacity to consent by the cognitively impaired resident. During an interview on 4/14/23 at 2:04 PM registered nurse (RN) #19 stated they were aware of the incident between Resident #38 and Resident #15 on 12/16/22 but was not aware of any incidents prior to that. RN #15 stated that following the 12/16/22 incident Resident #15 was not allowed to be alone anywhere, staff needed to be watching them when they were out of their room and monitor where they were and who they were with. They stated that staff would be aware of Resident #15's interventions as they would be on the Kardex (care instructions from the CCP). During an interview on 4/14/22 at 2:18 PM, the DON stated that they were responsible for the incident reports submitted to the NYS DOH. The DON stated they utilized the Nursing Home Incident Reporting Manual and if after a thorough investigation, the incident was reportable they would report it. The DON stated that they reported the incident between Resident #15 and Resident #38 in December on the day of the incident (12/16/22). DON stated that they did not report the incident between Residents #15 and #38 in October due to Resident #38 grabbing Resident #15's arm and putting Resident #15's hand on their breast. DON stated that the only thing they felt was wrong about the situation was that Resident #38 had dementia and Resident #15 did not take their hand away until staff intervened. DON stated that they spoke to Resident #15 following that incident about Resident #38's mental status and Resident #38 did not know what they were doing. The DON stated they discussed perception with Resident #15 and that Resident #15 was alert and orientated but others were not, and Resident #15 cannot engage in that behavior. The DON stated that there were no care plan changes following that incident. The DON stated that the incident in November between Residents #15 and #38 was an overreaction by the CNA, so no interventions were put into place following that incident. The DON stated that it was an issue if a cognitively intact resident inappropriately touched a cognitively impaired resident. The DON stated that even if the cognitively impaired resident was the aggressor that resident could not give informed consent so the cognitively intact person should remove themselves from the situation immediately. 10NYCRR 415.4(b)

Based on observation, record review, and interview during the recertification survey conducted 4/11/23-4/14/23, the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection, and prevent new ulcers from developing for 1 of 2 residents (Resident #16) reviewed. Specifically, Resident #16 developed a Stage 2 pressure ulcer (partial-thickness skin loss), and the ulcer was not monitored, treatments were not completed as ordered, and the resident's plan of care was not followed. Additionally, the resident had a significant weight loss, and their nutritional needs were not reassessed after the development of the pressure ulcer and significant weight loss. Findings include: The facility policy Prevention and Care for Skin Impairment - Pressure Ulcers revised 1/2023 documented: -A resident who had pressure ulcers would receive necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing. -Prevention interventions included turning repositioning the resident at a minimum every 2 hours while in bed and every 1 hour while in their chair. -Nursing staff would notify the Food and Nutrition department of any Stage 2 or greater pressure ulcer. - All wounds would be assessed by a registered nurse (RN) and the wound team would assess the wound weekly. - When a pressure ulcer was present the area should be monitored daily by the licensed practical nurse (LPN). The facility policy Significant Weight Loss revised 2/2023 documented: -Weights would be obtained monthly and significant weight changes would be communicated to and addressed by the registered dietitian (RD) and/or diet technician (DT), physician, and interdisciplinary team (IDT). - Re-weights must be obtained within 24 hours if meets the following criteria: 5-pound (lbs.) change in 1 week, 5% or 5 lbs. in 30 days, 7.5% in 90 days, and 10% in 180 days. - Nursing would notify the physician and family regarding significant weight changes. - The RD/ DT would reassess the resident's nutritional needs and intake with the noted weight change. -The resident's weight would be monitored weekly until their weight stabilized or weight returns to goal weight. Resident #16 was admitted to the facility with diagnosis including dementia and dysphagia (difficulty swallowing). The 1/25/23 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, did not reject care, required extensive assistance of 2 with bed mobility, transfers, dressing, personal hygiene, and toilet use, extensive assistance of 1 with eating, used a wheelchair, had an indwelling urinary catheter, was always incontinent of bowel, weighed 144 pounds, had no significant weight changes, was at risk for developing pressure ulcers, did not have pressure ulcers, had a pressure relieving device for their chair, and was on a turn and positioning program. The 10/27/20 physician order documented the resident's skin was to be checked on their bath day on Wednesdays on the 2:00 PM-10:00 PM shift. A nutritional assessment dated [DATE] (does not indicate who completed the assessment) documented the resident received a regular pureed diet with nectar thick liquids. The resident's intakes averaged 49% at breakfast, 53% at lunch, and 54% at dinner. The resident weighed 144 pounds (lbs.) via a mechanical lift on 1/24/23. The resident had excoriation to the buttocks and sacrum (lower back). The resident required 1540 Kcals (kilocalories) per day, and 66 grams of protein due to high risk for skin breakdown. The resident received 120 milliliters (approximately 4 ounces) of Ensure Compact (an oral nutritional supplement) at breakfast, lunch, and dinner. The resident's appetite was fair and had declined from last quarter. Weight was trending down which was consistent with decreased intake. The resident did not trigger for significant weight loss, however continued loss was undesirable. The resident received supplements at all meals and HS (hour of sleep) to help meet nutritional needs and stabilize weight. The comprehensive care plan (CCP) revised 1/30/23 documented the resident had potential for pressure ulcer development related to immobility and had maceration (skin breakdown related to moisture) to their buttocks. Interventions included to lay the resident down after meals to keep pressure off their bottom; follow facility protocol and procedures for the prevention/ treatment of skin breakdown; a gel overlay for their mattress; monitor, document, and report any skin changes; a gel cushion for their wheelchair; reposition every 2 hours while in bed, and every 1 hour while in their chair; and check skin daily with care and weekly by the nurse. The CCP revised 1/31/23 documented the resident was at nutritional risk due to dementia, their body mass index (BMI, measurement of body fat based on height and weight) was low 20.1, intakes were fair, their weight was trending down, they were at high risk for skin breakdown, and had an excoriated area on their buttocks. Interventions included providing adaptive equipment at meals, pureed solids and mildly thick (nectar) fluids, assistance with meals, 4 fluid ounces of Ensure Compact at all meals, and Magic Cups (frozen nutritional supplement) at lunch and dinner. The undated Kardex (care instructions) documented the resident used a tilt and space wheelchair (redistributes pressure), a gel cushion for the wheelchair, a gel overlay mattress for their bed, reposition every hour while in their chair and every 2 hours while in bed, their bath day was Wednesday evening, extensive assistance of 2 people with bed mobility, total dependence to assist with feeding, received pureed solids and mildly thick (nectar) liquids, required assistance of 2 for toileting, and was incontinent of bowel. Physician orders documented: - on 1/31/23 the resident was to receive pureed solid, mildly thick fluid (Nectar) consistency with no straws. - on 2/23/23 use wedges to offload pressure for positioning every shift. On 2/27/23 physician #3 documented they saw the resident for a routine visit. The resident was noted to have deep tissue injury (purple/maroon area of intact skin due to damage of underlying tissue) bilaterally over their buttocks. Apparently, it was noted last week. The resident was at high risk for skin breakdown and had a history of stool incontinence. The resident had a couple of open areas over their buttocks bilaterally towards the mid to upper areas approximately the size of a half dollar, they were not measured, and they appeared to be Stage 2 pressure injuries. The plan included to encourage staff to turn and reposition the resident every 2 hours as needed; clean the area with wound cleanser, pat dry, apply wound gel, and cover with foam dressing every 3 days and as needed; and follow up within a week. The 2/28/23 physician orders documented to cleanse and apply wound cleanser to the buttocks topically one time a day every 3 days for skin impairment, pat dry, apply wound gel, let dry, and cover with foam dressing every three days and as needed. Registered nurse (RN) #9 entered the order into the medical record on 2/28/23. There was no further documentation regarding the buttocks wound. The March 2023 Treatment Administration Record (TAR) documented: Apply wound cleanser to the buttocks topically one time a day every 3 days at 9:00 AM for skin impairment, pat dry, apply wound gel, let dry, and cover with foam dressing every three days and as needed. The treatment was marked as not completed by licensed practical nurse (LPN) #7 on 3/18/23 due to the resident being out of the facility. There were no nursing notes on 3/18/23 documenting the resident was out of the facility or the treatment was administered at a different time. The Weights and Vitals Summary documented the resident weights as follows: - on 3/5/23 145 lbs. via mechanical lift. - on 4/2/23 137.5 lbs. via mechanical lift and was re-weighed at 137.5 lbs. via mechanical lift (a 7.5 lbs./5.1% significant weight loss at one month and 12.5 lbs./ 8.3% significant loss at 3 months). - on 4/9/23, the resident weighed 138.1 lbs. via mechanical lift (a 6.9 lbs./ 5.1% loss at one month and 11.9 lbs./ 7.9% loss at 3 months). There was no documentation the resident's significant weight loss or skin impairment was addressed by clinical nutrition staff (RD or DT). The April 2023 TAR documented to apply wound cleanser to the buttocks topically one time a day every 3 days at 9:00 AM for skin impairment, pat dry, apply wound gel, let dry, and cover with foam dressing every three days and as needed. On 4/2/23 and 4/11/23 the treatment was signed as not completed by LPN #7 due to the resident being out of the facility. There was no documented evidence the wound treatment was administered when the resident returned to the facility on [DATE] and 4/11/23. There were no nursing notes on 4/2/23 or 4/11/23 documenting the resident was out of the facility. Observations of Resident #16 included: - on 4/11/23 at 11:39 AM sitting in their tilt and space wheelchair with a blanket over their lap in the dining room. At 12:15 PM, the resident was assisted with their pureed solid lunch meal and mildly thick (nectar) liquids. At 2:31 PM, sitting in their tilt and space wheelchair in their room with a blanket over their lap. - on 4/12/23 at 8:18 AM sitting in their tilt and space wheelchair in the main dining room with a blanket over their lap. At 8:19 AM, the resident was brought out to the television lounge area by an unidentified staff member. At 12:58 PM, the resident was seated in their tilt and space wheelchair in the television area near the nurse's station with a blanket over their lap. At 1:58 PM, LPN #8 brought the resident to their room and closed the door. At 2:04 PM, the door to the resident's room opened and there were 2 CNAs in the room. The resident was in their bed with their eyes closed. - on 4/13/23 at 7:19 AM sitting in their tilt and space wheelchair in the dining room with a blanket over their lap. During a continuous observation starting at 8:11 AM, the resident was brought out to the television lounge area from the dining room. At 8:36 AM, LPN #8 brought the resident to the medication cart for their medication and brought them back to the television area at 8:39 AM. The resident remained in the television lounge area until 10:51 AM, when an activity staff brought the resident outside to the patio for an activity. The resident was not repositioned every hour in their chair as planned. At 11:10 AM, an activity staff brought the resident back inside from the patio to the television lounge area. At 11:48 AM, an unidentified staff brought the resident into the dining room. At 12:07 AM, a nursing student was seated with the resident feeding them lunch which included a pureed hamburger, pureed bun, puree pears, mildly thick (nectar) apple juice, a Magic Cup, and 4 ounces of Ensure Compact. During an interview with CNA #10 on 4/13/23 at 12:30 PM, they stated they knew how to care for the residents by reviewing their care plans. Repositioning a resident helped prevent skin breakdown. If a resident needed to be repositioned it was listed on their care plan. They stated Resident #16 only needed to be repositioned in their bed not in their wheelchair. There was nowhere for the CNAs to document they had repositioned a resident. They stated residents who needed a mechanical lift for transfers should be checked and changed prior to getting out of bed, after breakfast, and after lunch. They stated they had Resident #16 on their assignment on this day. The resident required a mechanical lift for transfers, they did not check or change the resident after breakfast or before lunch, the resident had a skin issue on their buttocks, the resident did not wear a brief, and they were unaware the resident needed to be repositioned while in their wheelchair. They stated it would be important to follow the care plan to prevent further skin breakdown. During an interview with RN #9 on 4/13/23 at 3:22 PM, they stated the RN Charge nurse would complete any wound assessments and document their findings in the computer. Residents who had pressure areas and other wounds were followed weekly by the RN and the LPNs did daily skin documentation in the computer as well. They stated they entered the 2/28/23 physician orders into the electronic health record. They did not assess the resident's pressure ulcer after entering the physician orders. They stated they dropped the ball. They should have documented the resident had a pressure ulcer, assessed the resident's skin, and triggered them to followed weekly for their pressure ulcer. They did not do this, and nobody had been assessing the resident's wound because it was not documented. It was important for pressure ulcers to be monitored to ensure the treatment was working and the area was improving. If it was not followed the wound could get worse. They stated the LPNs should document a skin observation on shower days, but there was no documentation that had been done either. They stated the resident's current interventions included a gel cushion for their wheelchair, gel overlay mattress for their bed, and the resident should be laid down after meals. Any RN could update the CCP, and the resident's pressure ulcer should have been added to the care plan when they entered the order into to the computer. If a resident needed to be repositioned that meant they needed to move the resident in their chair or bed to a different position to aid with preventing skin breakdown. Staff should check and change resident's every 2 hours and as needed. They stated if the resident was in the same position for 2 hours that was a long time as they were at risk for further skin breakdown. During an observation on 4/13/23 at 4:06 PM 2 CNAs and RN #9 rolled the resident over to their side. No dressing was observed on the resident's buttocks. There was a reddened area on their bilateral buttock/ sacral area approximately 10 centimeters (cm) x 12 cm, with a small quarter sized superficial open area at approximately 11 o'clock. RN #9 stated the area looked like a Stage 2 pressure ulcer. The RN stated they recalled entering the physician's orders for the wound but did not know when the wound treatment should be completed. They stated the resident should have a dressing in place as ordered and the LPNs should check the placement of the dressing each shift and write a note. They stated the resident's pressure ulcer should have monitored and had not been since it was found. During a follow up interview with CNA #10 on 4/13/23 at 4:37 PM, they stated they the resident did not have a dressing on when they got them up in the morning. They were unaware the resident needed to have a dressing and they told the LPN the resident's skin looked the same. They said the resident had an open area but did not tell LPN #8. It was important for a nurse to observe the resident's skin if they had any skin issues. During an interview with LPN #8 on 4/13/23 at 4:45 PM, they were unaware the resident had any skin issues and needed to have a dressing in place. They stated if the CNA observed any skin issues, they should have let them know so a nurse could look at the resident's skin. During a telephone interview with LPN #7 on 4/14/23 at 8:10 AM, they stated wound treatments were usually done in the morning before the resident got up. They were aware Resident #16 had a scheduled treatment every 3 days on the day shift for a wound on their buttocks. They stated they did not complete the treatment on 4/11/23 because LPN #6 told them they had completed the treatment on the 10:00 PM to 6:00 AM shift. They documented on the TAR that the resident was absent from home without medications as the resident was either at an appointment or at an activity. They thought LPN #6 documented they completed the treatment. They did not tell anyone they did not complete the treatment or were unable to observe the resident's skin. They should have followed up to make sure the treatment was completed as ordered and they were unsure how the resident's skin looked. It was important to follow physician's orders to ensure the treatment was completed and the wounds was improving and did not get worse. During a telephone interview with LPN #6 on 4/14/23 at 8:40 AM, they stated worked the night shift on 4/10/23. If they completed a treatment when it was not scheduled, they would document it was completed in a progress note. They were aware the resident had an open area on their buttocks, but they had not seen the resident's wound. LPN #6 stated they did not change the dressing on 4/10/23 or 4/11/23 as it was not scheduled to be completed on their shift. They stated it was important for the physician orders to be followed as the wound could get worse. They stated the resident was to be turned and positioned every 2 hours while in bed. During an interview with RN Unit Manager on 4/14/23 at 9:08 AM, they stated treatments should be completed per the physician's orders and the staff member who entered the physician orders into the electronic computer system should have triggered a weekly skin assessment so it could be followed. They were unaware Resident #16 had a pressure ulcer and was not being followed weekly. They stated they were unaware the treatment was not being followed per physician orders and they expected one of the RNs to be notified if a treatment could not be completed as ordered. They stated there could have been negative outcomes including the wound getting worse or infected if it was not monitored and the treatment was not completed as ordered. They stated the resident should be repositioned every hour in their chair and every 2 hours while in bed. They stated the RD let the Unit Managers, RN charge nurses, and the Director of Nursing (DON) know who had significant weight changes by a list they sent out on Mondays and Fridays via electronic communication. After reviewing the resident's record, they stated the resident appeared to have lost weight and their intakes were hit or miss, and the resident was assisted at meals by staff. The RN Unit Manager stated the RD probably did not know the resident had a Stage 2 pressure ulcer and should have made aware so nutritional intervention could be put into place. They stated it was the responsibility of either the RN Unit Manager or RN charge nurse to update the care plan if a resident had a pressure ulcer. During an interview with the DON on 4/14/23 at 12:23 PM, they stated if a resident had any changes to their skin an RN should assess the resident. They expected them to complete a skin assessment, update the care plan, ensure orders were in place for treatments, and make sure the weekly pressure ulcer assessment task was initiated so the wound could be monitored. They stated it was important for the treatments to be completed as ordered and the wound to be monitored to ensure the wound was healing and not getting worse. They stated nurses should checking the placement of the dressing each shift and replace or change as needed per the physician order. The DON stated it would be important for the RD to know if the resident had skin breakdown to make sure their nutritional needs were being met. During an interview with RD #22 on 4/14/23 at 11:32 AM, they if a resident had a 5 lbs. weight change from their previous weight a reweight was to be obtained. They considered significant weight changes 5 lbs. or 5% at 30 days, 7.5% at 90 days, and 10% at 180 days. If a resident had a significant weight change, they would discuss the weights with the IDT, document in a progress note, and review the resident's current nutrition plan of care to determine if any interventions should be added or changed. If they were aware a resident had a pressure ulcer and a significant weight loss they would complete a full nutrition assessment, determine their estimated daily nutritional needs, review current nutritional interventions to determine if any changes were needed, and update the care plan. They were unaware Resident #16 had a Stage 2 pressure ulcer. They stated Resident #16 triggered for a significant weight loss 2 weeks ago, they had emailed the team about the weight loss and were told the scales had been serviced. They requested another reweight and that was obtained on 4/9/23. The resident triggered again for a significant weight loss, but they had not addressed it yet and were currently working on their weight notes. They stated they would have completed their notes or assessment earlier and updated the care plan had they known the resident had a pressure ulcer. The RD stated the resident had a stomach bug a couple of weeks ago which may have affected their appetite and intakes. During a telephone interview with physician #3 on 4/14/23 at 1:19 PM, they stated they expected any resident who had a pressure ulcer to be followed by the RN and the nurses should be documenting on the resident's skin. They stated Resident #16 was at high risk for skin breakdown, they saw them in February and had written orders for wound care. They expected staff to ensure the treatment was completed as ordered. He also expected staff to reposition the resident due to their high risk for skin breakdown. 10NYCRR 415.12(c)(2)

Based on observation, record review, and interview during the recertification survey conducted 4/11/23-4/14/23, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, and the comprehensive person-centered care plan for 1 of 3 residents (Resident #14) reviewed. Specifically, Resident #14 was observed receiving oxygen (O2) via a nasal cannula (NC, a tube delivering oxygen through the nose) and did not have a physician order or indications for use, and did not have ongoing assessments of respiratory status, and response to O2 therapy. Findings included: The facility policy Oxygen Therapy last reviewed on 6/2021 documented routine oxygen therapy required a physician order to include device and percentage of liter flow. Resident #14 had diagnoses including chronic obstructive pulmonary disease (COPD, airflow obstruction), iron deficiency anemia, and congestive heart failure. The 1/31/23 Minimum Data Set (MDS) assessment documented the resident had intact cognition, required extensive assistance for most activities of daily living (ADLs), and required oxygen therapy. The comprehensive care plan (CCP) initiated 8/3/22 did not include a plan for the resident to receive oxygen. Physician's orders with a date range of 8/30/22-3/30/23 did not include oxygen administration. A physician #3 progress note dated 2/27/23 documented the resident was seen for a routine visit. The resident was ambulating in their room with their walker and did not appear to be in acute distress. The resident's lungs were clear to auscultation (listening with a stethoscope). There was no documented evidence the resident required oxygen therapy. The 3/30/23 at 10:44 AM, registered nurse (RN) #24's progress note documented the resident was congested and had wheezes. Vitals signs included oxygen saturation on room air (no oxygen) was 99%. A nursing progress note dated 3/30/23 at 2:03 PM by RN #21 documented the resident had a chest X-Ray (CXR) with results including right basilar (right lung base) atelectasis (lung collapse) or pneumonia. New orders were received from the nurse practitioner for antibiotics. There was no documentation of a plan for oxygen therapy. The April 2023 medication administration record (MAR) and treatment administration record (TAR) did not include administration of oxygen or respiratory status evaluation. The 4/4/23 nurse practitioner (NP) #25's progress note documented the resident was seen for a follow up visit for pneumonia. The resident had a chest X-ray that showed the resident had pneumonia and would need to be started on antibiotics for seven days. The resident was feeling better. The resident was on oxygen chronically. The resident was short of breath at rest and had some wheezes. The resident's pulse oximetry (measurement of a person's blood oxygen saturation, O2 saturation) with oxygen on was 98% (did not document the flow rate of oxygen the resident was receiving) and respiratory rate (number of breaths per minute) was 22. The 4/1/23-4/14/23 Vitals Summary documented the resident had oxygen saturations measured daily. The summary documented the saturations were taken while the resident was on oxygen via a NC on 4/1/23-4/13/23. The resident was observed on 4/11/23 at 11:00 AM and 1:19 PM, 4/12/23 at 9:45 AM, and 4/13/23 at 7:28 AM, receiving oxygen at 2 liters per minute via a nasal cannula. During an interview on 4/13/23 at 3:34 PM, licensed practical nurse (LPN) #12 stated residents that required oxygen should have a physician order for the oxygen. The order would than show up on the electronic MAR or TAR and that would include when the oxygen tubing was changed. Nursing was responsible for checking the resident's oxygen tubing and rate of flow. Resident #14 did not have a physician order and used oxygen daily and should have had an order. During an interview on 4/14/23 at 9:40 AM, RN #19 stated if a resident was on oxygen, they should have a physician order. Resident #14 was on oxygen. The RN reviewed the current physician orders and stated there was no physician order for them to receive oxygen. The oxygen order should include the required liters per minute and the nurse would be responsible for checking this routinely. If a resident routinely used oxygen, the CNAs would check their oxygen level when they completed their vital signs, but the nurse was responsible for the tubing and setting the flow rate. During an interview on 4/14/23 at 1:16 PM, physician #3 stated there should be an order for the resident to receive oxygen. Prior to switching to electronic medical record, they had a standard checklist when a resident was admitted and that had oxygen orders on the list as a reminder. The oxygen order did not make it over to the electronic record and should have because Resident #14 required oxygen. They thought the resident should have an as needed (PRN) order, the resident required use of oxygen routinely and staff should also be checking the resident oxygen saturation. They stated they would expect to be notified by nursing staff if a resident required oxygen and did not have an order. During an interview on 4/14/23 at 2:18 PM, the Director of Nursing (DON) stated the resident used oxygen and every resident that required oxygen should have a physician order. The nurses knew that if a resident used oxygen, it was just like a medication and required a physician order. The order should include the frequency of use and the flow rate. 10 NYCRR 415.12(k)(6)

Based on observation, record review, and interview during the recertification survey conducted 4/11/23-4/14/23 the facility failed to ensure that licensed nurses had specific competencies and skill sets to provide nursing services to assure resident safety for 1 of 3 licensed nurses (licensed practical nurse [LPN]) #12 observed during medication administration. Specifically, LPN #12 was observed pre-pouring resident medications before the ordered times and placing them in plastic cups in the medication cart. Findings include: The facility policy titled Medication Administration Overview revised 4/2023 documented prior to medication administration, scan all required medications, and visually confirm that the correct dose, correct medication, and correct resident ID were displayed on the eMAR (electronic medication administration record) screen. The facility policy Pharmacy Services revised 1/2021 documented when administering medication to review the following: Is it the correct resident? Correct medication? Correct dose? Correct time? Correct route? Identify the resident with the picture ID and medical record number, compare the medical record number with the resident's picture, or pharmacy sticker. Pour medication. Re-check labels with the MAR after pouring and initial and date the blister pack. Re-check the resident's identity. Administer medication with adequate fluids. Stay with the resident until the medication was completely taken. Re-check unit dose/blister pack with MAR. Sign the MAR. Re-check all MARs after medication was completed. During a medication administration observation on 4/12/23 at 3:16 PM, LPN #12 was behind the nursing station with the Unit 3 East medication cart. LPN #12 had the electronic MAR screen displayed with Resident #9's 8:00 PM medications and was placing the medications in a plastic medication cup. The LPN completed pouring Resident #9's 8:00 PM medications and covered them with a paper medication cup. The paper medication cup had the resident's name and 8:00 PM written on it. LPN #12 placed the cup in the top drawer of the medication cart. While the drawer was opened, 2 additional medication cups with medications inside were observed. The medication cups contained pills and were labeled for Resident #32 at 8:00 PM and for Resident #9 at 5:00 PM. LPN #12 stated those medications were removed from the original pharmacy packaging (blister packs). The locked narcotic drawer in the medication cart was observed with 4 medication cups containing pills. LPN #12 stated they had removed the pills in the narcotic drawer from the pharmacy packaging and placed them in the cups. The medication cups in the narcotic drawer contained methadone (opioid agonist) 10 milligrams (mgs) for Resident #5 scheduled to be given at 8:00 PM; clonazepam (benzodiazepine, anti-anxiety) 0.5 mgs for Resident #40 scheduled to be given at 7:00 PM; Xanax (anti-anxiety) 0.5 mgs for Resident #10 scheduled to be given at 8:00 PM; and lorazepam (anti-anxiety) 0.5 mgs for Resident # 4 scheduled to be given at 4:00 PM. LPN #12 stated the medications would be signed out on the narcotic reconciliation book at the times they were to be given. The LPN stated their usual routine was to prepare meds early, because it was very busy after dinner. LPN #12 stated they were not sure what the facility policy was for pre-pouring medications, and they felt that organizing the medications for later administration allowed them to help the certified nurse aides (CNAs) if needed. They stated that the required checks (the 5 rights of medication administration, the right medication, dose, time, route, and resident) were performed when the medications were poured. LPN #12 stated they visualized what medications were in the cup before giving them but did not pull medication cards (blister packs) to verify the pill's appearance or accuracy. The LPN stated they did not feel their practice was unsafe. During an interview on 4/12/23 at 3:51 PM, registered nurse supervisor (RNS) # 20 stated pre-pouring medications was not an acceptable practice because the nurse could not identify the medications at the time of administration. The medications could get mixed up, and the wrong medication could go to the wrong person. It was not safe for residents. Narcotics should not be pre-poured and should be signed out at the time of administration. During an interview on 4/13/23 at 9:51 AM RN #21 stated during medication administration medications should not be pre-poured. The medications could get mixed up and possibly given to the wrong person. Medications should be prepared and given at the same time using the 5 rights of medication administration. During an interview on 4/14/23 at 1:39 PM, the Director of Nursing stated medications should never be pre-poured. The nurse may not give the medications to the right resident and an adverse reaction could occur if a resident received the wrong medications. A medication pass should not be interrupted. It was extremely important to resident safety. 10NYCRR 415.26(c)(I)(iv)

Based on observation, interview, and record review during the recertification survey conducted [DATE]-[DATE], the facility failed to ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles and included the expiration date when applicable for 1 of 2 medication carts (Unit 3 East) reviewed. Specifically, the Unit 3 East medication cart contained an insulin pen for Resident # 9 that did not have an opened date. Findings include: The facility policy Insulin Injection Administration reviewed ,d+[DATE] documented insulin pens could be housed outside the refrigerator safely for 28 days. Check for labeled date/time/initialed when opened. Discard vial if opened more than 30 days. During a medication cart observation with licensed practical nurse (LPN) #12 on [DATE] at 3:16 PM, the Unit 3 East medication cart contained an insulin glargine (long acting insulin) pen for Resident #9. The insulin pen was not labeled with an opened date. LPN #12 stated insulin pens should be dated when opened by the nurse opening the pen to ensure the insulin was in date. They stated insulin was good for 30 days after opening, and all medication nurses should be checking the opened date when administering insulin. They stated they had worked the evening shift on [DATE] and had administered the insulin glargine with the pen to Resident #9. They did not remember if they checked for an opened date at the time of administration. During an interview on [DATE] at 3:51 PM registered nurse (RN) Supervisor #20 stated insulin pens should be labeled by a nurse with the date opened. Insulin was good for 30 days after opening, and the medication nurse should be checking for expiration dates when administering the insulin. Expired insulin could be less effective, less potent, and possibly cause an adverse reaction. During an interview on [DATE] at 1:39 PM, the Director of Nursing (DON) stated insulin pens should be checked for expiration dates and refrigerated until opened. Once opened insulin was good for 30 days, the date opened should be documented on the pen by the nurse who opened it. Every medication nurse should check insulin for the date opened. The danger of administering expired insulin included the insulin may not be effective. Expiration dates should always be checked before administration. 10 NYCRR 415.18 (d)

Based on record review and interviews during the abbreviated survey (NY 209) the facility failed to ensure residents had their advance directives honored for 1 of 6 residents reviewed (Resident #1). Specifically, on [DATE], resuscitation efforts were made when Resident #1 became unresponsive despite a Do Not Resuscitate (DNR, allow natural death) order included in the resident's medical record. On [DATE], the Resident's representative changed the resident's advance directives from Full Code (initiate cardiopulmonary resuscitation, CPR) to DNR / Do Not Intubate (DNI). Registered nurse (RN) Manager #1 updated the electronic medical order and the MOLST (Medical Orders for Life-Sustaining Treatment) and failed to remove the full code identifiers from the resident's room, bracelet, code status list, and the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . RN Manager #1 did not designate other staff to complete the steps for the change in the resident's advance directives and the facility did not have a system in place to ensure code status changes were immediately implemented. The resident remained with a bracelet signifying Full Code, a Full Code indicator over their bed, and a notation in the MAR/TAR that their status was Full Code from [DATE]-[DATE]. On [DATE], when the resident became unresponsive, staff began CPR based on the full code identifiers. The facility's failure to honor advance directives placed the facility's 14 Full Code and 41 DNR residents at risk for serious injury, harm and death that was Immediate Jeopardy. The facility policy CPR (cardiopulmonary resuscitation) Identification reviewed ,d+[DATE] documented: After a resident elected CPR, the admitting registered nurse (RN) would identify CPR by the following: - Place a red heart sticker identification bracelet on the resident. - Place a red heart with the resident's picture above the bed. - A CPR mouthpiece to be place in the resident's closet. - Place a heart sticker on the resident's picture in the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] - Enter in the electronic medical record (EMR) under the patient profile. - Anytime a DNR was implemented or rescinded, ward clerks would send an updated notification. - The medication nurse was to check each shift for the bracelet and picture for those requesting CPR and document on the treatment record. - At any time during the resident's stay, if the resident or family member requested DNR and an order was written, the picture above the bed, heart picture on the MAR, and bracelet would be removed. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment. The [DATE] physician Admission History and Physical documented the resident's current advance directive was full code (initiate CPR). The comprehensive care plan (CCP) initiated [DATE] documented the focus area (revised [DATE]) included: the resident established advance directives, their relative was appointed as the resident's surrogate on [DATE] and completed a new MOLST to include DNR with limited medical interventions. The interventions initiated [DATE] included: Full code, a heart bracelet was to be worn, and a heart above the bed and the chart was to reflect their wishes to include full code. The Care Plan meeting signature sheet date [DATE] documented the team met to review the resident's plan of care, MOLST, DNR and DNI, and HCP (healthcare proxy, person appointed to make decisions on the resident's behalf). RN Manager #1, social worker (SW) #4, therapy, nutrition, and dietary staff were in attendance and the resident's relatives participated via telephone. The resident's MOLST documented the resident's surrogate decision maker (relative) consented to a change. The resident's MOLST documented DNR status with limited medical interventions via verbal consent on [DATE] at 1:10 PM. SW #4 signed as the first witness and RN Manager #1 signed as the second witness. Physician #14 signed the MOLST on [DATE], with no time noted. There were no documented interventions on the CCP to reflect the change to the DNR on [DATE]. The [DATE] at 4:57 PM nursing progress note entered by RN Manager #1 documented the resident's MOLST was changed over the telephone with the resident's relative. The new MOLST form included DNR/DNI and limited medical interventions. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] - Full code, check heart bracelet, over head of bed, and mouthpiece in closet every shift with a start date of [DATE]. The order was discontinued on [DATE] by RN Manager #1 with a note the resident was now DNR. - Code Status DNR/DNI with limited medical interventions with a start date of [DATE], entered by RN Manager #1. The ,d+[DATE] treatment administration record (TAR, a paper copy printed from the EMR and physically signed by staff) documented: - Full code: check heart bracelet, heart over the head of the bed, and mouthpiece in closet every shift, start date [DATE]. There was no discontinue date. - Code Status: DNR/DNI with limited medical interventions, start date [DATE]. - The TAR was signed [DATE]-[DATE] for the full code verification. - The TAR was signed on 7 shifts from [DATE] through [DATE] for both full code verification and DNR/DNI status by licensed practical nurses (LPNs) #2, 3,16, 17, 18, and 19. - The TAR entry for DNR/DNI had the word duplicate written across signature blocks after [DATE] and contained no further signatures. The [DATE] Patient Incident Form documented the resident became unresponsive at approximately 7:15 AM. A Rapid Response (emergency response) was called. The resident had a heart bracelet as well as a heart symbol on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Code Blue (medical emergency) was called when no pulse was detected. CPR was initiated and when the resident was being transferred to the emergency department (ED) the responding physician asked for the chart. Upon looking at the MOLST, it was realized the resident's status was DNR/DNI. The resident subsequently passed in the ED at 7:51 AM. The [DATE] hospital CPR Flow Sheet documented (chest) compressions and Ambu bag/mask (handheld mask and bag to provide positive pressure ventilation) were started at 7:35 AM and stopped at 7:37 AM. The [DATE] at 8:17 AM nursing progress note entered by RN Supervisor (RNS) #5 documented a Rapid Response was called, RNS #5 along with hospital RN #9 and LPN #6 responded to the unit. Resident #1 was at the nurse's station slumped forward and unresponsive. LPNs #2 and 7 were at the nurse's station with the resident, RNS #5 attempted to get a response (from the resident) and there was no response. RNS #5 questioned the resident's code status, LPN #2 responded they were a full code, their left wrist was checked for a full code heart bracelet, and RNS #5 and LPN #7 verified the heart bracelet. The resident was lowered to the floor and their carotid (main artery in the neck) pulse was checked. Initially, the resident had a carotid pulse but then it was lost. By this time RN #9 responded from the acute care setting (attached hospital). A Code Blue was called, (chest) compressions were started by RN #9, and the crash cart (contains supplies needed during the code) was retrieved. RNS #10 from acute care along with the code team were present on the unit. The resident was put on a stretcher and their chart was handed to code team physician #24. At that point, the MOLST dated [DATE] was seen and code team physician #24 team stated the resident was DNR status. The resident was taken to the ED by the code team. RN Manager #1 was interviewed on [DATE] at 1:38 PM and stated it was their responsibility to perform all the code status changes immediately following the notification from the resident's family representative of the change. The RN changed the order in the electronic record, completed and signed a new MOLST, notified the medical provider to obtain their signature, and placed the change on the 24-hour report. The RN Manager did not place it on the order change report, which was used for verification of order changes. The RN Manager stated they got pulled away to address an urgent situation and did not complete the process of removing the bracelet, the red heart symbol over the bed, or the sticker in the MAR, and did not discontinue the TAR order to check for placement of full code indicators. The RN Manager did not notify the ward clerk or other designated staff to complete the process to change the code status indicators. From [DATE] to [DATE], the RN Manager stated they had forgotten and did not think to go back and remove the indicators. During an interview with the Director of Nursing (DON) on [DATE] at 10:06 AM, they stated it was the sole responsibility of the RN making the code status change to complete all aspects of the change. RN Manager #1 should have removed the bracelet, the heart sign over the bed, the heart sticker on the page in the MAR, and should have highlighted the TAR entry to verify full code status (indicating the order was discontinued). The DON stated the error was not caught over the next 11 days, and when the resident became unresponsive, staff who responded verified the resident's code status by the bracelet with the red heart and the red heart sticker in the MAR. The DON stated ideally, they should have utilized the MOLST at the time, however their policy was to verify with the physical indicators that were present. During an interview with LPN #2 on [DATE] at 4:45 PM, they stated they were on the floor when Resident #1 became unresponsive and when the Code Team arrived. The code team asked LPN #2 to verify the advance directives and LPN #2 utilized the MAR, which contained the resident's picture and a red heart sticker. LPN #2 did not recall hearing of any changes to the resident's advance directives and if that happened, they expected it would be completed at the time of the change, as that is not typically something left for other staff to complete unless specifically stated. During an interview with the DON on [DATE] at 3:53 PM, they stated when the resident's order was changed and entered into the electronic record by RN Manager #1, it created a new order for DNR/DNI, however it did not drop off the order for full code verification. The pages from the electronic TAR were printed and placed in the treatment book, and staff signed the paper copy of the TAR each shift. The DON did not initially identify the error on the TAR for Resident #1, where the full code verification and DNR/DNI verification were both signed for on the same days and shifts. The DON acknowledged 6 different LPNs (LPNs #2,3,16,17,18, and 19) signed for verification of both DNR/DNI and full code on the same shifts ,d+[DATE], ,d+[DATE], and the night shift of [DATE]. Following the [DATE] TAR entry for DNR/DNI, it was hand-written duplicate, and no further signatures were noted. Staff continued to sign the TAR to verify the full code status and presence of the full code indicators. The DON expected the nurses who signed both orders would have identified the discrepancy and notified a supervisor for clarification. During a telephone interview on [DATE] at 10:57 AM, physician #14 stated they physically signed Resident #1's new MOLST for DNR/DNI on [DATE] following the family's decision to change the orders. The resident lacked decision-making capacity and the family reviewed the advance directives at the care plan meeting. The Medical Director stated the facility lacked a system for checks and balances to ensure changes in advance directives were carried out accordingly. There were multiple indicators for full code status, and this could lead to confusion and errors, as in the case with Resident #1. The Medical Director stated they would expect any changes to advance directives be implemented immediately in the event the resident had a sudden change in condition and to ensure the resident or their family's wishes were honored. During a follow-up interview on [DATE] at 11:40 AM, RN Manager #1 stated they were not aware LPNs # 2, 3, 16, 17, 18, and 19 all signed for both verification of full code status and DNR/DNI at the same time from ,d+[DATE]-[DATE]. The RN Manager expected licensed staff who signed the TAR to read what they signed for and take note of any discrepancies. The RN Manager stated they were not made aware of any discrepancies on the TAR from any of the 6 LPNs and was not aware duplicate was written on the page in the TAR with the DNR/DNI order. The RN Manager stated the person who wrote duplicate on the TAR for the DNR/DNI should not have done so without clarification of both orders. The DNR/DNI order was dated [DATE] and that should have alerted staff to the change and to verify further. During a telephone interview on [DATE] at 2:49 PM, RNS #10 stated they worked at the hospital and responded to the Code Blue call on the nursing home unit. By the time RNS #10 arrived, CPR had been stopped. There was some confusion as to the resident's code status because the resident had on the bracelet for full code, but the MOLST in the chart had DNR. At that time, the resident was brought to the emergency department and pronounced deceased . During a telephone interview on [DATE] at 11:10 AM, LPN #17 stated they did not recall any information related to Resident #1's change in advance directives when signing the TAR for full code verification. LPN #17 looked for the bracelet with the red heart and was not aware of what was to be verified if they signed the TAR for DNR/DNI. The LPN did not recall any discrepancies in the TAR with both full code and DNR/DNI orders to be verified. When LPN #17 signed the TAR, they went through the motions of signing the sheets at the end of their shift and was not aware they signed for 2 contradicting orders. During a telephone interview on [DATE] at 11:46 AM, LPN #18 stated they were not familiar with Resident #1's unit. When LPN #18 signed the TAR to verify full code status, they looked at the bracelet. To verify DNR/DNI status, they may look at the Kardex, the care plan, or the sticker in the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . They stated they usually completed the medication pass first and went back to do the treatment book and signed what needed to be signed. If the full code was discontinued, it should have been highlighted in the TAR and LPN #18 did not notice both orders remained active. During a telephone interview with LPN #16 on [DATE] at 12:01 PM they stated for full code verification they were to check the physical indicators and sign the treatment book. For DNR/DNI verification, they should check the MOLST. As an overnight nurse, they checked orders for accuracy and would use the printed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #16 was not aware of the reason they signed both entries without seeking clarification. During a telephone interview with LPN #19 on [DATE] at 10:16 AM, they stated when they signed the TAR for full code verification, they observed the physical indicators like the bracelet with the heart and the heart over the bed. For verifying DNR status, they would note if no bracelet was present. LPN #19 could not recall the reason they signed the TAR for Resident #1 when both the full code and DNR orders were there and did not recall addressing the discrepancy with a supervisor. LPN #19 stated it was possible they wrote duplicate on the TAR when they signed on [DATE] but was not certain. _____________________________________________________________________________________ Immediate Jeopardy was identified, and the facility Administrator was notified on [DATE] at 4:15 PM. Immediate Jeopardy was removed on [DATE] at 11:20 AM prior to survey exit based on the following corrective actions taken: - Resident #1 was no longer in the facility. - The facility identified 14 full code and 41 DNR residents at risk for serious injury, harm, and death. The 55 residents were audited on [DATE] to ensure their wishes for advance directives were accurately reflected in their medical record, hard chart, MAR/TAR, physician orders, MOLST, and on any physical identifiers including the bracelets, room signage, and any lists posted at the unit. No discrepancies were identified. - Any changes in advance directives would be addressed by an RN and/or the social worker only and would include the 2 staff verification during all steps to the changes. - In the event a second RN or social worker was not available in the facility, an RN from the acute care setting would be notified. - If no facility staff RNs were on site, the DON or ADON would be notified to report to the facility to ensure the 2-person verification could be performed., - The 2-person verification would include following the steps as identified in the current CPR policy. - Both parties of the 2-person verification would enter a progress note in the resident record. - All RN and social work staff were educated on the 2-person verification system, including the hospital RN Supervisor on [DATE] and [DATE]. The hospital RN supervisor would educate hospital RNs on the procedure and their role as a second verifier in the event of an advance directive change. 10NYCRR 400.21(c)

Based on observation, interview and record review during the recertification and abbreviated surveys (NY 612 and NY 167) the facility did not ensure it maintained an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 nursing units (North/South and East) and 1 of 1 laundry room (first floor laundry room) reviewed. Specifically, dirty lunch trays were observed placed on top of multiple clean PPE (personal protective equipment) carts on 2 of 2 nursing units (North/South and East); and two drying tumblers and two front loading washer-extractors were not maintained per manufacturer instructions. Findings include: NURSING UNITS/MEAL TRAYS The facility's infection control policy, under RHCF Policy Updates for COVID-19 Pandemic effective 9/23/2020 documented meal trays from isolation rooms will be handled with gloves and will be placed directly onto the transportation cart for return to the Food and Nutrition Department. If the carts have already been removed from the RHCF (residential health care facility) area, the meal tray will remain in the isolation room. Nursing staff will then call Food and Nutrition and request for a cart to be brought to the unit for removal of the meal tray. From 4/12/21-4/15/21 all residents were on contact and droplet precautions and remained in their rooms due to a recent COVID-19 positive staff member. There were no COVID-19 positive residents. On 4/12/2021 the following observations were made on North/South unit: - At 12:45 PM a dirty lunch tray was sitting on top of the PPE (personal protective equipment) cart, between rooms [ROOM NUMBERS]. The tray was lying directly on 3 boxes of gloves, procedure masks and sanitizing wipes. The dirty lunch tray contained a food lid, plate, cutlery, two empty juice cups, 2 empty coffee mugs and aluminum foil. An unidentified staff lifted the dirty tray and set two meal tickets underneath and proceeded to walk down the hall. At 12:54 PM the unidentified staff removed the dirty tray from the PPE cart and placed it on the food cart. The PPE cart was not wiped down with a sanitizing cloth. On 4/14/2021 the following observations were made on North/South unit: - At 12:17 PM a dirty lunch tray with two food lids, plates, multiple empty coffee mugs, multiple empty juice cups, a soiled napkin, plastic and foil wrappers, two meal tickets and a soiled white towel was placed directly on top of the PPE cart between rooms [ROOM NUMBERS]. - At 12:20 PM two dirty plastic cups were on top of the PPE cart next to room [ROOM NUMBER]. - At 12:25 PM unit helper #5 reached beyond the dirty tray to obtain a hand sanitizing cloth out of the cannister on top of the PPE cart located between rooms [ROOM NUMBERS]. - At 12:34 PM unit helper #5 picked up the two dirty plastic cups on the PPE cart next to room [ROOM NUMBER] and placed them on the food cart. Unit helper #5 was not wearing gloves and did not wipe the top of the PPE cart with a sanitizing cloth. - At 12:35 PM unit helper #5 picked up the dirty tray on the PPE cart next to rooms [ROOM NUMBERS] and placed it on the food cart. Unit helper #5 was not wearing gloves and did not wipe the top of the PPE cart with a sanitizing cloth. When interviewed 4/14/2021 at 12:36PM unit helper #5 stated the dirty food trays should not have been placed on top of the PPE carts where all the clean PPE was sitting. This was an infection control concern. The dirty trays should have been placed back on the food cart. She stated she should have worn gloves and wiped the top of the PPE cart with a sanitizing cloth after the dirty tray was removed. She stated she just set the trays wherever she could find a spot to put them since all the residents were now eating in their rooms. On 4/14/2021 the following observation was made on East unit: - At 12:40 PM a dirty plate, soup bowl and a two-handled sip mug were sitting on top of the PPE cart next to room [ROOM NUMBER]. The dirty items were placed directly on procedure masks, gloves, and sanitizing wipes. An empty food cart was sitting next to the PPE cart. When interviewed on 4/15/21 at 9:03AM, CNA #6 stated meal trays should not be placed on top of the PPE carts due to infection control. Normally she would leave the dirty trays in the resident rooms. She would then take an empty tray to place the dishes on and find another table to set those down on until all the dirty dishes could be placed on the food cart that goes back to the kitchen. She stated staff should be wearing gloves when picking up trays because all the residents were on isolation precautions. When interviewed on 4/15/2021 at 11:02AM the Infection Preventionist (IP) stated all the residents in the facility were on contact and droplet precautions due to a recent COVID-19 positive staff who had been on all the units. She stated when picking up meal trays staff should be wearing gloves and placing the dirty trays on the food cart. The food cart was sent to the elevator where dietary staff waited to take it down to the kitchen. Staff should not be putting trays or anything else on top of the PPE carts. If any items were placed on top of the PPE carts the area should be wiped down with a sanitizing cloth. When interviewed on 4/15/21 at 12:45PM the Director of Nursing (DON) stated used meal trays should be placed directly on the food cart and gloves should be worn. This was especially important for infection control as all the residents were on contact and droplet precautions. The food carts were then taken to the elevator so dietary staff could take them down to the kitchen, where they were cleaned and sanitized. The facility COVID-19 policy for meal trays addressed this procedure. WASHER/DRYER During an observation on 4/13/21, between 12:35 PM and 1:05 PM, there were two washing machines (#1 and #2) and two dryers (#1 and #2) located in the first floor laundry room. The manufacturer instructions for drying tumblers #1 and #2 documented the following requirements: -Quarterly, clean the lint and any other foreign materials from the air vents located on the front and back of the drive motor; check the steam coils and remove any lint buildup in the coil area; exhaust ducts should be periodically inspected to ensure there has been no build-up of lint which could obstruct the air flow; inspect the dryer area to make sure nothing is obstructing the flow of combustion and ventilation air; and remove front panel and remove any lint buildup; and check belt tension and adjust if needed. -Semi-Annually, check the tumbler over thoroughly for loose nuts, bolts, and screws, and for loose gas, steam, and or electrical connections. The facility dryer inspection dated 3/19/21 documented the following maintenance was done by the facility monthly: - remove cap from large dryer manifold and check for excessive lint; and - check lint screens in bottom of dryers for gaps between frame and housing and for holes, replace if necessary. There was no documented evidence maintenance was completed per manufacturer recommendations. The manufacturer instructions for the front load washer-extractors #1, and #2 documented the following requirements: -Monthly, check V-belts for uneven wear and frayed edges; and for groove-pulley drive systems, verify alignment by placing a straight edge across both pulley faces. There was no documentation maintenance for washer-extractors #1 and #2 was completed per manufacturer recommendations. On 4/13/21 at 3:00 PM, the Director of Plant Operations stated that most of the items listed in the quarterly and semi-annual dryer manufacturer maintenance were completed but not documented. On 4/14/21 at 12:20 PM, the Director of Plant Operations stated that he could not locate documentation for the maintenance of the facility washer-extractors. He was not sure what maintenance had been done for washer-extractors #1 and #2. 10NYCRR 415.19(a)(2)(b)(2)

Based on observation and interview during the recertification survey, the facility did not store drugs and biologicals in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 3 medication carts (north hall medication carts #1 and #2) reviewed for medication storage and labeling. Specifically, multiple expired medications were observed stored in two north hall medication carts. Findings include: The facility policy Pharmacy Services for Rural Health Care Facility (RHCF) reviewed 01/2021, documented the facility stores stocked medications locked in medication carts and medication rooms. All outdated, discontinued, changed, or otherwise unusable drugs will be pulled from the medication cart by the medication nurse and placed in the medication room. The 6:00 AM through 2:00 PM medication nurse is responsible for delivering these medications to the pharmacy by the end of their shift, daily. During an observation on 04/13/21 at 10:41 AM, the 2 north hall medication carts were inspected with LPN #2. The following expired, outdated, and/or unused medications were observed: -on the north medication cart #1 a 430 ml (milliliter) bottle of liquid [MEDICATION(S)] (stool softener) with an expiration date of 02/2020. -on the north medication cart #2 a bottle of vitamin B1 expiration 2/2020; a bottle of calcium antacid 500 mg (milligram) expiration 1/2021; a bottle of vitamin B12 expiration 2/2020; a bottle of vitamin B6 expiration 1/2021; a bottle of [MEDICATION(S)] (used for dizziness) 12.5 mg expiration 7/2020, and a bottle of [MEDICATION(S)] -24 hour (allergy medication) expiration 3/2021. During the observation LPN #2 stated the nurse assigned to the medication cart should check for medication expiration dates. The expired medications in the carts were stock medications and had not been administered to any residents. When interviewed on 4/14/21 at 11:53 AM, pharmacist #3 stated the pharmacist was responsible for checking the medication room for outdated stock medications and removing them. She stated the nurse was responsible for checking for outdated stock medications or unused medications on the medication carts. When interviewed on 4/14/21 at 11:55 AM, the Director of Nursing (DON) stated it was the responsibility of the nurse assigned to a medication cart to check for expired, outdated, and unused medications. 10NYCRR 415.18(e)(1-4)

Based on interview and record review during the abbreviated survey (NY 313), the facility did not ensure 1 of 3 residents (Resident #1) reviewed was free from involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Specifically, Resident #1 experienced anxiety and exhibited behaviors and the nursing staff restrained the resident in their bed and held the resident down while administering as needed medication. The resident was restrained in their bed until the next shift came on duty who found the resident with skin tears that were bleeding. Findings include: The 5/2014 Restraint policy documented that physical restraints used should be the least restrictive means to protect the health and safety of the resident and to assist the resident to attain and maintain optimum levels of physical and emotional functioning It was the facility's policy to not use chemical restraints. The 12/2020 Abuse policy documented it was the policy of the facility to prohibit mistreatment, neglect, or abuse. The facility would not tolerate or permit verbal, mental, sexual, or physical abuse including involuntary seclusion of residents. Resident #1 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The comprehensive care plan (CCP) and the certified nurse aide (CNA) care guide (care instructions) dated 2/3/2020 documented the resident was alert and oriented with varied mental function throughout the day, had memory impairment, and behavioral disturbances. The resident had an ADL deficit, poor coordination, impulsiveness, needed more assistance when confused or resistive. The resident's behaviors included yelling out, screaming, and combativeness. They were followed by a mental health provider and recent medication changes were made. Interventions included leaving the resident alone if they put themselves on the floor, was agitated, kicking, or hitting, and to call for help if the resident was in danger of hurting themselves. If medications were refused, staff were to notify the physician. Updates to the CCP included: - On 3/5/2020, if the resident was resistive to care, staff were to reapproach later in the day. - On 5/18/2020, the resident had a 1:1 sitter for safety. The CCP specified the 1:1 sitter may need to be on the other side of the curtain or just outside the doorway with a camera on when the resident was agitated by them being in the room. - On 8/10/2020, if the resident became agitated, staff were to intervene before the agitation escalated and if the resident responded with aggressiveness, staff were to walk calmly away and reapproach later. The 9/2/2020 to 9/14/2020 nursing progress notes contained no documentation the resident exhibited behaviors. The 9/15/2020 nurse practitioner (NP) #12's progress note documented staff reported increased agitation. A psychiatric evaluation was ordered. The resident seemed to be worse in the evenings and had been found crawling on the floor. The resident had been agitated and combative towards staff. Medications were adjusted and a 1:1 sitter continued. On 9/16/2020, a psychiatry consult documented medication changes were made and staff were to monitor behaviors and call the medical provider as needed. The 9/16/2020 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/16/2020 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no nursing progress notes written for the resident for the evening shift (2 PM to 10 PM) on 9/16/2020. The facility investigation dated 9/16/2020 documented at 10:00 PM, licensed practical nurse (LPN) #5 came into work at the facility, heard Resident #1 yelling, and went to the room. The resident's bed had been moved against the wall, preventing the resident from being able to exit that side of the bed. The bedside table was lowered and was on top of the bed to prevent the table from moving and to prevent the resident from being able to exit the bed. Certified nurse aide (CNA) #3 was at the resident's bedside. LPN #5 raised the bed, removed the bedside table, and checked the resident's leg that was bleeding. The resident was combative, resistive, and punched LPN #5 in the face and bit her arm. LPN #5 and certified nurse aide (CNA) #10 put pants on the resident and assisted the resident to a chair at the nurse's station. CNA #10 was interviewed on 1/26/2021 at 5:36 AM, and stated when she arrived at 10 PM on 9/16/2020, she went to the resident's room to receive report form CNA #3. Resident #1's bed was against the wall and this was not usual and CNA #3 was sitting in a chair at the head of the bed. Resident #1 was very agitated, attempting to get out of the bed, her leg was bleeding and blood was on the bed, headboard, and the sheets. CNA #3 told her the resident was combative and that was why the room was positioned the way it was. CNA #3 reported Resident #1 had received a medication and it took 6 staff members to give her the medication. She called LPN #5 and they cleaned up the resident took her to the nurse's station. LPN #5 was interviewed on 1/26/2021 at 5:51 AM, and stated she arrived on the unit at 10 PM on 9/16/2020 and LPN #1 gave her report. She heard a lot of noise from the resident's room and when she went there, the room was arranged differently than usual. She asked LPN #1 what was going on and LPN #1 told her the resident was agitated and combative most of the evening shift, was given medication, and changes were made to the furniture in the room. LPN #5 observed the resident's bed was against the wall in the corner, the dresser blocked the head of the bed, the bedside table was wedged under the bed and a blanket was tied to the bed and looked like a siderail. A wheelchair blocked any gap where the resident could get out of bed and CNA #3 was sitting at the head of the bed in a chair. Resident #1 was completely enclosed, was thrashing and combative, and was unable to get out of the bed. Resident #1 was undressed from the waist down and there were 2 soiled briefs on the floor. The resident had a cut on the leg with blood on the siderail, the heater, the headboard, the side of the bed, the floormat, and the dresser. The resident had some new skin tears and some old ones. LPN #5 attempted to move the bedside table and it was holding the bed down. Resident #1 was very upset, shaking, and began to vomit. She heard CNA #3 state that 5 staff held the resident down while medicine was administered. The resident was cleaned up and did not have any more behaviors the remainder of the shift. Interviews obtained by the facility's Director of Nursing (DON) on 9/17/2020 and included with the 9/16/2020 investigation documented: - CNA #3 reported on 9/16/2020 at around 7:30 PM to 7:45 PM, the resident slid from bed, was hitting and kicking, and caused a skin tear to the left wrist that was bleeding. CNA #2 came to the room and CNAs #2 and 3 could not get the resident off the floor as they continued hitting and screaming. CNA #2 got LPN #1 and LPN #1 tried to give the resident a medication but the resident kicked LPN #1 and said, it was poison. LPN #1 left the room and returned with CNAs #2 and 11 and LPN #4. The resident was contained while LPN #1 gave the medication in the mouth through a syringe. CNA #3 reported LPN #4 told the staff to move the bed against the wall so the resident only had one way to get out of the bed and then suggested the overbed table be positioned next to the bed and lowered so the base would not move. Resident #1 continued to kick and hit. Resident #1's cut was still bleeding at 9:45 PM. When the next shift staff in at 10:05 PM, Resident #1 calmed down and they put pants on the resident and took the resident to the nurse's desk. - LPN #4 reported on 9/16/2020, she assisted LPN #1 when the resident was on the floor. She saw blood and LPN #1 said it was from an old area that reopened. LPN #4 and CNAs #2 and 3 assisted the resident onto the low bed while Resident #1 continued to kick and attempted to climb out of bed. They positioned the bed against the wall with the floor mat down. Resident #1 continued to throw themselves around, so they placed the overbed table in front of the bed. - LPN #1 reported on 9/16/2020, she gave Resident #1 a medication at 8:45 PM for behaviors of kicking and hitting. The staff in the room moved the bed against the wall and placed a floor mat on the outside of bed. She stated the overbed table was at the bedside, but she did not realize it was wedged so that it would not move away from the bed. - CNA #2 reported on 9/16/2020, she heard yelling and went to Resident #1's room. She got LPN #1 who gave the resident medication and LPN #4 put the resident's bed against the wall for safety. - CNA #8 reported on 9/16/2020 at 8:20 PM, he assisted helping other staff put the resident's legs on the bed. He denied having part in moving furniture and assisted LPN #4 in giving the resident medication. The nursing progress note by LPN # 5 documented on 9/16/2020 at 10:40 PM, the wounds to the left shin were bandaged and the resident was hitting and biting staff. The 9/17/2020 NP #12's progress note documented the resident was seen due to increased behaviors. The resident had dementia and over the past few weeks seemed worse. Last evening, the resident's behaviors escalated, and the resident slapped and bit staff and was observed crawling around the floor. Staff reported the resident was confused and a 1:1 sitter remained with the resident for safety. The note documented there were recent medication changes and the resident was to be monitored. CNA #3 was interviewed on 1/19/21 at 11:50 AM, and stated on 9/16/2020, she was the resident's 1:1 sitter from 2 PM to 10 PM and: - between 7 and 7:30 PM, the resident became exceptionally unruly, rolling side to side, and she thought the resident may have hit their leg on the enabler bar as the leg was bleeding. - CNA #2 and LPN #1 came to the room to help her. CNAs #2 and 3 and LPN #1 put the resident back into bed and CNA #3 stayed with the resident who calmed down a little. - About 15-20 minutes later, LPNs #1 and 4 and CNA #2 came back to the room with medication and the resident became combative again. CNA #3 held the resident's left arm, CNA #2 held the right arm, and a CNA from another unit held the resident's leg. LPN #4 administered the medication and after the medication was given, everyone let go of the resident. - CNA #3 stated that she, CNA #2, and LPNs #1 and 4 decided to place the bed against the wall. The foot of the bed was in the corner and the head of the bed had a headboard. The floor mat was on the left side of the bed and the tray table was placed on the fall mat blocking the resident from being able to get out of bed. The resident was not thrashing just yelling and screaming at that time. - CNA #3's shift ended at 10 PM and at that time, LPN #5 came to the room with CNA #10 and provided care and addressed the resident's leg. CNA #3 was interviewed a second time on 2/4/2021 at 10:23 AM, and stated: - when the medication was given via a syringe in the resident's mouth, she held the resident's right arm and CNA #2 held the resident's left arm. The resident was combative and she had to hold the resident's arm tightly. LPN #1 was interviewed on 1/20/2021 at 9:21 AM, and stated on 9/16/2020, she took care of the resident from 2 PM to 10 PM: - at around 9:30 PM, an unknown CNA told her the resident had behaviors and she said she would see if there were medications ordered. She went to the resident's room and the resident was on the floor mat, kicking and hitting at CNA #3. LPN #1 tried to talk to the resident but couldn't reach her. She tried to give the resident the medication, but the resident would not take it so she called LPN #4. - LPNs #1 and 4 went to the room together and the resident again refused the medication from LPN #1. The resident pushed LPN #1's arm away and LPN #4 gave the medication. - LPN #1 did not notify a Supervisor of the resident's behaviors because the resident had an as needed medication ordered. - As LPN #1 was leaving the room, she heard LPN #4 or CNA #2 mention moving the furniture. CNAs #2 and 3 and LPN #4 moved the bed against the wall, and she did not know who moved the tray table. - When LPN #5 arrived for the next shift at 10 PM, LPN #1 told her what occurred and LPN #5 got the resident out of bed, brought the resident to the nurse's station, reported the resident had a cut on the leg, and applied a dressing. - After the medication was given to Resident #1 at around 9:00 PM to 9:30 PM, LPN #1 did not return to the resident's room again during her shift and did not check on the resident. LPN #4 was interviewed on 1/20/2021 at 11:20 AM and stated on 9/16/2020: - She was called to the unit by LPN #1 who reported Resident #1 was having behaviors and she needed help to administer medications. When she entered Resident #1's room, she observed Resident #1, on the floor without pants on. A cut was on Resident #1's her leg with active bleeding. - The resident was combative and did not want to be bothered. She was not aware of any intervention to leave the resident alone when she exhibited behaviors or re-approach. - She administered the medication to the resident. At some point, CNA #8 arrived and assisted by holding the resident's arm out of the way. She told CNA #8 that was not necessary. - After the medication was given, LPN #1 suggested Resident #1's bed be moved to against the wall and 3 sides of the bed were blocked so the resident could not get out of the bed. CNA #2 suggested the tray table be positioned long ways to the remaining exit of the bed. - Resident #1 continued to be combative and CNA #3 remained in the room with the resident for safety. - She did not contact the Supervisor to report the incident or the resident's behaviors. NP #12 was interviewed on 2/26/2021 at 9:45 AM, and stated the resident had confusion and behaviors, became agitated, and had been followed by psychiatric and the medical team. Many adjustments had been made to the resident's medications. She was made aware of the incident that occurred on 9/16/2020 on 9/17/2020 when she was asked to follow-up with the resident due to her behaviors. She performed an assessment and was not made aware of any skin tears that occurred during the incident and did not see them. She stated during the incident, if the resident was agitated, the staff should have backed away and allowed the resident to settle down and reapproach. Barricading the resident would have caused her to be more agitated and anxious. The DON was interviewed on 3/4/2021 at 11:01 AM and stated Resident #1 had behaviors and interventions included a 1:1 sitter. When the resident refused the medication, staff should have backed away and reapproached the resident up to 3 more times. If the resident continued to refuse the medication, the nurse was to document refusal and notify the medical provider. He was not made aware staff held the resident down while the medication was administered. No restraints were to be used in the facility. If the resident had behaviors, staff were expected to back away until the resident calmed down and then reapproach. 10 NYCRR 415.4(a) (2-7)

Based on record review and interview during the abbreviated survey (NY 313) the facility did not ensure services provided met professional standards of quality for 1 of 3 residents reviewed (Residents #1). Specifically, Resident #1 exhibited anxiety and behaviors and sustained skin tears with active bleeding during an incident with staff members and: - licensed practical nurses (LPN) #1 and 4 did not address the resident's skin tears at the time of the incident; did not notify a registered nurse Supervisor (RNS) that an assessment of the skin tears was needed, and did not notify the medical provider of the resident's behavior resulting in the skin tears; - Certified nurse aides (CNA) #2, 3 and 8 transferred the resident back to bed using an arm and leg technique; - LPNs #1 and 4 administered [MEDICATION(S)] (anxiety medication) to the resident via a syringe into the mouth after the resident refused the tablet and the resident was not evaluated after receiving the [MEDICATION(S)] to determine if the medication was effective; - when RNS #13 was notified of the resident's skin tears by the next shift of nurses, RNS #13 did not perform an assessment. Findings include: Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident needed two staff members to assist with activities of daily living (ADLs) and the resident did not exhibit behaviors during the assessment period. The comprehensive care plan (CCP) and the certified nurse aide (CNA) care guide (care instructions) dated 2/3/2020 documented the resident was alert and oriented with varied mental function throughout the day, had memory impairment, and behavioral disturbances. The resident had an ADL deficit, poor coordination, impulsiveness, needed more assistance when confused or resistive. The resident's behaviors included yelling out, screaming, and combativeness. They were followed by a mental health provider and recent medication changes were made. Interventions included leaving the resident alone if they put themselves on the floor, was agitated, kicking, or hitting, and to call for help if the resident was in danger of hurting themselves. If medications were refused, staff were to notify the physician. Updates to the CCP included: - On 3/5/2020, if the resident was resistive to care, staff were to reapproach later in the day. - On 5/18/2020, the resident had a 1:1 sitter for safety. The CCP specified the 1:1 sitter may need to be on the other side of the curtain or just outside the doorway with a camera on when the resident was agitated by them being in the room. - On 8/10/2020, if the resident became agitated, staff were to intervene before the agitation escalated and if the resident responded with aggressiveness, staff were to walk calmly away and reapproach later. The 9/16/2020 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/16/2020 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . there was no documentation of the effects of the medication after it was administered. The facility investigation dated 9/16/2020 documented at 10:00 PM, licensed practical nurse (LPN) #5 heard Resident #1 yelling and went to the room. LPN #5 checked the resident's leg that was bleeding. LPN #5 and CNA #10 were able to get the resident to allow them to put the resident's pants on, assisted the resident to the chair, and transported the resident to the nurse's station. Interviews/statements obtained by the facility Director of Nursing (DON) on 9/17/2020 and included with the 9/16/2020 investigation documented: - CNA #3 reported on 9/16/2020 at around 7:30 PM to 7:45 PM, the resident slid from the bed, began hitting and kicking, and caused a skin tear to the left wrist that was bleeding. CNA #3 tried to stop the resident from hurting themselves when LPN #1 came to the room with a medication. Resident #1 kicked LPN #1 and stated, it was poison and LPN #1 left the room. LPN #1 returned with CNAs #2 and 11 and LPN #4 and the resident was contained while LPN #1 gave the resident a medication in her mouth with a syringe. LPN #4 then sat next to the resident, close to her body so Resident #1 did not hurt themselves. Resident #1 continued to give the nurse a hard time and the cut was still bleeding at 9:45 PM. When the next shift staff came to the facility at 10:05 PM, Resident #1 seemed to calm down. - LPN #4 stated on 9/16/2020, she assisted LPN #1 when the resident was on the floor. She saw blood and LPN #1 reported it was from an old area that reopened. LPN #4 and CNAs #2 and 3 assisted the resident onto the low bed while Resident #1 continued to kick and attempted to climb back out of the bed. - LPN #1 reported on 9/16/2020, she gave Resident #1 new medications at 8:45 PM due to behaviors of kicking and hitting. Included with the 9/16/2020 incident report was a statement by RNS #13 dated 9/16/2020 which documented she was called to the unit by LPN #5 at 10:45 PM to 11:00 PM. Upon her arrival, LPN #5 had already contacted the DON and an investigation was underway. The nursing progress notes did not document Resident #1's skin tears were evaluated or addressed on 9/16/2020 from 8:30 PM to 10:00 PM and did not document a RN assessment was completed. There was no documentation the effects of the [MEDICATION(S)] were monitored or that the [MEDICATION(S)] was administered to the resident in the form it was ordered. The 9/16/2020 at 10:40 PM, LPN #5's progress note documented the wounds to the resident's left shin were bandaged and the resident was hitting and biting staff. The 9/17/2020 nurse practitioner's (NP) #12's progress note documented the resident was seen due to increased behaviors. The resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Last evening the resident's behaviors escalated where she had slapped and bitten staff and was observed crawling around the floor. Observation of the resident showed the resident lying in the bed asleep. Staff reported the resident was confused and a 1:1 sitter remained with the resident for safety. The note documented recent medication changes and the resident was to be monitored. The documented physical exam did not address the residents skin tear to her right leg or wrist, or a physical exam had been completed. LPN #1 was interviewed on 1/20/2021 at 9:21 AM and stated on 9/16/2020 at around 9:30 PM, she was told by a CNA the resident was exhibiting behaviors and she went to see if there were any as needed medications ordered. She attempted to give the resident the medication, but the resident would not take it. LPN #1 called LPN #4 and they went to the room together. The resident was sitting on the floor mat and LPNs #1 and 4 and CNAs #2 and 3 arm and legged the resident back to bed. She could not state who held the resident where on their body during the transfer. The resident was combative during the transfer. LPN #1 attempted again to give the resident the medication and the resident refused, turning her head pushing the LPN's arm away. LPN #4 gave the medication. LPN #1 said she did not see any bleeding from the resident's leg. LPN #1 did not notify a Supervisor of the behaviors because the resident had an as needed medication ordered. When LPN #5 arrived for the next shift at 10 PM, LPN #1 told her what occurred and LPN #5 got the resident out of bed, brought the resident to the nurse's station, reported the resident had a cut on the leg, and applied a dressing. After the medication was given to Resident #1 at around 9:00 PM - 9:30 PM, LPN #1 did not return to the resident's room again during her shift and did not check on the resident. LPN #1 was re-interviewed on 2/4/2021 at 9:51 AM, and stated the resident was administered [MEDICATION(S)] by LPN #4. She stated the [MEDICATION(S)] was crushed and given on a spoon and she did not recall a syringe being used for medication administration. She did not recall any blood or skin tear present or anyone asking or mentioning blood or skin tears and stated, if LPN #4 saw the blood she should have addressed it. She denied assisting the resident back to bed and did not know if LPN #4 assisted with the transfer. She stated she thought the CNAs put the resident back to bed and was unable to recall if the resident was arm and legged back to bed. CNA #3 was interviewed on 1/19/21 at 11:50 AM, and stated on 9/16/2020, she was assigned to provide 1:1 supervision to Resident #1 from 2 PM to 10 PM. She stated on 9/16/2020, between 7 and 7:30 PM, she was in the resident's room and the resident became exceptionally unruly, rolling side to side. She thought the resident may have hit her leg on the enabler bar and the leg began to bleed. CNA #2 came to the room and got LPN #1 to help. CNAs #3 and 2 and LPN #1 armed and legged the resident back into bed and the resident was combative. CNA #3 remained with Resident #1 and the resident had calmed, and the bleeding had slowed down. About 15-20 minutes later, LPN #1, CNA #2 and LPN #4 came to the room with medication and the resident became combative again. CNA #3 held the resident's left arm, CNA #2 held the right arm, and a CNA from another unit held the resident's legs. LPN #4 administered the medication. After the medication was given, everyone let go of the resident. Resident #1's leg continued to bleed and was not addressed by anyone. CNA #3 was re-interviewed on 2/4/2021 at 10:23 AM and stated LPN #1, CNA #2 and 8 and she were present when LPN #4 gave Resident #1 medication and she thought she threw a syringe in the resident's mouth. She was located on the right side holding the resident's right arm, CNA #2 was on the left side holding the resident's left arm when LPN #4 squirted the medication in the corner of the resident's mouth. The resident was combative, and she had to hold the resident's arm tightly. CNA #2 had to hold the left arm to prevent the resident from raising a hand to the CNA's face. During the arm and leg transfer she held Resident #1's arm, CNA #2 held the resident's other arm and CNA #8 held the resident's legs while they lifted the resident onto the bed. Both LPN #1 and 4 were present during the transfer. LPN #4 was interviewed on 1/20/2021 at 11:20 AM and stated on 9/16/2020 she was called to the unit by LPN #1 who reported Resident #1 was having behaviors and she needed help to administer medications. When she entered Resident #1's room, she observed Resident #1 on the floor without pants on. A cut was on Resident #1's leg with active bleeding. The staff in the room got the resident off the floor and onto the bed using an arm and legged approach. She told the staff in the room they could not transfer the resident that way. Once Resident #1 was in bed, she administered medication. At some point, CNA #8 arrived and assisted by holding the resident's arm out of the way. She told CNA #8 that was not necessary. She did not contact the RNS to report the incident or the resident's behaviors. CNA #10 was interviewed on 1/26/2021 at 5:36 AM and stated she arrived on the unit for her shift and went to receive report form CNA #3. When she arrived in Resident #1's room she observed the resident's bed against the wall, CNA #3 was seated in a high back chair at the head of the bed. Resident #1 was very agitated and attempting to get out of the bed. The resident's leg was bleeding and blood was on the bed, headboard ,and the sheets. CNA #3 told her Resident #1 was combative and that's why the stuff was positioned that way. CNA #6 reported Resident #1 had received medication and it took 6 staff members to give the injection. She called LPN #5 and they cleaned up the resident and removed the resident from the room. LPN #5 was interviewed on 1/26/2021 at 5:51 AM and stated she arrived on the unit at 10 PM on 9/16/2020 and heard a lot of noise from Resident #1's room. She asked LPN #1 what was going on, LPN #1 stated Resident #1 had been agitated and combative most of the shift, had medication and changes were made to the furniture in the room. She went to the room and Resident #1 was undressed from the waist down with a cut on the leg with blood present. The resident had some new skin tears along with some old ones. The resident was cleaned up, the skin tear on the leg was cleaned and bandaged and the resident did not have any more behaviors the remainder of the shift. She notified the DON and RNS #13. RNS #13 was interviewed on 2/4/2021 at 11:41 AM and stated on 9/16/2020 LPN #5 called her at around 10:30 PM. She arrived to the unit between 10:45 PM and 11 PM and LPN #5 showed her the position of the bed and furniture in the room. She stated there was blood on the sheets. LPN #5 told her about the resident's skin tears on the arm and the leg. She stated she did see the resident in the hall, the resident's arm and leg had been wrapped and she did not assess the resident's skin tears or other injuries. She stated she did not document the skin tears and did not inquire if the physician had been notified. She stated crushing [MEDICATION(S)] and administering it in water through a syringe was not an appropriate method of medication administration. NP #12 was interviewed on 2/26/2021 at 9:45 AM and stated she was told the resident had an incident on 9/16/2020 and she was not made aware of any skin tears that occurred during the incident and did not see them. She stated when a skin tear occurred, the nursing staff were supposed to contact the medical provider by written communication or a phone call. She stated the areas needed to be approximated and if a dressing was needed an order would be obtained. She stated she was not aware the resident was administered medication through a syringe and stated that was not an appropriate method. NP #12 was re-interviewed on 3/1/2021 at 12:24 PM and stated when a by mouth medication was administered the pill should be whole or crushed in applesauce or pudding. Crushing a pill, putting the medication in a syringe, and squirting it in a resident's mouth was not appropriate. The DON was interviewed on 3/4/2021 at 11:01 AM, and stated it was not appropriate for a resident to be given a by mouth medication in a syringe and Resident #1 did not take her medications that way. Using an arm and leg technique for transfers was not an appropriate way to transfer any resident. He was not aware LPNs #1 and 4 administered medication through a syringe. He was not aware LPNs #1 and 4 did not address Resident #1's skin tears or that the RNS did not assess the resident when notified of the incident. 10NYCRR 415.11(c)(3)(i)

Based on observation, record review and interview during the recertification survey the facility did not maintain an infection prevention and control program for 1 of 1 residents (Resident #32) reviewed for urinary catheters (a tube that drains urine from the bladder). Specifically, Resident #32 was observed with his catheter tubing and collection bag uncovered and directly on the floor. Findings include: The 3/2017 Catheterization of the Urinary Bladder and Management of Indwelling Catheters Policy did not include information pertaining to the infection control standard for urinary collection bag and tubing placement. Resident #32 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The 1/8/19 Minimum Data Set (MDS) assessment documented the resident was cognitively intact. He required total dependence of two staff for bed mobility, transfers, dressing, toileting. He had an indwelling catheter for urination. The 9/26/18 physician order [REDACTED]. The 10/24/18 comprehensive care plan documented the resident had an indwelling urinary catheter related to enlarged prostate and [MEDICAL CONDITION]. Interventions included change catheter every 4 weeks, call urologist with any issues, and monitor for signs and symptoms of urinary tract infections such as pain, burning, fever, and foul-smelling urine. The resident was observed: - On 1/24/19 at 1:51 PM, with his urinary catheter collection bag hanging on the bed frame. The drainage opening was in contact with the floor. There was no dignity bag covering the drainage bag. - On 1/25/19 at 1:10 PM, the resident was sleeping in bed. The catheter was hanging on the lower end of the bed frame and the catheter bag and tubing were lying directly on the floor. At 3:08 PM, the resident was positioned on his back, the Foley collection bag and tubing were resting directly on the floor uncovered. - On 1/28/19 at 10:00 AM, the resident was in bed and his catheter was on the bed frame closer to the head end of the bed and the collection bag was resting directly on the floor. During an interview with the resident's assigned certified nurse aide (CNA) #1 on 1/28/19 at 11:55 AM, she stated when the resident was in bed, the CNAs hung his catheter on the side of the bed and it should not be touching the floor in order to prevent infections. CNA #1 observed the uncovered catheter collection bag resting on the floor and stated she would find a cover for the catheter collection bag. She repositioned the collection bag and left the room to retrieve a covering. During an interview with registered nurse (RN) Unit Manager #2 on 1/28/19 at 12:20 PM, he stated he would expect the resident's catheter to be off the floor to prevent infections and covered for his dignity. During an interview with the Infection Control Nurse on 1/28/19 at 12:38 PM, she stated the resident's catheter should be covered and never on the ground. She stated staff received yearly training and competency for catheter care. 10NYCRR 415.19

Based on record review, interviews, and observations conducted during the recertification survey, it was determined the facility did not ensure care and services were provided to attain or maintain the highest practicable physical well-being for 1 of 9 residents (Resident #3) reviewed for quality of care. Specifically, Resident #3 was ordered to have an abductor pillow (wedge cushion to place between the legs for positioning) in place at all times and was observed without it. Findings include: Resident #3 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident had severely impaired cognition and required extensive assistance for activities of daily living (ADLs). She had a lower body impairment on one side, utilized a wheelchair, and was non-ambulatory. The resident was hospitalized from 8/18-8/23/2017, for a subcapital fracture (fracture of femur bone near the hip joint) and underwent an ORIF (open reduction and internal fixation) surgery to repair the fracture. Physician orders [REDACTED]. The treatment administration record (TAR) for 8/2017 and 9/2017 documented the resident was to have an abductor pillow in place at all times, removed only when walking, and she was not to cross her legs. The TAR was initialed every shift by the nurses as completed. There was no documentation the resident refused the abductor pillow or any other notes regarding non-use of the device. The plan of care follow-up questions report (record of tasks for certified nurse aides, CNAs) dated 8/23/2017 -9/14/2017, documented the resident's care was provided per the resident profile (care instructions) each day, each shift. The resident profile updated 9/6/2017 documented the resident was non-ambulatory, required extensive assistance with dressing and bed mobility, was to have an abductor pillow between her legs at all times, and a smaller pillow while in the wheelchair. The resident was observed without an abductor pillow between her legs: - on 9/13/2017 at 4:15 PM, while seated in a wheelchair; - on 9/14/2017 at 9:26 AM, while in bed (the pillow was observed on the windowsill in her room); - on 9/14/2017 from 12:15-12:38 PM, in a wheelchair in the dining room; and - on 9/14/2017 at 2:43 PM and at 2:58 PM, while in bed (the pillow was observed on the windowsill in her room). During an interview with CNA #5 on 9/14/2017 at 3:17 PM, she stated the resident was in bed when she arrived at 2:00 PM for her shift. She did not have the abductor pillow in place, and was not sure if the pillow was still being used while the resident was in bed. She stated the large, blue, wedge-shaped foam pillow in the windowsill was the resident's abductor pillow and it was used to keep her legs apart following the [MEDICAL CONDITION]. She located a small blue foam wedge pillow from the resident's closet and stated it was the one to be used when the resident was up in the wheelchair. When interviewed on 9/14/2017 at 4:45 PM, registered nurse (RN) Unit Manager #6 stated the resident was to have an abductor pillow between her legs at all times, the purpose was for proper positioning and alignment as the resident healed from the recent [MEDICAL CONDITION], and it was the current instruction on the resident's care profile. On 9/15/2017 at 10:25 AM, the resident's family member stated during an interview she visited often and had never seen the abductor cushion used in bed or in the wheelchair. On 9/15/2017 at 10:45 AM, licensed practical nurse (LPN) #7 stated during an interview the resident was to have the large abductor pillow between her legs while in bed, and the small pillow between her legs while up in a wheelchair. She stated it was on the TAR and LPNs were to verify placement and initial the TAR. The TAR was signed for every shift. 10 NYCRR 415.12

Based on record review, observations, and interviews conducted during the recertification survey, it was determined the facility did not ensure it maintained an Infection Control Program designed to provide a sanitary environment to help prevent the development and transmission of disease and infection for 2 of 5 residents reviewed for blood sugar testing. Specifically, a nurse did not disinfect a shared glucometer (equipment for blood sugar testing) with an approved disinfectant before, between, or after testing blood sugars for Residents #16 and #17. Findings include: Resident #16 was admitted [DATE] with [DIAGNOSES REDACTED]. The physician order [REDACTED]. The orders documented the resident received [MEDICATION NAME] (insulin) on a sliding scale depending on blood sugar readings. Resident #17 was admitted [DATE] with [DIAGNOSES REDACTED]. The physician order [REDACTED]. The orders documented the resident received [MEDICATION NAME] on a sliding scale depending on blood sugar readings. During a medication administration observation on 9/13/2017 at 5:05 PM, licensed practical nurse (LPN) #1 gathered her supplies and glucometer, donned gloves, and entered Resident #16's room. She performed the fingerstick and placed the glucometer on the resident's overbed table without a barrier. She exited the room, set the glucometer on top of a page of the medication administration record (MAR) without a barrier, ungloved and did not disinfect the glucometer. At 5:10 PM, the LPN gloved and gathered supplies to perform a fingerstick on Resident #17. She entered the resident's room and placed the glucometer and supplies on top of the over bed table without a barrier. She performed the fingerstick, gathered supplies and placed the glucometer on top of the cart without disinfecting it. During an interview on 9/15/2017 at 9:10 AM, LPN #1 stated the glucometer had to be wiped down with a germicidal wipe or alcohol pad between residents and she usually used alcohol wipes. She stated she did not clean the glucometer with an alcohol wipe on 9/13/2017 between Residents #16 and #17 as she was nervous. She stated she performed a competency on glucometers twice a year with registered nurse (RN) #2. During an interview on 9/15/2017 at 10:00 AM, RN #3 Manager stated the policy for disinfecting glucometers was to use germicidal wipes between residents. She stated she expected all staff to disinfect glucometers between residents and additionally once a shift. She stated bleach wipes could be used if a Super-Sani (germicidal) wipe was not available. During an interview with Infection Control RN #2 on 9/15/2017 at 10:20 AM, she stated staff were in-serviced on Infection Control when hired, after 6 months from hire, and then yearly. She stated all nursing staff were taught to wear gloves for procedures and the reason to disinfect the glucometer was to prevent cross contamination and prevent transmission of germs and infection. The disinfecting solution must contain 10% bleach and a barrier must be used under glucometers. She stated nursing staff were educated to disinfect between all resident and were not taught to use alcohol as a disinfectant. During an interview with the Director of Nursing (DON) on 9/15/2017 at 10:35 AM, she stated glucometer disinfection was expected of nursing staff between residents with bleach wipes and alcohol was not an acceptable solution for disinfectant. 10NYCRR 415.19(b)(2)

Based on record review and interview conducted during the recertification survey, it was determined for 4 of 5 newly newly hired employees (Employees #1, 2, 3, and 4), the facility did not ensure required pre-employment training was completed timely. Specifically, abuse prevention training was not provided for Employees #1, 2, 3, and 4 prior to them working in the facility. Findings include: An undated list of newly hired staff documented: - RN (registered nurse) #1 was hired on 1/18/2016; - LPN (licensed practical nurse) #2 was hired on 2/1/2016; - CNA (certified nurse aide) #3 was hired on 4/29/2016; and - Utility Worker (housekeeping staff) #4 was hired on 1/18/2016. The undated General Orientation Checklists documented abuse orientation was completed: - For Employee (RN) #1, on 2/9/2016; - For Employee (LPN) #2, on 2/18/2016; - For Employee (CNA) #3, on 5/12/2016; and - For Employee (Utility Worker) #4, on 2/9/2016. During an interview with the Staff Educator on 5/25/2016 at 3:10 PM, she stated general hospital orientation was offered monthly, and general nursing home orientation was provided either monthly or every other month. For orientation related to abuse and neglect, in the event a new employee was hired after orientation had been held in that month, the employee would receive abuse and neglect orientation in the following month. Nursing facility employees were provided with self-study information regarding abuse and neglect at the time they were hired. Any non-nursing facility employees from ancillary departments such as dietary and housekeeping attended general hospital orientation and did not receive self-study material related to abuse. The Staff Educator stated she had not been advised that there was an expectation related to the timeliness of abuse prevention orientation. The facility policy Employment Process, reviewed 5/2015, did not address the timeliness of abuse orientation. 10NYCRR 415.4(b)

Based on record review, observation, and interview conducted during the recertification survey, it was determined that the facility did not ensure privacy was provided for 1 of 2 residents observed for treatments (Resident #2), and that full visual privacy was provided in 2 of 5 sampled resident rooms (rooms [ROOM NUMBERS]). Specifically, Resident #2 was not provided visual privacy during a dressing change, and the cubicle curtains in the door side of rooms [ROOM NUMBERS] were too small to provide full visual privacy. Findings include: 1) Resident #2 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident required extensive assistance with activities of daily living (ADLs) and had a Stage III pressure ulcer (full thickness skin loss). The comprehensive care plan (CCP) dated 5/10/2016 documented the resident's cognition was impaired due to a TBI. She required a total assist with transfers and bed mobility, and had a Stage III pressure ulcer on the coccyx (tailbone). Interventions included wound care, the resident's needs would be anticipated by staff, her routines would be kept consistent to aid with poor cognition, and consistent care givers would be provided. During an observation on 5/25/2016 at 9:25 AM, licensed practical nurse (LPN) #5 assembled dressing supplies in the resident's room as an unidentified female housekeeper removed the center cubical privacy curtain from the ceiling. The resident's roommate was present in the room and in full view of the resident's bed after the curtain was removed. LPN #5 and an unidentified certified nurse aid (CNA) positioned the resident on her side, exposed her buttocks, and removed the dressing from the coccyx. While the resident was thus exposed, the unidentified housekeeper walked past the resident's bed and out of the room. LPN #5 cleansed the resident's coccyx and applied a new dressing as the roommate looked on. LPN #5 said hello to the roommate as she reapplied the resident's clothing and rolled her onto her back. During an interview on 5/26/2016 at 10:40 AM, LPN #5 stated that privacy was to be provided during care and only medical staff should be present for care. She stated that she did not say anything to the housekeeping staff because she was in the middle of taking the curtain down. She stated it was not acceptable the housekeeping staff was there during the resident's care. During an interview on 5/26/2016 at 10:45 AM, registered nurse (RN) Manager #6 stated that during care, doors should be shut, privacy curtains pulled, and the only staff present should only be the ones providing care. She stated it was not appropriate that housekeeping staff was present during the resident's dressing change. 2) A surveyor observed resident rooms [ROOM NUMBERS] on 5/25/2016 between 11:20 and 11:30 AM. The door side of the room had a cubicle curtain that was 3 feet too small to be wide enough to provide full visual privacy. During an interview with the Director of Building Services on 5/26/2016 at 10:30 AM, he stated those curtains may be temporary curtains, because temporary curtains were used when the regular curtains were being laundered. He stated having some curtain up was better than not having a curtain at all. 10NYCRR 415.3(d)

Based on observation and interview conducted during the recertification survey, it was determined the facility did not ensure the resident environment was as free of accident hazards as possible in 1 of 8 sampled rooms (room 340) in the East Unit. Specifically, the window in room 340 lacked a means to prevent the window from opening fully to prevent falls. Findings include: A surveyor observed resident room 340 on 5/25/2016 at 11:30 AM; the window in the room was open. When the surveyor tested the window, the window opened fully without restriction, creating an opening approximately 2 feet high by 18 inches wide. During an interview with the Plant Operations Director on 5/25/2016 at 11:30 AM, he stated the windows on the units should have hardware limiting the window opening. He was not aware the window restrictor in room 340 was not working properly/missing. He stated the facility's preventative maintenance program did not check the window restriction devices. 10NYCRR 415.12(h), 713-2.18(a)(8)

Based upon observation, record review and staff interview conducted during the abbreviated survey (Complaint #NY 902), it was determined the facility did not ensure 1 of 2 reviewed residents (Residents #1) received the necessary care and services to attain or maintain the highest practicable well-being. Specifically, Resident #1 had a lap tray restraint. The lap tray was replaced with a "Lift-Off Lap Cushion" and the facility did not recognize and assess the safety factors prior to removal of the lap tray restraint. The facility did not ensure interventions were implemented in accordance with the resident's needs and standards of practice, and did not monitor and evaluate the resident's response to the cushion. With the cushion in place the resident fell , fractured his nose, and required surgery. This resulted in actual harm that was not immediate jeopardy. Findings include: The "Lift-Off Lap Cushion" manufacturer's directions documented "Important notice: Because of its easy-release design, the Lift-Off Lap Cushion should not be used as a restraint." Resident #1 had [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The MDS (Minimum Data Set) assessment dated [DATE], documented the resident had severely impaired cognition, a history of falls, and a trunk restraint. The 6/13/2013, "Daily Assessment Inquiry" for physical restraints, documented the resident leaned forward, pulled himself forward when he was in a chair, and restraint usage was discussed and reviewed on 5/14/2013, at the ICP (Interdisciplinary Care Plan) meeting. The recommended restraint was a wheel chair tray. The 6/28/2013 CCP (Comprehensive Care Plan) documented the resident used a lap tray when he was in his wheel chair, as he had a tendency to lean forward. The "Treatments" sheet dated 7/1/2013 through 7/31/2013 documented the resident was to have a lap tray when he was in the wheel chair. The RN (registered nurse) supervisor's nursing progress notes dated: - 7/6/2013, documented the resident fell . - 7/7/2013, documented a late entry for 7/6/2013. In addition to my previous documentation on 7/6/2013, in the best interest of the resident the current tray was removed because of a concern related to his pressure area. A lap buddy (lift off cushion) was put in place and the resident's wife was present when the device was placed. There is no documented evidence the physician was notified the ordered restraint was irritating the resident's skin prior to removal of the restraint or that the physician was asked for direction on alternate means of keeping the resident safe. The "Summary of Investigation" included an "Adverse Incident Statement" signed by the RN supervisor, and documented the lap tray cut into the resident's left side. A "lap buddy" (lift off cushion) was applied to the wheel chair and the resident's wife took him to the dining room. The resident's wife turned the resident in the wheel chair, he jerked forward, and fell . The surveyor was provided with an "Adverse Incident Statement" dated 7/8/2013 which was written by the resident's wife. In the statement the wife documented: - LPN (licensed practical nurse) #1 stood next to the resident, CNA (certified nurse aide) #1 stood behind the resident, with her right arm stretched across the resident's chest, holding him back so he did not thrust himself out of the chair. The RN supervisor, and other staff, members were present. - LPN #1 stated they were going to try to use the Velcro belt he had in his hand, instead of the tray on his chair, "so he won't get cut on his lower rib/abdomen area". - LPN #1 applied the Velcro belt to the arms of the resident's wheel chair and the resident's wife stated she did not know if it would hold the resident in. An unknown female stated "Yeah, I'm thinking the same" thing. - LPN #1 stated "Well, we'll try and see" and proceeded to put the belt on the resident's chair. The "Conclusion of Facility Investigation", dated 7/8/2013, signed as complete by the RN supervisor, documented: - the RN supervisor made a clinical judgment to use a "lap buddy" (lift off cushion). - the resident leaned forward and the "lap buddy" (lift off cushion) gave way. - the resident had a fractured nose. A hospital physician's progress note dated 7/10/2013, documented the resident fell at the nursing home. The resident had a fractured nose and facial trauma, and surgery was scheduled to repair the septal (nasal) fracture. During an interview with the DON (Director of Nursing) on 7/24/2013 at 12:30 PM, she stated the RN supervisor was acting in the best interest of the resident and it was her judgment to apply the "lap buddy" (lift off cushion). During interview on 7/30/2013 at 10:00 AM, LPN (licensed practical nurse) #1 provided the surveyor with a "Lift-Off Lap Cushion" he stated was used on the resident at the time he fell . The cushion was as wide as the wheel chair and was to be placed across the resident's waist. The 2 Velcro straps were brought over the armrest support bars on the left and right side of the wheel chair. The cushion was fastened to the armrest support bars by pressing the "hook" material of the Velcro strap to the "loop" material of the Velcro strap. The manufacturer's directions documented the straps kept the cushion in place and the device should not to be used as a restraint. LPN #1 returned to the surveyor on 7/30/2013 at 1:15 PM and stated the "lap buddy" (lift off cushion) he provided to the surveyor earlier was "very similar" to the one the resident had on at the time of the fall. He could not find the "lap buddy" (lift off cushion) that was on the resident at the time of his fall. The DON stated during an interview on 7/30/2013 at 1:40 PM, she saw the "lap buddy" (lift off cushion) that was applied to the resident, she would not have used the device; "but" it was the RN supervisor's judgment to use the "lap buddy" (lift off cushion). The DON stated she did not know where "lap buddy" (lift off cushion) came from, as she had not seen it in use in the facility prior to the resident's fall. The surveyor asked to see the actual cushion used at the time of the resident's fall and the DON stated it could not be found. During interview on 7/30/2013 at 2:35 PM, CNA #2 stated LPN #1 applied the "lap buddy" (lift off cushion) to the resident, the resident's wife stated it would not hold the resident, and the LPN stated "let's try it out." The CNA stated the usual lap tray was not "there." During an interview with the RN supervisor on 8/12/2013 at 2:20 PM, she stated: - she was present when LPN #1 placed the lap cushion on the resident; - she did not read the manufacturer's directions for the "Lift-Off Lap Cushion" and did not know documentation included the cushion should not be used as a restraint; - she determined the lap cushion was safe when she observed LPN #1 wrap the straps of the lap cushion under the arms of the wheel chair and pull on the cushion. She did not consider having the resident lean forward with the lap cushion on; - she was not inserviced by the facility on restraints used at the facility, including the manufacturer's guidelines for proper use; and - the resident was not evaluated or monitored by facility staff for use of the lift off cushion, and she was responsible for the resident's safety. 10NYCRR 415.12