Every finding on record at Sea Crest Nursing And Rehabilitation Center

Number of residents sampled: 5Number of residents cited: 1 Based on record review and interview conducted during the Recertification survey, the facility did not ensure that a resident's comprehensive care plan was reviewed and revised to accurately reflect the needs of the resident and in response to current interventions. This was evident for one (Resident #163) of five residents reviewed for Unnecessary Medication out of 38 sampled residents. Specifically, Resident #163's comprehensive care plan did not document that Resident's anticoagulant medication was changed.The findings are:The facility policy and procedure titled Care and Treatment of Residents - Care Planning Process dated 03/2017, last revised 07/2022, stated the facility shall have a care planning process that is person centered which includes integrating assessment findings, developing an interdisciplinary care plan, regularly reviewing and revising the care plan, providing the care and documenting the care. The policy also stated the services provided by the facility will be provided by qualified persons in accordance with each resident's written plan of care. The policy further stated the care plan is revised by the members of the interdisciplinary team based on changing goals, preferences and needs of the resident and in response to current interventions.Resident #163 was re-admitted to the facility with diagnoses that included Atrial fibrillation, Heart failure, and Hypertension.The Significant Change in Status Minimum Data Set, dated [DATE] documented Resident #163 was not taking Anticoagulant medication.The Comprehensive Care Plan with focus Potential for bleeding initiated on 07/11/2025 documented Resident has Potential for bleeding related to Anticoagulation therapy-Apixaban (Eliquis). Goals included Resident will be free of signs/symptoms of bleeding, such as bleeding gums, tarry stool, epistaxis, hematuria, petechiae bruising. Interventions included reinforce safety measures to prevent injury/bleeding, watch for signs of bleeding, report changes to Nurse/Physician, instruct staff/resident to notify nurse if bleeding gums, nose bleeds, tarry stools, hematuria, petechiae or bruising is noted.The Physicians Order dated 07/11/2025 documented Aspirin Oral Tablet Chewable 81 MG (Aspirin) Give 1 tablet via PEG-tube one time a day for A-fib.The Medical Progress note dated 08/02/2025 documented 07/28/25 Cardiology consult reviewed with recommendation to restart Eliquis 5 mg twice daily for Atrial Fibrillation.The Medical Progress note dated 08/03/2025 documented nursing staff reported small amount of hematuria noted on resident's brief; complete blood count, complete metabolic panel, urine analysis/culture and sensitivity ordered. The Physician's order dated 08/18/2025 documented Aspirin 81mg Oral Tablet Chewable 1 table daily for DVT PPX (Deep Vein thrombosis prophylaxis). The Medication Administration Record dated July 2025 documented Resident #163 received Apixaban 5mg via Tube feeding for Atrial Fibrillation on 07/01/25, 07/02/2025, medication was held 07/03/2025-07/05/2025 and discontinued on 07/06/2025. The Medication Administration Record dated July 2025 also documented Resident #163 received Aspirin Oral Tablet Chewable 81 MG (Aspirin) Give 1 tablet via PEG-tube one time a day for A-fib. The Medication Administration Record dated August 2025 documented Resident #163 received Aspirin 81mg via Tube feeding daily for Atrial Fibrillation. There was no documented evidence the care plan on Anticoagulant was updated to reflect Apixaban (Eliquis) was discontinued for Resident #163, and Aspirin was started on 07/11/2025. On 08/21/2025 at 12:01 PM, Registered Nurse #1 was interviewed and stated Resident #163 had been taking Eliquis, but it was discontinued, and they were started on Aspirin. Registered Nurse #1 also stated they were not aware that Resident #163's care plan was not updated when Eliquis was discontinued. Registered Nurse #1 further stated the nurse on duty when Eliquis was discontinued should have updated the care plan to indicate the reason for the discontinuation. Registered Nurse #1 stated they were not regular on the unit, and was not aware the care plan had been not updated. On 08/22/2025 at 10:28 AM, Registered Nurse #2 was interviewed and stated Resident #163 was admitted on [DATE] and was prescribed Eliquis 5mg every 12 hours for Atrial Fibrillation, which was discontinued on 07/05/2025 as there was blood noted in the urine and they were started on Aspirin 81 mg. Registered Nurse #2 also stated Resident #163 has a care plan related to the risk for bleeding due to Eliquis, which was updated on 05/31/2025, 07/11/2025 and 07/31/25, and there is no documentation Eliquis was discontinued. Registered Nurse #2 further stated the nurses caring for Resident #163 when bleeding was noted and Eliquis discontinued, or the supervisor on duty at that time could have updated the care plan to indicate Eliquis was discontinued due to bleeding, but they cannot explain why it was not updated. On 08/22/2025 at 11:45 AM, the Director of Nursing was interviewed and stated the nurse on the unit is responsible for updating the care plan, and the unit supervisor is to oversee that a resident's care plan is updated as soon as there is a change in resident's condition or resident's plan of care. The Director of Nursing also stated they do spot checks to see that everything is in order, but they were unaware this care plan was not updated when Resident #163's anticoagulant therapy was changed. 10 NYCRR 415.11(c)(2)(i-iii)

Based on observations, record review, and interviews conducted during the Recertification survey, the facility did not ensure infection control practices were maintained to prevent the transmission of foodborne illness. This was evident during Dining Observation on the 3rd Floor, [NAME] side, dining room. Specifically, two Certified Nursing Assistants were observed assisting multiple residents with hand hygiene without performing hand hygiene in between residents. The findings are: The facility policy titled Meal Service-Assistance of Residents last revised 04/2016 stated residents who are unable to feed themselves or require feeding assistance to finish meals will be served and assisted with their meals. Offer and/or assist resident to cleanse their hands with a hand wipe. The facility policy titled Hand Hygiene Protocol effective 11/2017 stated the facility will follow a hand hygiene protocol in preventing the spread of potential pathogens on the hands. The policy also stated the guidelines for hand hygiene as before and after eating and before and after each resident/patient contact, and resident hand hygiene should be performed after toileting and before meals. On 08/19/2025 from 11:43 AM to 11:57 AM, dining was observed on the 3rd floor dining room on the [NAME] side. Certified Nursing Assistant #6 was observed donning gloves and giving handwipes to residents in the dining room. Certified Nursing Assistant #6 assisted Resident #308, Resident #235, Resident #40, Resident #108, Resident #115, Resident # 280 to clean their hands using the same gloves. Certified Nursing Assistant #6 then placed a paper placemat on the table for Resident #280 table and then assisted Resident #63, and Resident #258 with hand hygiene and did not change their gloves. In addition, Certified Nursing Assistant #5 was observed assisting both Resident #88 and Resident #157 with hand hygiene while wearing the same unchanged gloves. On 08/19/2025 at 11:56 AM, Certified Nursing Assistant #6 was observed washing their hands in the sink after taking off gloves. On 08/19/2025 at 11:57 AM Certified Nursing Assistant #5 was observed washing their hands in the sink in the dining room. During an interview on 08/19/2025 at 3:09 PM, Certified Nursing Assistant #6 stated that they noticed they did not do hand hygiene, and this was their first time assisting in the dining room. Certified Nursing Assistant #6 also stated they completed training on hand hygiene online, and did recall completing any hand hygiene observation competency. Certified Nursing Assistant #6 further stated hand hygiene should be done to remove germs, so they do not get residents infected with germs from another resident. During an interview on 08/19/2025 at 02:59 PM, Certified Nursing Assistant #5 stated that they forgot to clean their hands between residents. Certified Nursing Assistant #5 also stated they are supposed to clean their hands so they do not transmit any kind of infection to residents. Certified Nursing Assistant #5 further stated they had hand hygiene inservice last week. During an interview on 08/22/2025 at 3:02 PM, Registered Nurse #6 stated that they monitor dining every time residents are fed, and Certified Nursing Assistants clean resident's hands before they begin eating. Registered Nurse #6 also stated frequent in-services have been done downstairs with the Assistant Director of Nursing who is the in-service Coordinator. During an interview on 08/22/2025 at 3:30 PM, the Assistant Director of Nursing was interviewed and stated hand hygiene should be performed before donning gloves, after taking gloves off, and after assisting residents with dining. During an interview on 08/26/2025 at 1:34 PM, the Director of Nursing stated that they do facility rounds 5 times during a shift and observe preparation of residents for dining including the cleaning of resident hands. The Director of Nursing also stated if gloves are used, they should be changed between residents, and if gloves are not used hands should be sanitized between residents and washed after. During an interview on 08/26/2025 at 1:59 PM, the Infection Preventionist was interviewed and stated they do random infection control audits and monitor infection control in the resident dining rooms. The Infection Preventionist also stated staff are supposed to do hand hygiene before dining, after removing gloves, and after assisting residents with hand hygiene. 10 NYCRR 415.14 (h)

Based on observation, record review, and interviews conducted during the Recertification survey, the facility failed to ensure the nursing staff information posting was accurate and complete. This was evident during the Nursing Staffing Task. Specifically, the daily nurse staffing information posting did not include the total number and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift.The findings include:The facility policy titled Posting of Nursing Staff with effective date of 08/2025 documented it is the policy of the facility to provide sufficient nursing staff with the appropriate competencies and skills to provide nursing and related services. The facility shall post daily and by the shift, number of licensed and unlicensed nursing staff working, who are directly responsible for resident care. Staffing information shall consist of the total number and the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift.During observations from 08/19/2025 at 9:15 AM to 08/23/2025 at 1:00 PM, the facility Daily Staffing posting information sheets were observed at the security front desk and the 2 [NAME] elevators. The Daily Staffing sheets documented the date, census at the start of shift, the number of registered nurses, licensed practical nurse, and certified nurse aides, and shift supervisors, but did include the total number and actual hours worked by the Registered Nurses, Licensed Practical Nurses, and Certified Nurse Aides.On 08/22/2025 at 3:02 PM, the Staffing Coordinator was interviewed and stated that their job includes posting the daily staffing and making sure the morning supervisors post the Daily Nursing Staffing Information sheets for the day shift, they post the evening staffing sheet in the evening after 3:00 PM, and the night supervisors do the posting on the night shift. The Staffing Coordinator also stated the daily staffing is posted at the 2 South elevator, reception desk, and the 2 [NAME] elevators, and is split into shifts 7 AM-7 PM, 7 AM to 3 PM, and 3 PM to 11 PM, 7 PM to 7 AM and 11 PM to 7 AM as the Registered Nurses work 12-hour shifts and Certified Nurse Aides work 8 hours. The Staffing Coordinator further stated the current census per shift is also documented on the staff posting, and the nurses and Certified Nurse Aides for each floor is documented. The Staffing Coordinator stated they were not aware that the total number and actual hours worked had to be included on the posting.On 08/22/2025 at 3:03 PM, the Administrator was interviewed and stated they were not aware the daily staffing posted had to document total number and actual hours worked.On 08/22/2025 at 3:29 PM, the Director of Nursing was interviewed and stated that on the previous survey there was an issue with the daily staffing not being posted, but they were not aware they were posting incorrect information. The Director of Nursing also stated they were not aware the total number and actual hours worked by nursing staff had to be included on the posting. 10 NYCRR 415.13

Based on observations, record review, and staff and resident interviews conducted during the Recertification survey from 10/2/23 to 10/10/23, the facility did not ensure that notice of the availability of the survey results in areas of the facility that are prominent and accessible to the public was posted. Specifically, the survey results were in a binder placed behind the security desk outside of the second-floor nursing office. The label of the binder faced away from the reception area. There was no notice posted about the availability of results in any facility location. This was observed on 6 of 6 resident units and in the facility lobby. The findings are: During multiple building observations conducted between 10/2/23 at 9:00 AM and 10/10/23 at 2:00 PM survey results were observed in a binder in the lobby area. There were no notices observed posted on any of the resident units about where the survey results could be located. On 10/4/23 at 11:00 AM, during the Resident Council meeting, residents were asked about the location and availability of survey results. 12 of the 12 residents in attendance stated they did not know where the results were located. On 10/10/23 at 1:45 PM, the Administrator was interviewed and stated that the binder with the survey results is located near the front of the building entrance or near security. The Administrator stated that they are responsible for survey results and the binder can be made available to residents, family members or visitors when requested. The Administrator further stated that the survey results could be visualized from the reception desk so could easily be located. On 10/10/23 at 2:00 PM, an observation of the lobby are from the the security desk was made with the Administrator. The Administrator confirmed that they could not see the label on the survey results binder while standing by the side of the security desk or when passing by from the lobby to the elevators. 415.3 (d)(1)(v)

Based on observation, record reviews and interviews conducted during the Recertification survey from 10/2/23-10/10/23, the facility did not ensure that infection control practices and procedures were maintained to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Specifically, while performing wound care for Resident #251, Registered Nurse (RN) #13 was observed not performing hand hygiene directly after removing a soiled dressing and during the dressing change did not maintain aseptic technique while cleansing the wound according to professional standards. This was evident for 1 of 5 residents reviewed for Pressure Ulcer/Injury out of a sample of 38 residents. The findings are: The facility policy and procedure titled Clean Dressing Change effective 3/16 documented that it is the policy that wounds are cared for in a safe, sanitary manner to promote healing, to protect adjacent skin surfaces from irritation from drainage, and to prevent infection. The policy also documented procedural steps for performing a dressing change which included don clean gloves, remove old dressing, deposit dressing into disposable plastic bag, observe wound, remove gloves, deposit into plastic bag, perform hand hygiene, don new clean gloves, cleanse wound maintaining aseptic technique (i.e., cleaning from inner to outer aspect), and irrigate all deep and necrotic wounds with piston syringe as ordered by the physician. Resident #251 was admitted with diagnoses that include End Stage Renal Disease. The Quarterly Minimum Data Set (MDS) dated [DATE] documented that Resident #251 was severely cognitively impaired, was dependent on staff for all Activities of Daily Living, was at risk for pressure ulcer development, and had an unhealed Stage 4 sacral pressure ulcer on admission. Physician Order dated 6/9/23 documented Calcium Alginate Silver. Apply to sacrum topically every day shift for PU (pressure ulcer). Clean with NS (normal saline), cover with dressing. Physician Order dated 6/13/23 documented Santyl Ointment 250Unit/GM (collagenase) Apply to sacrum topically every day shift for S4 Pressure Ulcer/Injury. Apply to sacrum topically for removal of devitalized tissue. Clean wound first using Normal Saline. Apply ointment to wound bed, Calcium alginate, then cover with comfort foam Border or Border Foam dressing. On 10/06/23 at 09:00 AM, a wound care observation was conducted for Resident #251. Registered Nurse (RN) #13 washed their hands, applied gloves, wiped the over bed table with disinfecting wipes and then waved their gloved hand over the table for several seconds to dry the disinfectant. A paper barrier was placed on the table followed by a cardboard tray on which foam dressing packets were opened and labeled (with a marker) with date and time, and calcium Alginate dressings and gauze dressings to which Santyl Ointment was applied. RN #13 then removed gloves, washed hands with soap water, and applied a new pair of clean gloves. RN #13 informed Resident #251 that the dressing change would be performed, and with the assistance of CNA #14 positioned resident on the right side of their body. RN #13 removed the soiled dressing which contained moderate bloody and serosanguinous drainage, discarded it in the garbage bag and opened the sealed normal saline bottle without removing gloves or performing hand hygiene. RN #13 then applied clean gloves and poured normal saline solution onto the open gauze dressings and placed a barrier between the wound and the soiled brief. RN #13 cleansed the wound with the normal saline-soaked gauze in a swiping motion from the outer edge of the wound to the inner area of the wound. Santyl Ointment was then applied to all areas of the wound bed which was then covered with Calcium Alginate dressings and secured with bordered foam gauze. Soiled dressings, barriers and gloves were disposed of in the garbage bag which was then taken to the soiled utility room. RN #13 then washed hands. On 10/6/23 at 10:11 AM, an interview was conducted with RN #13 and described steps in the dressing change procedure as follows: preparation of supplies, handwashing, application of gloves, removal of old dressings, handwashing, putting new gloves on, cleansing wound with one swipe across from the outer edge to the inner area of the wound, patting the wound dry, placing Santyl on the wound, applying calcium alginate and then a dry dressing. RN #13 also stated that they thought they had removed gloves and performed hand hygiene after removing the soiled dressing and before opening the normal saline bottle. RN #13 further stated that hand hygiene should be performed, and clean gloves donned after removal of a soiled dressing. The RN was unable to describe aseptic wound cleansing technique. On 10/10/23 at 11:43 AM, an interview was conducted with the Assistant Director of Nursing (ADNS) #1 who sometimes covers for the Wound Care Coordinator. ADNS #1 stated that they observe wounds and the nursing staff that performs the dressing changes when they are on the floor. ADNS #1 also stated that hands should be washed and new gloves donned after removing soiled dressings, and wound should be cleansed in a circular motion from the center of the wound outward to the edges of the wound. On 10/13/23 at 11:57 AM, an interview was conducted with the Wound Care Coordinator (WCC) who stated that their role primarily consisted of inspecting wounds at admission, skin inspections and ensuring orders are in place. The WCC stated that they perform a wound consultation if requested but that it is the responsibility of the charge nurse to assist the staff nurses with wound care treatments and the role of the ADNS (in-service education) to ensure that the treatments are performed appropriately. On 10/10/23 at 12:08 PM, ADNS #2, the Inservice Coordinator, was interviewed and stated that they observe wound care on the units once or twice a week, complete staff competencies, education, and re-education if they observe incorrect procedures. ADNS #2 also stated that hand washing should be done when the soiled dressing is removed, the wound observed, clean gloves donned, wound cleaned from inside out, gloves removed, hands washed, treatment applied and all soiled items discarded. The ADNS #2 further stated that a competency was completed with RN #13 on 9/29/23 and that they were nervous when observed by surveyors and so did not perform wound care correctly. On 10/10/23 at 12:20 PM, an interview was conducted with the Infection Preventionist (ICP) who stated that they make observations of wound care as needed to remind staff about what needs to be done. The ICP also stated that hands should be cleaned after the soiled dressing is removed, and the wound should be cleaned from inner to outer. The ICP further stated that they make observations of staff twice a week and as needed and offer more verbal cueing if needed. The ICP also stated that whenever gloves are removed hands should be washed if a sink is available. 415.19 (b)(4)

Based on observation, record reviews, and staff interviews conducted during the Recertification Survey from 10/2/23 to 10/10/23, the facility did not ensure that residents were free from unnecessary antipsychotic medications. This was evident for 1 of 5 residents reviewed for Unnecessary Medications out of 38 sample residents (Resident #206). Specifically, Resident #206 was given psychotropic medication (Celexa) for resistive and aggressive behavior which was increased without documented evidence of ongoing behaviors or of any nonpharmacological interventions applied to address behavior. The findings are: The facility Policy and Procedure for Psychotropic medications created 12/13 effective 11/16 documented it is the policy of the facility to utilize psychotropic drugs appropriately for the purpose of assisting the resident in attaining and maintaining optimum and emotional functioning. Procedure: Medical provider/Psychiatrist will only order psychotropics based on a comprehensive assessment of a resident to treat a specific documented condition except in emergencies, only as an integral part of resident comprehensive care plan. Only when alternative method has been tried and failed. Never for purposes of discipline or convenience. Resident #206 was admitted with diagnoses that included Non-Alzheimer's Dementia and Depression. The Quarterly Minimum Data Set (MDS) assessments dated 05/08/2023 and 08/04/2023 documented resident had short and long-term memory impairment and severely impaired cognitive skills for decision making, and was feeling down, had trouble sleeping, feeling tired, poor appetite, trouble concentrating and moving slowly on 7-11 days for a total mood score of 12. The care plan titled resident received antipsychotic medication R/T Citalopram Hydrobromide Tab 10mg for resistive behavior created 11/06/2022 and reviewed 08/12/2023 documented a goal of resident will participate in daily activities without interference of symptoms or side effects through review period. Interventions included administer medication as per order, monitor medication response, and observe and report side effects abnormal s/s or any adverse condition. On 10/03/2023 at 9:50 AM, Resident #206 was observed eating breakfast, pureed renal diet with good appetite. Resident was verbally responsive when greeted and was not displaying any signs of resistive or aggressive behaviors. On 10/06/23 at 10:50 AM, Resident #206 was observed in bed, finishing breakfast with 100% consumed. Resident's mood was pleasant and resident displayed no behaviors. On 10/06/23 at 4:50 PM, Resident #206 was observed completing dinner with the assistance of the Certified Nursing Assistant (CNA), with calm mood, and no behaviors displayed. Psychiatry notes dated 09/17/2023 documented possible intermittent delirium, restlessness, and agitation due to GMC (general medical condition). Recommendation increase Celexa to 15mg daily to address poor self-control and resistiveness behavior. Instead of clonazepam can give Ativan 1 mg 45 minutes prior to HD (hemodialysis). Patient lacks capacity for medical or discharge decisions. Follow up 4-6weeks. Nursing, MD, or NP progress notes dated 01/11/2023 to 10/05/2023 did not document an increase of resistive and aggressive or depressed behavior by Resident #206. There was no documented evidence of ongoing resistive, aggressive, or depressed behaviors and the use of any nonpharmacological interventions applied to address behavior when dosage of medication was increased in September 2023. Review of the Dialysis Interfacility Communication Forms dated 08/02/2023 to 09/27/2023 were blank in the section designated dialysis notes to floor and contained no documented evidence that resident was displaying resistive or aggressive behavior while receiving dialysis treatment. During an interview on 10/10/23 at 12:30 PM, Certified Nursing Assistant (CNA) #7 stated that sometimes when it is time to provide care to Resident #206, they may try to grab the CNA's hand tight and try to hold on. CNA #7 also stated that if they talk to resident slowly, the resident relaxes and lets the CNA do their work. CNA #7 further stated that the had not observed Resident #206 display any depressed, aggressive, or resistive behavior. During an interview on 10/10/2023 at 12:40 PM, Registered Nurse (RN) #5 stated that sometimes Resident #206 refuses medication, has a very good appetite and is always asking for food and drink which they give to the resident. RN #5 also stated that CNAs had reported in the past that the resident can be aggressive and refuse care but when you speak to the resident calmly they are no longer aggressive. RN #5 further stated that after dialysis Resident #206 is usually much calmer. RN #5 further stated that they had not received any report that the dialysis nurse reported to nurses on unit that resident was behaving aggressively in dialysis. RN #5 stated that they had not observed aggressive or depressed behavior, and they did not know why the dosage of medication was increased as no one had explained to them why the dosage of medication had been changed. On 10/10/23 at 10:59 AM, Nurse Practitioner (NP) #1 was interviewed and stated that they responds to interim calls regarding resident concerns but was not contacted to see Resident #206 in relation to behaviors. On 10/10/23 at 11:25 AM, NP #2 interviewed and stated that Resident #206 has a diagnosis of Depression and that is the reason that the Celexa was prescribed. NP #2 also stated that they did not know why the Celexa would be increased, and they did not have documentation of any behaviors in their notes. On 10/10/23 at 01:05 PM, the Registered Nurse Supervisor (RN #6) was interviewed and stated that they think a consult was put in for Resident #206 because dialysis was reporting that resident was aggressive. RN #6 also stated that they were not sure of the date that the consult was requested. On 10/10/23 at 01:16 PM, the Medical Director (MD) #1 who is also Resident #206's Attending Physician was interviewed. MD #1 stated they increase resident's medication based on the recommendation of the Psychiatrist and the psychiatrist must have based it on what they saw at the time of evaluation. MD#1 also stated that Psychiatrist is the expert and if they believe the increase is necessary, they follow what the psychiatrist says. MD#1 further stated that they could not tell why Celexa dose was increased from 10mg to 15mg, and they had not reviewed the nursing progress notes to determine whether an increase in dosage was necessary for this resident. During an interview conducted on 10/10/23 at 01:50 PM, the Psychiatrist, (MD #2) stated the reason for the consultation was written on by the staff and they believed believe it was restlessness and agitation. MD #2 also stated that by the time they see the resident all their interventions would be pharmacological in nature, and they would not be able to say whether non-pharmacological interventions were attempted by the staff. MD #2 further stated they were responding to the staff request and Celexa can be helpful with agitation so that would be an appropriate diagnosis. MD #2 stated that they did not have a photographic memory so would not be able to tell what was going on with the resident or why nothing was documented. 415.18 (c)(1)

Based on interviews and record review conducted during Recertification and Complaint investigations (NY00321292), the facility did not ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported to the State Survey Agency. Specifically, the facility did not report an injury of unknown origin where there the resident sustained a hematoma to right side of their head. This was evident for 1 of 3 residents reviewed for Accidents out of a sample of 38 residents. (Resident #478). The findings are: The facility policy and procedure titled Reporting and Investigation of Resident Abuse, Neglect, Misappropriation/Exploitation and Mistreatment effective 10/2022 documented all personnel have the responsibility to report any incident or suspected incident of resident abuse including injuries of an unknown source. The facility shall conduct a thorough investigation of all alleged violations involving exploitation, mistreatment, neglect or abuse, and misappropriation of resident property and comply with state reporting regulations. All alleged violations and results of investigations shall be reported shall be reported immediately to the Administrator/DNS. To ensure that all alleged violations involving abuse, neglect, exploitation of mistreatment, including injuries of unknown source and misappropriation of result property, are reported immediately, but not later than 2 hours after the allegation is made if it involves abuse or result in serious bodily injury or not later than 24 hours if the allegation does not involve abuse and do not result in serious bodily injury. Resident #478 was admitted with diagnoses which included Non-Alzheimer's Dementia, Radiculopathy of the Lumbar and Cervical region, and Unspecified Glaucoma. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented that resident had severely impaired cognition and had no behavioral symptoms exhibited. The MDS also documented that Resident #478 had not exhibited any wandering behavior, required extensive assistance of 2 persons for transfer and had no impairment of upper and lower extremity. An Accident Report dated 7/29/2023 at 4:35 PM documented resident was lying on floor on right side of wheelchair and had a bump on right forehead. Oriented to person and time and confused and required extensive x1 for ambulation. The summary also documented that resident left for hospital at 5:55 PM and returned on 7/30/23 at 3:47 AM. CT of head with contrast- findings: right frontotemporal scalp hematoma, moderate atrophy, no acute territorial infarction, intracranial hemorrhage, or mass. The summary also documented no abuse, neglect, mistreatment was identified. Ice pack applied; acetaminophen given documented. The RN Supervisor Occurrence Investigative Form dated 7/29/23 documented that there was an unwitnessed occurrence and Resident #478 was not able to recall what happened. There was no documented evidence that the incident had been reported to the Department of Health in the Health Electronic Response Data System (HERDS). On 10/05/23 at 03:59 PM, Certified Nursing Assistant (CNA #10) voice mail left and no return call was received by survey exit. On 10/06/23 at 12:24 PM, the Registered Nurse Supervisor (RN) #4 was interviewed and stated that on 7/29/23 they were asked to see the resident. Resident #478 was already placed back to bed. The Nurse Practitioner (NP) was contacted for a telemedicine consultation and sent pictures of the resident's injuries as resident had a bump on head. The resident was sent out since they are on Aspirin and Nurse Practitioner (NP) recommend resident sent to hospital since it was a head strike. The resident was sent out for CT of the head. The resident was alert and oriented to person and had pain at the site of impact. The resident returned at 3AM in the morning and CT scan was unremarkable and resident monitored. The Accident and Incident (A& I) packet is reviewed by the ADNS and since it was a weekend they would see it on Monday and check if it was complete and notes entered in the electronic medical record. RN #4 also stated that if it is a reportable incident, then they contact the Assistant Director of Nursing (ADNS) and Director of Nursing (DNS) and the DNS will report right away. RN #4 further stated that they contacted the ADNS and informed them that the resident had a fall. During an interview on 10/06/23 at 01:00 PM, the Assistant Director of Nursing (ADNS) stated that the supervisor contacted them, and supervisor completed the Accident and Incident (A&I) report which they are in responsible for reviewing. The ADNS also stated that incidents reportable to the State include burns, altercation with resident to resident, resident to staff, falls to result in death and injury of unknown origin, misappropriation of property, and they did not believe the incident was a reportable incident. Resident #478 was not able to explain what happened, received care prior to the fall and they reviewed exit camera and there was no one there at the time for the fall. The ADNS further stated that they no longer had the video footage as it had been overwritten. The ADNS stated they have been trained on reporting incidents. On 10/06/23 at 01:16 PM and 2:21 PM, the Director of Nursing (DNS) was interviewed and stated that the ADNS informed them the resident had a fall and they were sent out to the hospital for a computerized tomography (CT) scan. They had an unwitnessed fall and had a raised area to right side of forehead; they had an abrasion related to fall on right side of forehead. The DON also stated that an injury of unknown origin needs to be reported. If there is any abuse, crime, injury of unknown origin should be reported within 2 hours and other incidents report within 24 hours. The DON further stated that the incident was not reportable, as they ruled out abuse neglect and mistreatment and they will ask the ADNS if there is a video available related to the incident. On 10/10/23 at 01:55 PM and 2:53PM, the Administrator was interviewed and stated they were notified that the resident had a fall and it was discussed at the morning meeting. For reporting of incidents, the DNS is in charge and if anything needs to be reported in a specific time frame they also have access. If there is any incident with an injury, suspicion of crime and call police and report to the state. They have to report within 2 hours anything with injury causing death, resident to resident and death. The resident had a negative CT scan and no injury reported for resident. An injury of unknown origin is reportable. 415.4(b)(1)(2)

Based on observations, record review, and interviews conducted during the Recertification survey conducted from 10/2/23 to 10/10/23, the facility did not ensure that residents were free of physical restraints. Specifically, hand mittens were not released every two hours as ordered by the physician. This was evident for 1 of 1 resident reviewed for Physical Restraints out of total sample of 38 residents. (Resident #251). The findings are: The facility's policy & procedure titled Restraints Devices and Siderails dated 11/16, last revised on 11/17 documented: Physical or chemical restraints will only be utilized after less restrictive alternatives have been attempted and considered as a last resort to treat the resident's medical symptoms. Restraints will be utilized for the least amount of time and documentation of ongoing evaluation of the need for the restraints is required. The release schedule is a minimum of every two hours for 15 minutes and as necessary. The CNA will record the restraint release schedule in the Point of Care Module of the EMR. Patients should be checked at least every two (2)hours (at time of the release of the restraints) for any evidence of adverse effects. The Restraint/Device evaluation will be completed quarterly or more frequently at a frequency determined by the resident's condition and reviewed during the CCP meeting. The interdisciplinary will focus on restraint reduction and discontinuance. The interdisciplinary Team will develop a care plan using CAA-18 Restraints for Restraint use. This care plan will be evaluated quarterly and as needed. Resident #251 was admitted to the facility with diagnoses that included Unspecified Dementia, End Stage Renal Disease, and Generalized muscle weakness. The Quarterly Minimum Data Set (MDS) dated [DATE] documented the cognitive skills of the resident as completely impaired for daily decision making. The MDS documented that the resident was dependent on staff for all Activities of Daily Living and had functional limitations in range of motion in upper and lower extremity. In addition, physical restraints were documented as other and used daily. On 10/04/23 at 09:45 AM, Resident #251 was observed out of bed in a reclining chair with mittens applied to both hands. On 10/05/23 09:25 AM, 10:51 AM, 11:42 AM, 12:02 PM, 12:20 PM, 12:38 PM, and 2:39 PM Resident #251 was observed lying in bed with bilateral hand mittens applied. On 10/06/23 at 09:00 AM and 10:11 AM, Resident # 251 was observed with bilateral hand mittens on awaiting transportation to dialysis. On 10/10/23 at 08:50 AM, 10:50 AM, and 10:58 AM, Resident # 251 was observed in bed supine, resting comfortably. Bilateral hand mittens observed on both hands. SBAR Progress note dated 6/3/23 at 20:12 documented: Situation: Pulled out right upper chest permacath (catheter inserted into a blood vessel which allows prolonged access into the bloodstream). Physician Orders for restraints: 6/9/23 19:00 documented: Device bilateral (B/L) hand mittens to be applied for protection against permacath self-removal to be released every 2 hours for 15 minutes. The Interdisciplinary Team Restraint/Device Evaluation (Non-Siderails) dated 06/09/2023: documented that Resident #251 was given Mittens as a restraint to prevent resident from injuring self, severe dementia, and history of removal of his tunneled dialysis catheter. The evaluation also documented that resident's mental status was confused, they were non-ambulatory, and totally dependent on staff. The reason for use was documented as danger to self on Hemodialysis and repeatedly removing tunneled dialysis catheter and plan was to continue device use. There was no documented evidence that the use of restraints had been re-evaluated quarterly. On 10/10/23 at 11:00 AM, an interview was conducted with the Certified Nursing Assistant (CNA) #11) assigned to the Resident #251 who stated that Mittens are taken off for 15 minutes to 20-25minutes with feeding. CNA #11 also stated they were not sure of when mittens are to be removed but they document every two hours. CNA #11 also stated that they report to the nurse if the resident removes the mittens. If dirty, clean mittens are obtained from downstairs. CNA #11 further stated that the resident has not been seen trying to remove the dialysis catheter by them, but had been observed trying to remove their brief and play with feces when the mittens were released. On 10/10/23 at 11:30 AM an interview was conducted with the Assistant Director of Nursing (ADNS) #1 who confirmed overseeing unit 5 [NAME] where the resident is housed. The ADNS #1 stated staff is observed/spot checked and assisted with providing care twice a shift, and that mittens are supposed to be released every two hours to check the resident's skin. The ADNS #1 further stated that a re-evaluation for continued use of the mittens is completed every quarter. The ADNS viewed the resident electronic record and stated that the initial evaluation was done on 6/14/23, and the re-evaluation should have been done already. The ADNS #1 further stated that the evaluation is usually done with quarterly MDS review, and the charge nurse would fill it out. MDS staff schedules it but they do not see where it was scheduled by MDS in the computer. On 10/10/23 at 11:50 AM, the Minimum Data System Assessor (MDSA) was interviewed and stated that when completing Section P of the MDS they check for the physician order and if a restraint is implemented. The MDSA also stated that they do not know how often the re-evaluation for use is completed because it is not the MDS staff that would re-evaluate. The MDS Assessor further stated that they do not open the evaluation in the computer. In an interview conducted on 10/10/23 at 12:03 PM, the MDS Coordinator (MDSC) was interviewed regarding MDS Assessors responsibility in the process of re-evaluating for restraints. The MDSC stated that assessors visit resident on units to see if the restraint is in place but have no additional responsibility. The MDSC further stated that that they were unsure of the frequency of the restraint use re-evaluation form and that MDS staff members do not open the evaluation form in the electronic medical record. On 10/10/23 at 01:34 PM, the Director of Nursing (DON) was interviewed and stated that the facility has one resident with treatment orders for mittens due to episodic behavior that removed an access and that the hospital sent a strong request to place mittens to prevent re-hospitalizing the resident. The DON also stated that the need for restraints is re-evaluated quarterly, and the MDS department is opening the evaluation form quarterly in the electronic medical record where it's scheduled as part of the MDS assessment. The DON further stated they were not aware that this was not being done by the MDS department. 415.4 (a)(2-7)

Based on observations and interviews conducted during the Recertification survey from 10/2/23 to 10/10/23, the facility did not ensure that two residents were cared for in a manner that maintained or enhanced his or her dignity. Specifically, 1) a resident's Foley catheter bag and tubing were left uncovered and exposed to public view, and 2) another resident was observed being transported in hallway with their back and buttocks exposed. This was evident for 2 of 2 residents reviewed for Dignity out of 38 sampled residents. (Residents #47 & #94). The findings are: 1. The facility's policy titled Foley Cather, Insertion, Removal, and Maintenance effective 09/2021 did not document the application of privacy bag for indwelling catheters to promote privacy and dignity at all times. Resident #47 was admitted with diagnoses which included Renal Insufficiency, Neurogenic Bladder, and Alzheimer's Disease. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented that Resident #47 had severely impaired cognition, required dependent two person assist for most Activities of Daily Living, and used an indwelling catheter. Physician orders active as of 10/05/2023 documented the use of indwelling catheter and urinary catheter care every shift. The Comprehensive Care Plan titled Alteration in Urinary Elimination related to Catheter usage, last reviewed on 09/11/23 documented the application of privacy bag/barrier cover for drainage bag to promote privacy and dignity. On 10/02/23 at 10:48 AM, 10/03/23 at 09:37 AM, 10/04/23 at 02:30 PM, 10/05/23 at 09:51 AM, and 10/05/23 at 02:25 PM, the resident was observed lying in bed with door wide open. The Resident's Foley catheter drainage bag and catheter tubing were on the side of the bed facing the door. There was yellow urine draining into the uncovered catheter bag, and the catheter bag and tubing were visible from the hallway. On 10/05/23 at 02:28 PM, Certified Nursing Assistant (CNA) #1 was interviewed and stated that they provide ADL care for, and turn and positioning the resident every two hours. CNA #1 also stated that they work with the resident during the day and they close the room door to ensure the resident's privacy. CAN #1 further stated that when they provide catheter care they empty the drainage bag and that they were told to apply the privacy bag to the catheter bag when resident is in the wheelchair. CNA #1 stated that no one told them that the catheter bag is supposed to be covered while the resident in bed. CNA #1 also stated that they were not sure if there are any privacy bags on the unit, will check the supply room to see if there any privacy bags in the supply room, and going forward will ensure that the resident's catheter bag is covered. On 10/05/23 at 02:39 PM, Registered Nurse (RN) #1 was interviewed and stated they were on the unit on most days doing MDS assessments and was aware that Resident #47 had a Foley catheter and required total assistance with ADL care. RN #1 also stated that the catheter bags must be covered at all times and residents who use wheelchairs need to use a privacy bag. RN #1 further stated that there are privacy bags in the supply room and all CNAs were trained on catheter care and how to provide privacy and maintain residents' dignity. During an interview on 10/06/23 at 10:29 AM, RN #2 stated that they are the charge nurse for the unit and does rounds frequently on the unit to ensure all residents are safe and to ensure that the CNAs are doing what they are supposed to do. RN #2 also stated that the residents' catheter bags are supposed to be covered with a privacy bag which are available in the supply room. RN #2 further stated that all CNAs were trained on catheter care and ensuring resident's privacy and dignity, and the CNAs most likely forgot that the privacy bag must be applied. During an interview on 10/06/23 at 03:06 PM, the Director of Nursing (DON) stated that it is the facility's policy that catheter bags are covered with privacy bags. The DON also stated that all CNAs were trained on maintaining resident's dignity and privacy, and were told to apply privacy bags on catheter bags The DON further stated that there are privacy bags on every unit, and catheter bags and the tubing are supposed to be covered and are not supposed to be exposed to the public. 42101 2. Resident #194 was had diagnosis that include Schizophrenia, Type 2 Diabetes Mellitus, and Unspecified Cataract. The Admission Minimum Data Set (MDS) dated [DATE] documented the resident was cognitively intact, required extensive assistance of 2 persons for toileting and extensive assistance of one person for dressing. There was no behavior documented. During an observation on 10/02/2023 at 11:06 AM, CNA #8 was observed pushing Resident #194 from the shower room in their rolling walker and assisting the resident back to their room down the hallway. The back of the hospital gown that Resident #194 was wearing was opened exposing their lower back and buttock while they were ambulating in the hallway on the way back to their room. Resident #194 was noted holding their clothes in their hands while they were escorted back to their room. On 10/02/23 at 12:00 PM, Resident #194 stated that staff show them respect and dignity most of the time and some staff are hard to get along with. During an interview on 10/10/2023 at 1:48 PM, CNA #8 stated that they noticed that Resident #194 was exposed. CNA #8 also stated that the is alert, they were trying to get them back to their room and there was nothing else they could do. and they wanted to get the resident back to their room and there was nothing they can do. CNA #8 further stated that they usually take two gowns with them when they take residents into the bathroom for showers. During an interview on 10/10/2023 at 12:10 PM, Licensed Practical Nurse (LPN) #2 stated that CNAs are supposed to make sure residents are fully covered when returning to their rooms after a shower. During interviews on 10/10/2023 at 12:19 PM and 12:42 PM, Registered Nurse (RN) #10 states that all parts of body should be covered when residents are being moved on the unit. RN #10 also stated that if they observe a resident is not covered, they will help CNA get more gowns and cover resident. RN#10 further stated that they do rounds on the unit every 30 minutes when they are not on occupied. 415.5(a)

Based on observation and interviews conducted during the Recertification survey from 10/2/23 to 10/10/23, the facility did not ensure the daily staffing was posted in a prominent place readily accessible to residents and visitors. This was evident for 7 out of 7 units (Unit 2W, Unit 3E, Unit 3W, Unit 4E, Unit 4W, Unit 5W, and Unit 6W). Specifically, daily staffing was not observed posted in a prominent place for residents and visitors for all 7 units. The findings are: The facility policy titled Posting of Nursing Staff with effective date 10/24/22 documented the staffing information shall consist of the facility name, current date and census, the total number and actual hours worked by licensed and unlicensed nursing staff directly responsible for the resident care per shift. It also documented the information shall be posted in an area which is accessible to staff, residents, and visitors to the facility. It documented the staffing coordinator shall be responsible for posting the staffing in a clear readable format. It also documented the RN supervisor will be responsible for posting the staffing information for off hours or weekends or when the staffing coordinator is not in the facility. It further documented the Director of Nursing and/or designee shall be responsible for ensuring compliance with this policy. On 10/02/23 at 09:16 PM, 10/02/23 at 03:38 PM, 10/03/23 at 08:53 AM, 10/03/23 at 01:08 PM, 10/03/23 at 03:53 PM, 10/04/23 at 08:51 AM, and at other times during the survey, observations of facility entry way were made. Visitors were required to do the screening at the security station before accessing the elevators opposite the security station to go to Units 3E, 3W, 4E and 4W or making a right turn to access Unit 2W and the elevators for Units 3W, 4W, 5W and 6W. Daily nurse staffing was not observed being posted in a prominent place where it could be accessed by persons going to any of the units serviced by the elevators on the [NAME] side of the building. On 10/05/23 at 08:44 AM, the Security official was interviewed and stated their shift was from 8:00 AM to 4:00 PM. The Security official also stated the Staffing Coordinator placed the daily nursing staff at the security station between 7:50 AM to 8:10 AM every day. The Security official further stated they might have placed the plastic stand holding the daily nursing staff behind the binders at the security station and which would have made it not visible for past few days. On 10/06/23 at 11:17 AM, the Staffing Coordinator (SC) was interviewed and stated they knew that they had to post the daily nursing staff information for every shift in a place readily accessible to residents and visitors. The Staffing Coordinator also stated they worked from 9 AM to 5 PM and were responsible to post the daily nursing staff around 3:20 PM to 3:30 PM for the evening shift staffing. The Staffing Coordinator further stated the nursing supervisors for day and night shifts were responsible to post the daily nursing staff for their shifts. The Staffing Coordinator stated the daily nursing staff for every shift every day was posted at the security station after confirming the staffing. The Staffing Coordinator also stated there were a lot of binders at the security station and someone might move the daily staffing to somewhere behind the binders and made it not visible to visitors and residents. On 10/10/23 at 09:20 AM, the Registered Nurse (RN) #4 was interviewed and stated they were the day shift RN supervisor. The RN #4 also stated they checked the nursing staff book and called each floor to confirm if the nursing staff were working as scheduled for the day. RN #4 further stated they document the resident census and number of nursing staff including the RN, LPN, certified nurse aides, and the nursing liaison on the daily staffing sheet and then posted it at 3 different areas including at the security station, by east side elevators, and by west side elevators at around 7:30 AM. The RN #4 stated they might forget to post the daily staffing on some days when they were busy with other things. On 10/06/23 at 11:29 AM, the Director of Nursing (DON) was interviewed and stated the daily staffing was posted at the security station and the staff clock in area in the hallway leading to the Unit 2W. The DON also stated the staff clock in area was not accessible to all residents and/or visitors. The DON further stated the nursing supervisors and the staffing coordinator were responsible to update the staffing census for each shift and place the daily staffing at the security station afterward. The DON was not able to explain why the daily staffing was not posted every day at a prominent place readily accessible to residents and visitors. On 10/06/23 at 11:37 AM, the Administrator was interviewed and stated the daily staffing was posted at the security station every day for visitors and residents as required by regulation. The Administrator also stated they did not notice it was not there from Monday 10/2/23 to Wednesday 10/4/23. The Administrator further stated they would check the video surveillance at the security station to see what happened to make sure the daily staffing was posted for all visitors and residents. 415.13

Based on interview and record review, the facility failed to refer four of eight sampled residents with a newly evident [DIAGNOSES REDACTED]. Findings include: Review of the National Institute of Mental Health website article titled, [MEDICAL CONDITION] (accessed on 03/10/2018 at: https://www.nimh.nih.gov/health/topics/[MEDICAL CONDITION]/index.shtml) indicated, [MEDICAL CONDITION] is a chronic and severe mental disorder that affects how a person thinks, feels, and behaves. People with [MEDICAL CONDITION] may seem like they have lost touch with reality . the symptoms can be very disabling. 1. Review of R5's Admission Record, with a print date of 03/06/2018, indicated the facility admitted the resident on 11/25/2016 with a primary [DIAGNOSES REDACTED]. Additional [DIAGNOSES REDACTED]. Review of R5's Preadmission Screening and Resident Review (PASARR) documentation (a review process which helps to ensure that individuals who have a mental illness or intellectual disability are not inappropriately placed in nursing homes for long term care), dated 11/23/2016, indicated under the section titled, Level I Review for Possible Mental Illness (MI), the state health department screener answered question number 23: Does this person have a serious mental illness? as No. Review of R5's Psychiatric Evaluation documentation indicated the psychiatrist examined the resident, reviewed the resident's medical record, and spoke with the staff regarding the resident's mental and behavioral status on 11/29/2016, 12/07/2016, 02/17/2017, and on 02/24/2017. Further review of the Psychiatric Evaluation, dated 02/24/2017, indicated under [DIAGNOSES REDACTED]. Review of R5's medical record provided no evidence that indicated the facility referred R5 to the state's mental health authority for a subsequent review to determine her care and service needs related to her new [DIAGNOSES REDACTED]. During an interview on 03/09/2018 at 11:00 AM, the psychiatrist stated he diagnosed R5 with [MEDICAL CONDITION] based on his examination of the resident, a review of her medical record documentation, and through discussions with the staff regarding the resident's behavior status since admission. 2. Review of R6's Admission Record, with a print date of 03/07/2018, indicated the facility admitted the resident on 01/07/2016 with a primary [DIAGNOSES REDACTED]. Additional [DIAGNOSES REDACTED]. Review of R6's PASARR documentation, dated 01/07/2016, indicated under the section titled, Level I Review for Possible Mental Illness (MI), the state health department screener answered question number 23: Does this person have a serious mental illness? as No. Review of a Consult Form - Psychiatry V2, with an effective date of 01/30/2018 at 4:31 PM, indicated the psychiatrist examined R6 on 02/02/2018, reviewed the resident's medical record, and discussed the resident's mental and behavioral status with the staff. Under 5. Impression/Diagnosis/ Recommendation, the psychiatrist documented, [MEDICAL CONDITION] (late onset), neurocognitive d/o (disorder) with depression and behavior disturbance. Review of R6's medical record provided no evidence that indicated the facility referred R6 to the state's mental health authority for a subsequent review to determine his care and service needs related to his new [DIAGNOSES REDACTED]. During an interview on 03/09/2018 at 11:00 AM, the psychiatrist stated he knew and treated R6 prior to the resident's admission to the facility, and the resident had a long history of mental illness, which included paranoia, violent behavior, delusions, and disorganized thought processes. The psychiatrist stated he provided R6's [DIAGNOSES REDACTED]. 3. Review of R7's Admission Record, with a print date of 03/07/2018, indicated the facility admitted the resident on 05/03/2016 with a primary [DIAGNOSES REDACTED]. Additional [DIAGNOSES REDACTED]. Review of R7's PASARR documentation, dated 05/03/2016, indicated under the section titled, Level I Review for Possible Mental Illness (MI), the state health department screener answered question number 23: Does this person have a serious mental illness? as No. Review of R7's medical record provided no evidence that indicated the facility referred the resident to the state's mental health authority for a subsequent review to determine her care and service needs related to her new [DIAGNOSES REDACTED]. During an interview on 03/09/2018 at 11:00 AM, the psychiatrist stated he knew and treated R7 prior to the resident's admission to the facility, and the resident had a long history of [MEDICAL CONDITION]. The psychiatrist stated he provided R7's [DIAGNOSES REDACTED]. 4. Review of R8's Admission Record, with a print date of 03/07/2018 indicated the facility admitted the resident on 03/01/2016. The resident's [DIAGNOSES REDACTED]. Review of R8's PASARR documentation, dated 02/26/2016, indicated under the section titled, Level I Review for Possible Mental Illness (MI), the state health department screener answered question number 23: Does this person have a serious mental illness? as No. Review of R8's medical record provided no evidence that indicated the facility referred the resident to the state's mental health authority for a subsequent review to determine her care and service needs related to her new [DIAGNOSES REDACTED]. During an interview on 03/09/2018 at 11:00 AM, the psychiatrist stated he diagnosed R8 with schizophreniform disorder based on his examination of the resident, a review of her medical record documentation, and through discussions with the staff regarding the resident's behavior status since admission. During interviews on 03/09/2018 at 11:35 AM and 2:00 PM, the Social Services Director (SSD) stated he was unaware that R4, R5, and R6 had received a [DIAGNOSES REDACTED]. The SSD stated although required by state and federal regulations, none of the four residents were referred to the state's mental health authority for a review of their care and service needs related to their [DIAGNOSES REDACTED]. The SSD stated that he attended the facility's morning meetings regarding status updates on the residents but he did not recall hearing information related to these four residents' [DIAGNOSES REDACTED]. As part of the quarterly reviews, the SSD stated he reviewed a resident's progress notes, care plan, talked with the resident (if they are able to communicate) and the staff. The SSD stated he does not review the resident's [DIAGNOSES REDACTED]. The SSD stated that on admission, residents are assigned to one of his three staff or himself and added that R7 and R8 were on his caseload. During an interview on 03/09/2018 at 2:15 PM, with the Administrator, Director of Nursing (DON), medical director, and the facility's chief executive officer, the DON stated the SSD attended the morning meetings and should have known about the residents' diagnoses. The Administrator acknowledged that a referral to the state's mental health authority should have been made for each resident (R5, R6, R7, and R8) so that a review could be completed for the residents' care and service needs related to their mental illness.

Based on observation, record review and interviews conducted during an abbreviated survey (NY 201), the facility did not ensure that a resident's/surrogate's right to formulate an advance directive was followed for one of four residents sampled for advance directives (Resident #1). Specifically, Resident #1's choice for Do Not Resuscitate (DNR) status was not implemented by the facility. The findings include: The facility Policy and Procedure for Do Not Resuscitate (DNR) dated [DATE] documented that, Hospital DNR remains valid indefinitely unless revoked by the resident or the designated representative for residents without capacity. On page two of the policy, item number nine stated that, a new admission admitted to the facility with an executed DNR from the transferring facility will remain in effect until otherwise rescinded by the resident and/or surrogate. The policy further documented on page three that, when a resident is admitted from a hospital or other Residential Health Care Facility with an order for [REDACTED]. The facility CPR Policy dated [DATE] documented that the first responder to an emergency event will determine the resident's choices for Advance Directives. A Hospital Discharge Summary for Resident #1 dated [DATE] noted a Non-Resuscitation Order (NRO) dated and signed by the hospital attending Physician on [DATE]. This order identified the decision-maker as Resident #1's family member. The Hospital Patient Review Instrument (PRI) dated [DATE] documented under primary [DIAGNOSES REDACTED]. Resident #1 was admitted to the facility from the hospital on [DATE] at 6:15 PM with [DIAGNOSES REDACTED]. The facility NSG Admission Record - V-2 dated [DATE] at 6:14 PM, identified Resident #1 with Advance Directives and DNR. The facility Health Status Note, written by a Registered Nurse, RN #1, dated [DATE] at 6:29 PM, documented that the resident was admitted to the facility at 6:14 PM. Resident #1 was alert and oriented times two with periods of confusion, but able to make her needs known. The note stated that Resident #1 is a DNR, that body assessment was done and the doctor was made aware with orders to continue the resident on the medications from the hospital discharge. An Accident Report dated [DATE] at 2:20 AM included a statement from a Registered Nurse Supervisor (RNS #2) that documented the resident had a fall with head injury and was found on the floor on her stomach; the resident was alert but then lost consciousness. The statement from RNS #2 in the Accident Report further documented that RNS #3 ambu bagged the resident (used a device to provide artificial respiration) and she (RNS #2) initiated chest compressions. 911 responded shortly and took over resuscitation. When one of the EMS staff lifted the resident's left arm, she (RNS #2) noticed a DNR band. RNS #2 also wrote that she did not realize that the resident had a DNR order. She was not able to review the whole chart and orders yet and she intended to review them by the end of the shift. Additionally, the facility Health Status Note, written by RNS #2 on [DATE] at 4:13 AM, documented that RNS #2 was called to the unit at 2:20 AM. Resident #1 was observed on the floor with a head injury and blood noted on the right side of the head. Resident #1 was alert and breathing, but lost consciousness and had a respiratory arrest. A STAT code and 911 were called. At 2:40 AM 911 responded and Resident #1 was pronounced dead at 2:50 AM. The doctor and Resident #1's family member were both called. RNS #2, who worked on [DATE] on the 7:00 PM - 7:00 AM shift, was interviewed by telephone on [DATE] at 11:25 AM. RNS #2 stated that, on [DATE] at 2:20AM, she received a call from RN #3 requesting that she come to the unit because Resident #1 was on the floor. RNS #2 stated that, when she arrived on the unit, she observed Resident #1 lying on her stomach on the floor next to her bed. She observed a moderate amount of blood on the floor. Resident #1's eyes were open, she was unresponsive, but breathing. RNS #2 asserted that she instructed RN #3 to call a STAT code and 911. RNS #2 stated that Resident #1 stopped breathing and she initiated CPR without checking Resident #1's DNR status. She stated that the Emergency Medical Technicians (EMTs) arrived on the unit and took over the resuscitation. One of the EMT staff lifted Resident #1's arm and she observed a purple hospital issued DNR ID band on Resident #1's arm. RNS #2 stated that she instructed the EMT staff to stop CPR, but they advised that once CPR is started, they cannot stop. In addition, she stated that when the RN #3 brought Resident #1's chart to the room, RNS #2 observed the DNR information in the hospital discharge summary. RNS #2 stated that she did not have prior knowledge of Resident #1's DNR status. RNS #2 stated that on [DATE], RNS #1 did not endorse to her that Resident #1 was a DNR. RNS #2 verbalized that she reviewed and reconciled the medication orders in computer, but that she did not see an order for [REDACTED].>RNS #1, who worked on [DATE] on the 7:00 AM to 7:00 PM shift, was interviewed via telephone on [DATE] at 3:00 PM. RNS #1 stated that she assisted the charge nurse, RN #1, with admitting Resident #1 to the facility. RNS #1 stated that she observed Resident #1 with a hospital purple ID band that had DNR written on the ID band. RNS #1 stated that RN #1 called the doctor and that the RN/Charge Nurse is responsible for putting the doctor's order and DNR in the EMR (electronic medical record). In addition, RNS #1 stated that the RN/Charge Nurse was also responsible for applying the facility's ID band with the appropriate charm to the resident's arm. She further stated that RNS #2 should have completed the admission process as per protocol. RN #1, who admitted Resident #1 on the ,[DATE] shift on [DATE], was interviewed on [DATE] at 1:50 PM. She stated that, during body assessment of Resident #1's right arm, she observed a hospital purple ID Band with the letters DNR. She also stated that she reviewed hospital discharge medication instructions and observed the DNR status for the resident. RN #1 affirmed that she called the doctor who gave a telephone order to continue the hospital discharge medications and DNR order. She further stated that she informed RNS #1 of the doctor's telephone order to continue the hospital discharge orders. RN #1 responded to questions regarding the doctor's order and procedure for new admissions. She stated that she did not enter the doctor's orders in the computer and that she did not apply the facility identification bands on Resident #1's arm. The Director of Nursing Service (DNS) was interviewed via telephone on [DATE] at 2:30 PM. She stated that the admission nurse is responsible for informing the physician of the new admission, obtaining a doctor's order for DNR, and entering the orders in the EMR system. In addition, the admission nurse should apply the facility identifier with purple charm to identify the resident as having DNR status and place a purple identifier on the spine of the resident's chart. The DNS stated the hospital DNR identifier should be honored until the facility identifier is applied to the resident's wrist. She further stated that, when a resident stops breathing, the first responder is supposed to check the resident identifier, call for help and instruct someone to bring the resident's chart to the room. She affirmed that more than one verification of DNR status must be performed before CPR is initiated. 415.15(b)(2)(iii)

Based on observations and interviews, the facility did not ensure that food was served under sanitary conditions to prevent food-borne illness. Specifically, the cold food items such as sandwiches and milk were not served at or below 41 degrees Fahrenheit. This was evident during the Kitchen/Food Service Observation.(Kitchen and Units 2 and 5) The finding is: On 3/2/17 at 12:09 PM, temperatures of the following cold food items were observed in the kitchen as follows: Chicken salad sandwich- 55 degrees Fahrenheit and a tuna fish sandwich- 57 degrees Fahrenheit. On 3/2/17 at 12:42 PM, temperatures of the following cold food items were observed from the tray line on 4 East dining room. Tuna fish sandwich- 61 degrees Fahrenheit and an 8 ounce (oz.) container of whole milk- 48 degrees Fahrenheit. On 3/3/17 at 11:53 AM, temperatures of the following cold food item was observed in the kitchen. Tuna fish sandwich- 46 degrees Fahrenheit. On 3/3/17 at 12:46 PM, temperatures of the following cold food item was observed from the tray line on 3 West dining room. Bologna sandwich- 52 degrees Fahrenheit. On 3/2/17 at 12:48 PM, the Food Service Worker (FSW #1) on 4 East stated that he does not check the temperature of the cold food items when the trays are on the floors. The temperatures are checked in the kitchen before they are brought up to the floor. He further stated that the temperatures of the sandwiches and milk should be 40 degrees Fahrenheit or below. On 3/3/17 at 12:48 PM, the FSW #2 on 3 West stated that he does not check the temperature of the cold food items when the trays are on the floor. The temperatures are checked down in the kitchen before it comes up. He further stated the sandwiches should be 40 degrees Fahrenheit. On 3/2/17 at 12:12 PM and on 3/7/17 at 12:38 PM, the Food Service Director stated that he and the food service supervisor are responsible for checking the cold food temperatures. He further stated cold food items are placed in the freezer for 30 to 60 minutes, and are taken out 10 to 15 minutes before being taken up to the floors. The cold food temperatures are checked when ready for service. He stated cold food temperatures should read 41 degrees Fahrenheit or below. The cold food is then placed on the tray and in the truck ready for transport to the floor. The director further stated it was not their practice to check the cold food temperatures on the floors. 415.14(h)

Based on observations and interviews the facility did not ensure that refuse and garbage from kitchen was disposed of and transported to meet sanitary guidelines. This was observed in the kitchen and at the compactor area located outside the building. This resulted in no actual harm with potential for more than minimal harm. The findings are: On 11/3/14 at 8:30 AM and on 11/5/14 at 11:54 AM, during tours of the kitchen the following was observed: 1) There were boxes on the floor at the corner of the kitchen, near the entrance area, that were not placed in a container; 2) Three garbage cans in kitchen were not covered with a lid; On 11/3/14 at 9:00 AM , the Food Service Director ( FSD) was interviewed and stated that the garbage cans need to be covered in the kitchen. On 11/3/14 at 9:00 AM the garbage Compactor area was observed. The compactor door was half open and a garbage bag was visible protruding from it. The compactor was leaking a foul smelling whitish liquid from the side which was running onto the ground. On 11/3/14 at 9:20 AM the Director of Maintenance was interviewed and stated that the compactor door should be closed. The Compacter leak is a new leak. 415.14 (h)

Based on observations, and staff interview, the facility did not ensure that foods were stored under sanitary conditions and temperatures were maintained to prevent potential food borne illness and cross contamination. This was evident for food storage practices in the kitchen, pantry refrigerator and unit steam table conducted during the Kitchen Tour and on Unit 2 West. This resulted in no actual harm with potential for more than minimal harm. The findings are: On 11/3/14 at 7:45 AM, the 2 west unit pantry refrigerator, inside the dining room, was observed with the following undated and/or unlabeled foods: A pocket book, inside the refrigerator bin, contained a plastic container of meat and cabbage; a yellow plastic bag with aluminum foil- wrapped salmon burger with cheese; a half -filled plastic container with pasta and cheese; a plastic bag with multiple containers of salad, mayonnaise, potato salad, cucumber and beet salad and vegetable soup labeled Room 215 and dated 10/31/14. On 11/3/14 at 8:30 AM, a tour of the kitchen was conducted and the following observed: 1) 5 boxes of foods were stored in the freezer with less than 6 inches of space from the ceiling; 2) In the refrigerator, a carton, containing 70 individual, 4- ounce skim milk containers, with an expiration date of 11/1/14; 3) The dry store room floor was heavily soiled with dark patches along the floor. 4) In a second store room, where the emergency food supplies were stored, 5 gallon-sized bottles of water (64 in total), were covered with a whitish substance. There was also one dented can of diced beets. On 11/3/14 at 7:50 AM the RN (Registered Nurse) Manager for the 2 west unit was interviewed and stated, " Foods should to be labeled with the name and date and after 2 days the foods need to be discarded. The CNA assigned to the pantry refrigerator is responsible for checking the refrigerator daily and discarding outdated foods. The nurses are responsible for ensuring that this is done. The facility policy is to discard all foods over 48 hours, to prevent food spoilage On 11/3/14 at 9:00 AM , the Food Service Director ( FSD) was interviewed and stated that he was aware that all the water bottles were covered with dust and did not know if they were delivered with dust and the garbage cans need to be covered in the kitchen. In a second interview, on 11/5/14 at 12:10 PM the FSD stated that the floor was last cleaned last Friday, and there was no food delivery over the weekend. On 11/5/14 at 12:20 PM, an observation of the steam table food temperatures on 4 west was conducted: The oriental Chicken temperature was measured at 120 degrees F (Fahrenheit) / 130 degrees F, in different areas of the pan. The apple sauce stored on a tray was measured at 60 F and the skim milk was measured at 45 degrees F. On 11/5/14 at 12:30 PM the Food Service Director was interviewed and stated that he was not sure why the temperature of the pan of chicken was lower than the other foods. The apple sauce was prepared in the kitchen and transported to the units. The facility policy dated 5/2013 for " Food Temperatures Monitoring of Meal Service" items # 4 and 5 documents that if foods on the steam table are not at appropriate temperatures between 140F to 160F, notify the Supervisor and replace with hot foods. There was no mention of cold foods standards to be maintained for service. The facility policy dated 5/2013 for " Food Storage Procedures " by the Dietary department documents: " All food items are stored at least 6 inches off floor and 18 inches off ceiling. " The policy did not document the procedure for the handling and disposal of dented cans. The Facility policy dated 6/14 for " Food storage in Unit Refrigerators " documents that all residents foods will be inspected by nursing, labeled with room number, name and date, before placing in the refrigerator; Perishable foods will be discarded after 48 hours. 415.14 (h)

Based on record review and interview, the facility did not ensure that a resident received notice prior to a change in roommate. This was evident for 1 residents reviewed for Admission, Transfer and Discharge. (Resident #361). This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. The finding is: Resident #361 is a [AGE] year-old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 assessment dated [DATE] documented the resident had intact cognition. On 11/3/14 at 11:52 am, a resident interview was conducted. The resident was asked if she had a room or roommate change in the last nine months. The resident stated that a new room mate was moved into her room and added that " nobody said anything, she just came. " Review of the facility "Census List" documented that the resident received a new roommate on 2/11/14. There was no documented evidence in the medical record that the resident was informed prior to getting a new roommate. On 11/7/14 at 11:15 am the Social Worker was interviewed and stated that residents are notified that someone will come and then they are introduced. She further stated that sometimes she would document about the pending room mate and resident notification. On 11/7/14 at 11:20 am the Director of Social Work was interviewed and stated we notify the resident if there is a room change and document the change on a " room change note. " He further stated if it is new roommate they are introduced but this is not documented in the medical record. The facility "Welcome Booklet and Resident Information Guide" was reviewed and documents in the section under Room Assignments "it is noted that residents in a semi-private room who do not have a roommate will receive a new admission/roommate." 415.5(e) (2)

Based on observations, it was determined that the facility did not ensure that all toilet rooms used by residents were provided with functional nurses' call system. Reference is made to the centralized toilet room located between the physical therapy area and the resident dining room, toilet rooms off resident room #'s 323/322, 318/319 and 321, that lacked functional nurse's call system. This resulted in no actual harm with potential for greater than minimal harm that is not immediate jeopardy. The findings include: On November 18, 2013 at 10:00 AM to 2:00 PM, it was observed that although, the centralized toilet rooms located between the physical therapy area and dining room had the nurses' call system installed, the call system did not register at the nurses' station and at the resident toilet room door. Also, the nurse's call system installed in toilet room, off room #'s 323/22, 318/319 and 321 did not register at the residents' room door as designed when tested by the facility staff. On November 18, 2013 at approximately 11:30 AM, the facility's director of maintenance stated that the nurse's call system is being repaired in the noted areas and being inspected in other resident areas to ensure that the system is in functional order. 713-2.22 (g)(2)

Based on observations and staff interview, the facility did not ensure that food was served at the proper temperatures. This was evident for 1 out of 8 dining rooms. (Dining room on 4 West). This resulted in no actual harm with potential for more than minimal harm. The findings are: 1) On 9/20/2012 at 12:31 pm, a test tray was done with the Dietitian in the fourth floor (4West) dining room. The following temperatures were taken: Meatballs was 120 degrees; Soup (MInestrone) was 120 degrees; Spaghetti was 130 degrees; Green Beans was 130 degrees; Coffee was 130 degrees; Pineapple rings was 70 degrees; and Milk was 60 degrees. An interview was conducted with the Dietitian right after the test tray was completed. The dietitian stated the hot foods should be a minimal of 140 degrees, and the cold foods should be maximum of 41 degrees when served to the residents. 415.14(h)

Based on observation, and staff interview the facility did not ensure that drugs and biologicals were stored under proper temperature controls. As evidence by observation of a drug which required refrigeration after opening being stored in the medication cart. This was noted on 1 out of 5 units. (3rd Floor) This resulted in no harm with potential for more than minimal harm . The finding is: On 09/19/2012 at 4:45 PM during a medication pass observation on the third Floor (Resident #16), the RN ( registered Nurse ) took the Mucomyst treatment vials from the lower drawer and stated "I will administer it later. The vial's box was observed with a pharmacy alert " 3 cc via nebulizer every eight hours (refrigerate after opening and good for 96 hours )". The RN was asked where do they keep the vials of Mucomyst after opening and he stated, "They have always been in the medication cart drawer ". He was then given the box and the pharmacy alert. He read the alert and stated, "I did not know that ". On 9/19/12 the 7-3 RN charge nurse was interviewed and also stated that the vials were kept in the medication cart drawer. Review of the drug insert literature on dosage and administration documents the following: Acetylcysteine (generic name for Mucomyst) Solution 10% and 20% is available in glass vials containing 30 ml(milliliter). Storage of open vials -- this product does not contain an antimicrobial agent and care must be taken to minimize contamination of the sterile solution. If only a portion of the solution in a vial is used , store the remainder in the refrigerator and use for only within 96 hours . 415.18 (d)

Based on observation, record review and staff interview, the facility did not ensure that services provided to residents' are in accordance with each resident's written plan of care. As evidenced by: 1) A laboratory test was not performed as per the physician's orders [REDACTED]. This was evident for one of thirty residents. (Resident #13). This resulted in no harm with potential for more than minimal harm. The findings are: Resident #13 is an [AGE] year old male with [DIAGNOSES REDACTED]. 1. The Physician order [REDACTED]. On 9/19/12, during a review of the resident 's medical record the laboratory (lab) results were requested. The facility provided the Vanco trough and peak results; however, the results for the CBC with differential and the CMP were not available. On 9/19/12 the Registered Nurse Manager (RNM) was interviewed. He reviewed the lab book. He stated, "The request is not in the lab book" . He then stated that the nurse who picked up the physician's orders [REDACTED]. On 9/20/12, the RNM informed the surveyor that the laboratory test request sheet for the CBC with differential and CMP was found in the shredding bin at the nursing station. The RNM who picked up the physician orders [REDACTED]. The RNM stated that she did not know why the lab request sheet ended up in the shredder instead of the lab book. She said that after picking up the physician's orders [REDACTED]. There was no explanation provided as to why the lab work was not done. 2. Resident # 13 Comprehensive Care Plan (CCP) for Diabetes Problem dated 7/20/12 includes the following approaches: Foot care daily, podiatry consult monthly, & PRN. There was no documented evidence that the physician ordered podiatric consultations for this resident. As a result there were no evidence that Podiatry consults were provided monthly for the time period 7/20/12 through 9/20/12. The most recent podiatry consult report documented for this resident was dated January 2012. Resident' s feet were observed on 9/21/12 and his toe nails were trimmed. The skin was intact. On 9/21/12 at 5:00 PM, the physician was interviewed regarding the care plan and he did not provide a reason for not ordering podiatry care. He stated, "It depends on the resident' s needs, he usually orders podiatry consults approximately every three months or as needed" . 415.11(c)(3)(ii)