Every finding on record at Silvercrest

Based on observations, record reviews, and staff interviews conducted during an Abbreviated Survey (NY00371678), the facility failed to ensure that a resident's Advance Directives were followed. This was evident for one (1) out of five (5) residents (Resident #1) sampled. Specifically, Resident #1, who was ventilator dependent, had a Medical Order for Life Sustaining Treatment indicating Do Not Resuscitate. Resident #1 was found without a pulse on 02/08/2025 and staff performed Cardiopulmonary Resuscitation that resulted in the return of spontaneous circulation. The resident was transferred to the hospital and remains there at this time. Based on several staff interviews, the resident received cardiopulmonary resuscitation efforts until staff members learned the resident was a Do Not Resuscitate. The resident was assessed after efforts were stopped and was found to have a pulse. Emergency Medical Services had previously been called and they transported the resident to the hospital. This resulted in Immediate Jeopardy Past Noncompliance with actual harm to Resident #1 with the likelihood for serious injury, serious harm, serious impairment, or death to all residents with Advance Directives. The findings include: The facility's Code 99-Basic Life Support Policy dated 08/31/2020, documented that the facility will provide basic life support for individuals who develop a sudden change in medical condition. The procedure documented if an individual is suddenly found unresponsive, activate Code 99. Staff are to verify Do Not Resuscitate status by checking physician orders, bring medication cart/laptop to location, review Advance Directive order in the Electronic Medical Record, a second person verify order/status, document verification on the code 99/RRT sheet, and if patient/resident is Do Not Resuscitate, do not proceed: provide comfort measures in a dignified manner. Resident #1 was admitted to the facility with diagnoses including respiratory failure, ventilator dependence, and tracheostomy. The Minimum Data Set (an assessment tool) dated 02/06/2025 documented Resident #1 had severe cognitive impairment. An Advance Directive Care Plan dated 02/07/2025 identified Resident #1 as Do Not Resuscitate. An Accident/Incident Investigation report dated 02/08/2025 documented Resident #1's chart showed an order for Do Not Resuscitate and a plan of care for Do Not Resuscitate in place. On 02/08/2025, Respiratory Therapist #2 responded to the ventilator alarm and observed Resident #1 not responding at their baseline with vital signs present. Respiratory Therapist #2 attempted to stabilize the resident by clearing the airway through suctioning and Ambu-Bagging (provides respiratory support to patient). Resident #1 did not respond, and Respiratory Therapist #2 began chest compression to circulate the oxygenated blood to stabilize the resident which was not effective. Registered Nurse #1 was called and asked to call a code. Registered Nurse #1 responded, saw chest compressions being performed, and assisted. Additional staff responded and asked about advance directives, and it was noted that Resident #1 had a Do Not Resuscitate order in the chart. The investigation concluded that providing cardiopulmonary resuscitation was contrary to Resident #1's wishes and that this was human error isolated to two (2) contracted employees who provided chest compressions without first verifying the resident's code status as per policy. During an interview on 02/18/2025 at 11:05 AM, Respiratory Therapist #2 stated they were walking in the hallway when they observed a green light and heard Resident #1's ventilator alarm beeping. Respiratory Therapist #2 stated they went into Resident #1's room and observed Resident #1 unresponsive. Respiratory Therapist #2 stated Resident #1 was not their assignment; therefore, they instructed Respiratory Therapist #1 to check Resident #1. Respiratory Therapist #2 stated when Respiratory Therapist #1 checked Resident #1, the resident was unresponsive. Respiratory Therapist #2 stated Respiratory Therapist #1 called for Registered Nurse #1 to call Code 99 (a code when resident is unresponsive). Respiratory Therapist #2 stated they manually ventilated Resident #1 with an ambu-bag until Respiratory Therapist #3 took over. Respiratory Therapist #2 left Resident #1's room to check on another resident. Respiratory Therapist #2 stated when they came back to Resident #1's room, Resident #1 was on the ventilator and emergency services left with Resident #1 to the hospital. Respiratory Therapist #2 stated they do not recall who started the chest compressions. During an interview with Respiratory Therapist #1 on 02/18/2025 at 11:15 AM, Respiratory Therapist #1 stated at approximately 3:30 PM on 02/08/2025 they were alerted by Respiratory Therapist #2 that Resident #1 was unresponsive. Respiratory Therapist #1 stated they went to Resident #1's room and assessed Resident #1 for a pulse and there was no palpable pulse, and the resident was not breathing. Respiratory Therapist #1 stated they asked Registered Nurse #1 to call Code 99, chest compressions were initiated, and 911 was called. Respiratory Therapist #1 stated they did not initiate chest compressions; chest compressions were initiated by Registered Nurse #1. Respiratory Therapist #1 stated they do not know how many chest compressions were administered. Respiratory Therapist #1 stated Registered Nurse # 2 came to the room with an Automated External Defibrillator and placed the leads on Resident #1 to initiate shocks. During an interview on 02/18/2025 at 11:43 AM, Registered Nurse #1 stated at 3:38 PM on 02/08/2025, they were called to Resident #1's room by Respiratory Therapist #1. Registered Nurse #1 stated when they went to Resident #1's room they observed Respiratory Therapist #1 performing chest compressions and Respiratory Therapist # 2 providing rescue breaths via an Ambu-Bag to Resident #1. Registered Nurse #1 stated Respiratory Therapist #1 told them Resident #1 was unresponsive and to call code 99 and 911. Registered Nurse #1 stated they asked Security Guard #1 to call code 99, and they called 911 and then went back to Resident #1's room. Registered Nurse #1 stated that Registered Nurse #2 showed up with an Automated External Defibrator and applied it to Resident #1 and the Automated External Defibrator announced no shock advised, continue Cardiopulmonary Resuscitation. Registered Nurse #1 stated during chest compressions, Registered Nurse # 2 asked about Resident #1's code status and the Respiratory Therapists were not able to answer. Registered Nurse #1 stated they went back to the nurse's station and verified Resident #1's code status in the Electronic Medical Record, which identified Resident #1 as having an order for Do Not Resuscitate. Registered Nurse #1 stated that they went back to Resident #1's room and informed the staff to stop cardiopulmonary resuscitation. Registered Nurse #1 stated Resident #1's sibling was notified that Resident #1 was unresponsive and that they were sending the resident to the hospital. Registered Nurse #1 stated that when they returned to Resident #1's room, Resident #1 had a pulse, and the Emergency Medical Technicians arrived and took Resident #1 to the hospital. Registered Nurse #1 stated Code 99 was called at 3:38 PM, but they do not know what time Cardiopulmonary Resuscitation ended. Registered Nurse #1 stated the protocol is for two clinicians to verify the resident code status in the Electronic Medical Record before touching the Resident. During an interview on 02/20/2025 at 12:04 PM, Registered Nurse #2 stated they were assigned to respond to Code 99 on 02/08/2025 at 3:38 PM on Five North. Registered Nurse #2 stated they responded to the location with the emergency cart and an Automated External Defibrillator. Registered Nurse #2 stated Resident #1 had in place a pulse oximeter (a device that measures the saturation of oxygen carried in the red blood cells) and a blood pressure cuff, but there was no pulse or blood pressure reading. Registered Nurse #2 stated they applied the Automated External Defibrillator to Resident #1, and it did not advise to give a shock, so cardiopulmonary resuscitation continued. Registered Nurse #2 stated when they first arrived at Resident #1's room, they observed Respiratory Therapist #1 providing rescue breaths via an Ambu-Bag and Registered Nurse #1 performing chest compressions. Registered Nurse #2 stated Respiratory Therapist #2 was not in Resident #1's room when they arrived. Registered Nurse #2 stated they asked if anyone checked on the resident's code status and Registered Nurse #1 left the room to check the code status. Registered Nurse #2 stated Registered Nurse #1 returned to the room and informed them to stop cardiopulmonary resuscitation. Registered Nurse #2 stated Resident #1 was reassessed with a pulse and at the same time the emergency medical service team arrived on the unit. During an interview on 02/21/2025 at 1:30 PM, Respiratory Therapist #3 stated they responded to Code 99 and when they arrived at Resident #1's room, they asked Respiratory Therapist #2 if they needed help and Respiratory Therapist #2 handed them the Ambu-Bag stating they needed to care for another resident and then left the room. Respiratory Therapist #3 stated they provided rescue breaths via the Ambu-Bag to Resident #1 until the Fire Department arrived. Respiratory Therapist #3 stated they do not recall who was performing the chest compressions when they arrived in the room. During an interview on 02/18/2025 at 4:44 PM, the Assistant Director of Nursing stated the facility's protocol when a resident is found unresponsive is for staff to assess the resident, and two clinicians must check resident code status in the Electronic Medical Record before touching the resident. The Assistant Director of Nursing stated once the code status is verified, the staff can initiate chest compressions. The Assistant Director of Nursing stated in the case of Resident #1, who had a Do Not Resuscitate order, chest compressions should not have been done. The Assistant Director of Nursing stated that every shift has a Code 99/Rapid Response Team who responds to all emergencies. The Assistant Director of Nursing stated they were informed by the Director of Nursing on 02/10/2025 at approximately 12:00 PM that Resident #1's sibling notified them that staff performed chest compressions on Resident #1. The Assistant Director of Nursing stated Registered Nurse Supervisor #1 was responsible for reporting the incident to management on 02/08/2025. During an interview with the Assistant Administrator on 02/19/2025 at 10:16 AM, the Assistant Administrator stated the Director of Nursing notified them of the incident on 02/10/2025 at 2:30 PM. The Assistant Administrator stated Respiratory Therapist #1 initiated cardiopulmonary resuscitation after Resident #1 was observed unresponsive, and Registered Nurse #1 followed and assisted. The Assistant Administrator stated that the staff did not follow the facility's protocol to check Resident #1's code status before touching the resident. The Assistant Administrator stated Registered Nurse #1 and Respiratory Therapist #1 were removed from the schedule pending outcome of the investigation. The Assistant Administrator stated Registered Nurse Supervisor #1 should have called the Director of Nursing or Administrator on Saturday to inform them of the incident. During an interview with the Medical Director on 02/20/2025 at 11:51 AM, the Medical Director stated staff should not have performed chest compressions on Resident #1. The Medical Director stated Resident #1 had a Medical Order for Life-Sustaining Treatment that indicated Do Not Resuscitate that was signed by them (Medical Director) on 02/07/2025. The Medical Director stated the Administrator informed them of the incident on 02/10/2025. Based on the following corrective actions taken, there was sufficient evidence that the facility corrected the non-compliance and was in substantial compliance for this specific regulatory requirement prior to and during the time of this survey. A Plan of Correction is not required for this citation. The facility took immediate corrective actions and was found to be in substantial compliance on 02/14/2025, prior to Surveyors' onsite visit on 02/18/2025. Facility has a Rapid Response Team (Code 99) comprised of a Registered Nurse and a Respiratory Therapist for each shift. Rapid Response Team is identified on the Daily Staff Assignment Sheet (RN Responder - Code 99/Rapid Response Team). On 02/10/2025, Policy and Procedure on Emergency Response and Code 99/Rapid Response was reviewed; no revision was done to the policy. On 02/10/2025, facility re-in-serviced Registered Nurses, Licensed Practical Nurses, Respiratory Therapists, and Certified Nursing Assistants. In-services are ongoing. Staff who are not available will be in-serviced before going to the unit. Lesson Plan Topics: Emergency Response Code 99/RRT, Reporting all Incidents during an emergency, Verifying/Checking Advance Directives during an Emergency, and Responding to Code 99. On 02/10/2025 the facility conducted audits from 02/08/2025 - 02/09/2025 on all residents needing emergency care. On 02/10/2025, the facility conducted audits on residents with Do Not Resuscitate orders. On 02/10/2025, the facility reviewed the Physician's Orders for all residents with code status, Advance Directives/ Care plans. On 02/14/2025, the Quality Assurance Committee held a meeting where the incident was discussed. Attendees included the Administrator, Director of Nursing, Assistant Director of Nursing, and other departmental heads. The facility has 71 Registered Nurses, 30 Licensed Practical Nurses, 25 Respiratory Therapists, and 155 Certified Nursing Assistants. 57 out of 71 Registered Nurses 80.3% in-serviced. 23 out of 30 Licensed Practical Nurses 88.5% in-serviced. 22 out of 25 Respiratory Therapists 88% in-serviced. 59 out of 155 Certified Nursing Assistants 38% in-serviced. 10NYCRR415.3e(2)(iii)

Based on record review and interviews conducted during the Recertification Survey and Complaint Survey (NY00361139, NY00361002, NY00353498, NY00348185 and NY00340617) from 12/12/2024 to 12/19/2024, the facility did not ensure sufficient nursing staff were available to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, 1). par levels documented in the Facility Assessment did not reflect actual weekend staffing levels. 2). interviews with members of the Resident Council, reflected ongoing concern about staffing levels at the facility, 3). five of eleven complaints investigated during the survey involved staffing concerns, and 4). interviews with other residents and staff reflected stafffing concerns. This was evident during the Sufficient and Competent Nurse Staffing Task. The findings include but are not limited to: The facility policy and procedure titled Nursing Coverage Plan last revised on 05/03/2024 documented that the Staffing Plan for Nursing Services reflects specific service needs to meet resident care and organizational needs. Evaluation of floor/unit specific needs is an ongoing process and ensures that staffing skill mix reflects the resident care needs. The policy also documented that the purpose was to ensure that the staffing needs of the facility are met. 1. The Facility Assessment last updated on 09/02/2024 documented a facility capacity of 320 residents with a staffing plan for weekdays, weekends, and holidays and by shift distributed as follows: Daily Staffing: Monday to Friday 7 AM-3 PM Shift: 1 Registered Nurse Manager per floor. Unit 2 North- 2 Registered Nurses and 4 Certified Nursing Aides. Unit 2 South- 2 Licensed Practical Nurses and 4 Certified Nursing Aides. Unit 3 North -2 Licensed Practical Nurses, 4 Certified Nursing Aides. Unit 3 South -2 Licensed Practical Nurses, and 4 Certified Nursing Aides. Unit 4 North- 2 Licensed Practical Nurses and 4 Certified Nursing Aides. Unit 4 South -1 Registered Nurse, 2 Licensed Practical Nurses, and 4 Certified Nursing Aides Unit 5 North-4 Registered Nurses, 5 Certified Nursing Aides. Unit 5 South-4 Registered Nurses, 5 Certified Nursing Aides. Monday to Friday 3 PM-11 PM Shift: Unit 1 Registered Nurse Supervisor for the entire facility Unit 2 North- 2 Registered Nurses and 4 Certified Nursing Aides. Unit 2 South- 2 Licensed Practical Nurses and 4 Certified Nursing Aides. Unit 3 North -2 Licensed Practical Nurses, and 4 Certified Nursing Aides. Unit 3 South -2 Licensed Practical Nurses, and 4 Certified Nursing Aides. Unit 4 North- 1 Registered Nurse and 1 Licensed Practical Nurse, and 4 Certified Nursing Aides. Unit 4 South- 1 Registered Nurse, 2 Licensed Practical Nurses and 4 Certified Nursing Aides. Unit 5 North-4 Registered Nurses, 5 Certified Nursing Aides. Unit 5 South-4 Registered Nurses, 5 Certified Nursing Aides. Monday to Friday 11 PM-7 AM Shift: 1 Registered Nurse Supervisor for the entire facility Unit 2 North- 2 Registered Nurses, and 2 Certified Nursing Aides. Unit 2 South- 1 Licensed Practical Nurse and 3 Certified Nursing Aides. Unit 3 North -1 Licensed Practical Nurse, and 3 Certified Nursing Aides. Unit 3 South -1 Licensed Practical Nurses, and 3 Certified Nursing Aides. Unit 4 North- 1 Registered Nurse and 1 Licensed Practical Nurse, and 3 Certified Nursing Aides. Unit 4 South- 1 Registered Nurse,2 Licensed Practical Nurses and 4 Certified Nursing Aides. Unit 5 North-4 Registered Nurses, 4 Certified Nursing Aides. Unit 5 South-4 Registered Nurses, 4 Certified Nursing Aides. The Facility Assessment also outlined coverage for Weekends and Holidays, which did not specify which shift the staffing pattern was for, as follows: Unit 2 North- 2 Registered Nurses, and 2 Certified Nursing Aides. Unit 2 South- 1 Licensed Practical Nurse and 4 Certified Nursing Aides. Unit 3 North -1 Licensed Practical Nurse, and 3 Certified Nursing Aides. Unit 3 South -1 Licensed Practical Nurses, and 4 Certified Nursing Aides. Unit 4 North- 2 Licensed Practical Nurses, and 3 Certified Nursing Aides. Unit 4 South- 1 Registered Nurse, 2 Licensed Practical Nurses and 4 Certified Nursing Aides. Unit 5 North-4 Registered Nurses, 5 Certified Nursing Aides. Unit 5 South-4 Registered Nurses, 5 Certified Nursing Aides. An asterisk indicated that there would be 2 Registered Nurse Managers on the day shift, and 1 Registered Nurse Manager on the evening and night shift. Review of the weekend staffing for October 2024 reflected the following: On 10/05/2024 on the 3 PM to 11 PM shift there was a shortage of 1 Certified Nursing Assistant on Unit 4S. On 10/05/2024 on the 11 PM to 7 AM shift there was a shortage of 1 Certified Nursing Assistant on Unit 2S, 3S, 4S, 5N and 5S, 1 Licensed Practical Nurse on Unit 4N and 4S, and 1 Registered Nurse on Unit 5S. Total shortage of staff was 6 Certified Nursing Assistants, 2 Licensed Practical Nurses, and 1 Registered Nurse in a 24-hour period with no replacement. On 10/06/2024 on the 7 AM to 3 PM shift there was a shortage of 1 Certified Nursing Assistant on Unit 5N and 5S. On 10/06/2024 on the 3 PM to 11 PM shift there was a shortage of 1 Certified Nursing Assistant on Unit 5N, 5S, 1 Licensed Practical Nurse on Unit 4N and 1 Registered Nurse on unit 5S. On 10/06/2024 on the 11 PM to 7 AM shift there was a shortage of 1 Certified Nursing Assistant on Unit 3S, 4S, and 5S, and 1 Registered Nurse on Unit 5S. Total shortage of staff was 7 Certified Nursing Assistants, 1 Licensed Practical Nurse, and 2 Registered Nurses in a 24-hour period with no replacement. On 10/12/2024 on the 7 AM to 3 PM shift there was a shortage of 1 Certified Nursing Assistant and 1 Registered Nurse on Unit 5S. On 10/12/2024 on the 3 PM to 11 PM shift there was a shortage of 1 Certified Nursing Assistant on Unit 2N, 5N, 5S, 1 Licensed Practical Nurse on Unit 2S and 3N, and 1 Registered Nurse on Unit 3S and 5S. Total shortage of staff was 4 Certified Nursing Assistants, 2 Licensed Practical Nurses, and 3 Registered Nurses in a 24-hour period with no replacement. On 10/13/2024 on the 7 AM to 3 PM shift there was a shortage of 1 Licensed Practical Nurse on Unit 4S and 1 Registered Nurse on Unit 5N. On 10/13/2024 on the 3 PM to 11 PM shift there was a shortage of 1 Certified Nursing Assistant on Unit 5N and 5S. Total shortage of staff was 2 Certified Nursing Assistants, 1 Licensed Practical Nurse, and 1 Registered Nurse in a 24-hour period with no replacement. On 10/19/2024 on the 7 AM to 3 PM shift there was a shortage of 1 Certified Nursing Assistant on Unit 5N and 5S. On 10/19/2024 on the 3 PM to 11 PM shift there was a shortage of 1 Certified Nursing Assistant on Unit 5S, and 1 Registered Nurse on Unit 5N and 5S. On 10/19/2024 on the 11 PM to 7AM shift there was a shortage of 1 Certified Nursing Assistant on Unit 4S, 5N, 5S, and 1 Registered Nurse on 5S. Total shortage of staff was 6 Certified Nursing Assistants and 3 Registered Nurses in a 24-hour period with no replacement. On 10/20/2024 on the 7 AM to 3 PM shift there was a shortage of 1 Licensed Practical Nurse on Unit 4N. On 10/20/2024 on the 3 PM to 11 PM shift there was a shortage of 1 Licensed Practical Nurse on Unit 4N. On 10/20/2024 on the 11 PM to 7 AM shift there was a shortage of 1 Certified Nursing Assistant on Unit 5N and 5S, and 1 Registered Nurse on 5S. Total shortage of staff was 2 Certified Nursing Assistants, 2 Licensed Practical Nurses, and 1 Registered Nurse in a 24-hour period with no replacement. On 10/26/2024 on the 3 PM to 11 PM shift there was a shortage of 1 Certified Nursing Assistant on Unit 5S, 1 Licensed Practical Nurse on Unit 4N and 1 Registered Nurse on Unit 5N and 5S. On 10/27/2024 on the 7 AM to 3 PM shift there was a shortage of 1 Certified Nursing Assistant on Unit 5S, and 1 Licensed Practical Nurse on Unit 4N and 4S. On 10/27/2024 on the 3 PM to 11 PM shift there was a shortage of 1 Licensed Practical Nurse on Unit 4N. On 10/27/2024 on the 11 PM to 7 AM shift there was a shortage of 1 Certified Nursing Assistant on Unit 4S, 5N and 5S, 1 Licensed Practical Nurse on Unit 4N and 1 Registered Nurse on Unit 5S. Total shortage of staff was 4 Certified Nursing Assistants, 4 Licensed Practical Nurses, and 1 Registered Nurse in a 24-hour period with no replacement. 51390 2. During the Resident Council meeting conducted on 12/16/2024 from 11:00 AM to 11:50 AM, 9 of 10 residents reported concerns with staffing. On 12/16/24 at 11:09 AM, Resident #160 stated that they were told there would be 4 Certified Nursing Assistants working on their unit and many times there are less than that. On 12/16/24 at 11:11 AM, Resident #184 stated that when it is short on weekends and holidays they are not able to get out of bed and this happens regularly. Resident #184 also stated that they often have to miss showers on both scheduled days because there is not enough staff. On 12/16/24 at 11:13 AM, Resident #114 stated that they often miss showers missed showers on their scheduled days. Resident #114 also stated that they might start the day with 4 Certified Nursing Assistants and then staff gets pulled to go to another floor or to escort a resident on an appointment. On 12/16/24 at 11:15 AM, Resident #6 stated that the facility only schedules 4 Certified Nursing Assistants most times, so if there are callouts there is shortage. Resident #6 also stated that when the facility receives sick calls from staff, there is a lot of scrambling and asking for staff to stay over which leads to staff being burnt out. 37787 3. Resident #12 (NY00340617) was admitted to the facility with diagnoses that include Quadriplegia, Muscle Spasm, Hereditary and Idiopathic Neuropathy. The Minimum Data Set assessment dated [DATE] revealed that the resident was cognitively intact. During an interview on 12/16/2024 at 3:43 PM, Resident #12 stated that there used to be 4-5 Certified Nursing Assistants on the unit and now, most of the time, there are only 3 Certified Nursing Assistants. Resident #12 also stated that the 3 nursing assistants have to take care of the whole unit including giving showers, getting residents ready for appointments, and helping residents out of bed after the morning care ended. Resident #12 further stated that because of the low staffing situation, residents cannot get out of bed on time, and it is impossible to have only 3 Certified Nursing Assistants working on the floor and get the work done properly. During an interview on 12/17/2024 at 4:25 PM, Certified Nursing Assistant #14 stated that sometimes the nurse has to come to help out with some residents when their work permits. On 12/18/2024 at 1:00 PM, Certified Nursing Assistant #3 was interviewed and stated that the floor used to have 5 Certified Nursing Assistants, and the facility has not been able to have 5 Certified Nursing Assistants working on the floor for months. Certified Nursing Assistant #3 also stated that it is very hard to work short with 3 to 4 staff as each nursing assistant gets 12 to 14 residents. Certified Nursing Assistant #3 further stated that even when staff is short, they still have to do everything for the residents. Some of the residents are mad, they want to get up early, some of them have appointment, some of them have therapy and it is impossible to do everything and many residents are not happy. On12/18/2024 at 5:15 PM, the Representative for Resident #182 (NY00361139) was interviewed and stated that the facility needs more aides as all residents do not have the same need. Resident #182's Representative also stated that the aides are exhausted, and residents are not getting their needs met. Resident #182's Representative further stated that Resident #182 needs to ambulate on the unit, but the aides do not have the time to ambulate Resident #182 because they are always short of staff. On 12/19/2024 at 11:41 AM, Certified Nursing Assistant #13 was interviewed and stated that not too long ago, in the morning shift on a Sunday, with a census of 40 residents, there were only 2 Certified Nursing Assistants on the unit. Certified Nursing Assistant #13 also stated that a night shift Certified Nursing Assistant did stay over until around 12 noon to help out. Certified Nursing Assistant #13 stated they saw their Union Representative to complain about feeling ill and not being compensated for their missing lunch break on that day. On 12/17/2024 at 1:02 PM, during an interview Registered Nurse #3 stated that an increase in staffing in the part of the Certified Nursing Assistants would be appreciated. Intake for NY00361002 was dated 11/19/2024 and stated that there were staffing issues on the night shift. Intake for NY00340617 was dated 07/15/2024 and stated that there was not enough staff as staff had left employment at the facility and had not been replaced. 33315 On 12/12/24 at 12:53 PM, an interview was conducted with Resident #79 (NY00353498) who stated that the facility is understaffed especially in the evening and mostly on weekends. Resident #79 also stated that sometimes they had not been toileted, and sometimes have to wait until the next day to get showers because there is no one to assist them. Resident #79 further stated that often no one is available to help them get toiletries or what they need to shower, and this has been an ongoing problem and they have complained to the Administrator and the nursing office, but nothing has been done about it. 4. On 12/13/24 at 11:55 AM, an interview was conducted with Resident #92 who stated that staffing is a big concern to them because often times they activate the call bell, and no one shows up. Resident #92 further stated that they could not recall the specific date but recalled that it was on a weekend that they activated the call bell around 11AM and a Certified Nursing Assistant did not assist them until 2 PM. On 12/17/24 at 12:07 PM, an interview was conducted with Certified Nursing Assistant #3 who stated there were times when there were only 2 or 3 Certified Nursing Assistants working on the unit, instead of 4 as scheduled. Certified Nursing Assistant #3 also stated they try to manage but there will definitely be a delay in caring for residents when there are not enough aides. On 12/17/24 at 09:54 AM, an interview was conducted with Ombudsman who stated they have attended Resident Council meetings several times and the Administrator has also attended at times. The Ombudsman also stated that the majority of residents who attended the meeting complained about low staff that is affecting care especially on the 11 PM to 7 AM shifts and on weekends. Ombudsman further stated that residents informed them that the facility is currently undergoing some transition in ownership which they think is affecting the care they receive. 45351 On 12/19/2024 at 09:59 AM, Certified Nursing Assistant #9 stated they work short especially on the weekends. Certified Nursing Assistant #9 also stated that usually they have two showers to be given on their daily task and are assigned multiple residents requiring two staff or more for their care, so showers are not always feasible when they are working short. On 12/19/2024 at 10:29 AM, Certified Nursing Assistant #10 stated that there are 4 nursing assistants scheduled the day shift and it appears that there is difficulty in covering the missing shift when staff calls out especially the weekends. Certified Nursing Assistant #10 also stated that they are short staffed almost every weekend due to the facility not being able to find coverage to replace staff. On 12/18/2024 at 05:11 PM, the Staffing Coordinator was interviewed and stated that the facility is in contract with three to four nursing agencies, that provide them with Registered Nurses, Licensed Practical Nurses, Certified Nursing Aides, and escorts as needed. The Staffing Coordinator also stated that they have a roster of per-diem staff and part time staff, and they also use overtime with their regular staff. The Staffing Coordinator further stated that a request is submitted to the agencies two weeks, the per diem provides the facility with their availability and the regular staff would call the Nursing office to have their names listed and are available. The Staffing Coordinator stated that vacations are also covered, however, when staff call out or cancel they do their best to find replacement and most of the time we are able to do so. In addition, on weekends or holidays, the Registered Nursing Supervisors are provided the list of names of staff available that they can call in. During an interview on 12/19/2024 at 12:33 PM, the Administrator stated that the current staffing level is sufficient, and staff are scheduled in accordance with the par level. The Administrator also stated that they have been assigning extra nursing staff when allowed to cover any call outs. The facility has sufficient staff to meet the daily par level but there are incidents of staff calling out and they are not able to find replacement staff. The Administrator further stated that the facility has been offering overtime pay for extra shifts and ensure that there are additional staff to call in cases where there are callouts during the weekends. 10 NYCRR 415.13(a)(1)(i-iii)

Based on observation, record review and interviews conducted during the recertification survey from 12/12/2024 to 12/19/2024, the facility did not ensure that an appropriate surety bond was purchased, or otherwise assurance satisfactory to the Secretary was provided, to assure the security of all personal funds of residents deposited with the facility. Specifically, there is no surety bond was provided to assure the residents fund against loss. This was evident for 138 residents who maintained personal funds accounts with the facility. The findings are: The facility policy titled Resident Personal Accounts did not contain any reference to the availability of a surety bond. The document titled Trial Balance Silvercrest documented balances as of 12/18/24 totaling #301,736.85 (three hundred and one thousand, seven hundred and thirty-six dollars, and eighty-five cents). On 12/19/2024 at 10:30 AM, the Administrator presented a document titled Standard Commercial Crime Binder. The policy listed the insured as New York Presbyterian Foundation, Inc. and the policy period was listed as 06/30/2024-06/30/2025 and outlined limits of insurance which ranged from $10,000 to $250,00 and deductibles ranging from $50,000 to $375,000. There was no documented evidence provided that the facility had purchased a surety bond to assure the security of personal funds of residents deposited with the facility. On 12/19/2024 at 12:15 PM, the Administrator was interviewed and stated that they had been informed by the Risk Management of New York Presbyterian that since Silvercrest was part of New York Presbyterian, the resident funds were insured under a Master Crime Policy and that the coverage afforded through a surety bond was covered through this insurance. The Administrator also stated that they were informed that the insurance policy provides greater coverage and greater limits than a traditional surety bond, as required by the Department of Health. 10 NYCRR 415.26(h)(5)(v)

Based on observation, record review and interviews conducted during the Recertification and Complaint survey (NY00340617) survey from 12/12/2024 to 12/19/2024, the facility did not ensure that adequate clean linen was provided to facilitate timely care of residents. Specifically, there were multiple complaints of insufficient linen from residents and staff. The findings are: The policy titled Laundry and Linen Management dated 10/13/1998 and revised 09/25/2024 stated that it is the policy of the facility to maintain an adequate supply of clean linen through safe and sanitary laundry procedures. The policy also stated that the Laundry Department will supply a sufficient quantity of linen for proper resident care and comfort. The undated document titled NEW PAR LEVEL documented towel distribution as follows: 2 North 7 AM-3 PM =40, 3 PM -11 PM=30, 11 PM to 7 AM=20 2 South 7 AM-3 PM =40, 3 PM -11 PM=30, 11 PM to 7 AM=25 3 North 7 AM-3 PM =40, 3 PM -11 PM=40, 11 PM to 7 AM=30 3 South 7 AM-3 PM =40, 3 PM -11 PM=40, 11 PM to 7 AM=30 4 North 7 AM-3 PM =40, 3 PM -11 PM=40, 11 PM to 7 AM=26 4 South 7 AM-3 PM =40, 3 PM -11 PM=40, 11 PM to 7 AM=26 5 North 7 AM-3 PM =60, 3 PM -11 PM=60, 11 PM to 7 AM=50 5 South 7 AM-3 PM =60, 3 PM -11 PM=60, 11 PM to 7 AM=50 During the Resident Council meeting held on 12/16/24 at 11:48 AM, 4 of 10 residents complained of insufficient linen which has been an ongoing issue for several months, and stated that they have been told by staff, particularly on weekends, that there is not enough linen, and linen is distributed on a first come, first served basis. On 12/18/24 at 10:51 AM, an interview was conducted with Certified Nursing Assistant #15 who stated that towels are always short, and additional linen has to be requested once or twice a week. On 12/18/24 at 11:03 AM, an interview was conducted with Certified Nursing Assistant #17 who stated that they are mostly short of towels on the unit and sometimes they run out before they can give care to all the residents on their assignment. Certified Nursing Assistant #17 also stated that daily on their assignment there are at least 2 residents out of 10 scheduled to have a shower and the availability of towels is an issue. When giving showers, they may use 2-3 towels per resident and 1 towel for a bed bath so they would need a minimum of 12 to 14 towels on their shifts. Certified Nursing Assistant #17 further stated that sometimes when they do not want to wait for towels to be brought up, they will use the nightgown that they take off to dry the resident off. On 12/18/24 at 11:37 AM, an interview was conducted with Certified Nursing Assistant #16 who stated that sometimes linen is not available on the unit to enable them to get residents out of bed by 10:30-11:30 every day. Certified Nursing Assistant #16 also stated that many times the linen is not enough, and they have to wait until it comes up from downstairs. On 12/19/24 at 10:25 AM, an interview was conducted with Certified Nursing Assistant #18 who stated that sometimes they have to wait to provide care because there is not enough linen. Certified Nursing Assistant #18 also stated that on their daily assignment they have 2-3 residents that need a shower, and they would use one towel for a bed bath, sometimes two for the shower, and some residents might want three towels if they wash their hair. Certified Nursing Assistant #18 further stated that they are frequently short of towels on the weekend, or the towels are delivered to the unit late so they would try to use washcloths to dry the residents until the towels are delivered to the floor. Certified Nursing Assistant #18 stated that at times they have to ask their peers to share the linen they have so as not to delay caring for the residents and completing their assignment on time. 37787 Resident #12 (NY00340617) was admitted to the facility with diagnoses that include Quadriplegia, Muscle Spasm, Hereditary and Idiopathic neuropathy. The Minimum Data Set assessment dated [DATE] revealed that the resident was cognitively intact. During an interview on 12/16/2024 at 4:17 PM, Resident #12 stated that the facility is always short of clean linen, including sheets, bed savers and towels. Resident #12 further stated that bed savers are being soiled more easily, so more linens are needed to change the beds. Resident #12 further stated that it is impossible for the staff to work without having enough linen. On 12/17/2024 at 1:16 PM, Registered Nurse #3 was interviewed and stated that beds are changed twice a week and as needed. Registered Nurse #3 also stated that when there is a problem with linen on the unit, they call the Director of Housekeeping to ask for more linen. Registered Nurse #3 further stated that sometimes, extra linen might not be available right away, and housekeeping would then call when it is ready. On 12/18/2024 at 12:47 PM, Certified Nursing Assistant #3 was interviewed and stated that not having enough supplies is something that happens often. Certified Nursing Assistant #3 also stated that most of the time, for 10 residents, they receive 8 towels, sometimes only 6 so they have to use clothing to dry off the residents. Certified Nursing Assistant #3 further stated that if there are not enough pads to put on the bed, the evening shift will continue, if linen becomes available on the evening shift. On 12/19/24 at 11:53 AM, Certified Nursing Assistant #13 was interviewed and stated that the facility is always short of linen on the morning shift. Certified Nursing Assistant #13 also stated that sometimes, they might find some sheets, towels, or bed savers left over from the night shift so use that to start. On 12/19/24 at 01:10 PM, an interview was conducted with the Director of Environmental Services who stated that par levels are determined with the interdisciplinary team, and they deliver according to what the need is. The Director of Environmental Services also stated that they believe the current par level list was developed as of August 2024. The Director of Environmental Services further stated that currently linen is being done in-house, and prior to August an outside company used to deliver the linen. The Director of Environmental Services stated that linens are packaged and delivered to the units 10 minutes prior to the start of shift, and they were not aware that there was an issue with late linen delivery, or of short linen supply. On 12/19/24 at 01:51 PM, an interview was conducted with the Director of Nursing who stated that they attended the Resident Council meetings when residents voiced a concern that there was not enough linen. The Director of Nursing also stated that they feel that since laundry is now being done in house, there is more control and no longer an issue with the linen supply. The Director of Nursing further stated that par levels are determined based on the acuity and the needs of the residents and were adjusted within the last month or so. the Director of Nursing stated that they have noticed that staff hoard towels, so they did environmental rounds and adjusted the par levels so try to stop that practice. On 12/19/24 at 02:30 PM an interview was conducted with the Administrator who stated that par levels were established when they started doing laundry in house. We monitored how many towels were being returned and we adjusted at one point, and we thought the issue was resolved. The Administrator also stated they did sporadic audits to determine what was being returned and we found that linen was being returned unused. The Administrator further stated that the audit did not include whether additional linen was sent to the unit and remained at the end of the shift. 10 NYCRR 415.5(h)(3)

Based on observation, record review and interviews conducted during the recertification survey from 12/12/2024 to 12/19/2024, the facility did not ensure residents' rights to send and receive mail. Specifically, residents did not have mail delivered to them in the facility on the weekend. The findings are: The facility policy titled Mail Delivery dated 01/17/2001, last revised 10/25/2023 documented that the mail delivered on Saturdays will be sorted by the Recreation department and the mail will be delivered to the resident. On 12/16/24 at 11:44 AM, during Resident Council meeting, all 10 residents present stated that mail is not delivered in the facility on Saturdays. Resident #106 stated that the mail has to be sorted by Administration, and then Recreation gets it, and so since no one from Administration works on Saturday, there is no mail delivery on Saturdays. On 12/19/24 at 09:36 AM, an interview was conducted with the Director of Therapeutic Recreation who stated that their work hours are Monday to Friday from 9:00AM-5:00PM. The Director of Therapeutic Recreation also stated that when the mail and packages arrive, they are delivered to the Security desk. Two persons from Administration or Finance sort the mail, and once the mail is sorted they receive an alert from Security and then deliver the mail to the residents. The Director of Therapeutic Recreation further stated that on weekends nobody works in the Administrative office so that delays mail delivery, but first thing on Monday morning they try to get to it promptly because sometimes there is a lot of mail. The Director of Therapeutic Recreation stated that Recreation staff will deliver packages on weekends but not mail. On 12/19/24 at 10:05 AM, an interview was conducted with the Security Officer who stated that mail and packages are sometimes delivered on Saturday and are placed on a table in the Security area. The Security Officer also stated that the mail stays there until it is picked up by someone from Administration on Monday morning, sorted and then it is picked up by Recreation staff and delivered to the residents. The Security Officer further stated that if packages are delivered on the weekend, they contact Recreation staff who will then deliver the packages to the residents on Saturday and Sunday. On 12/19/24 at 01:43 PM, the Medical Services Coordinator was interviewed and stated that they work at the facility Monday to Thursday from 8:30 AM to 4:30 PM. The Medical Services Coordinator also stated that they sort the incoming mail for residents and facility staff which they divide into separate bins and then resident's mail to Recreation staff. The Medical Services Coordinator further stated that they were not aware of the procedure on weekends regarding mail delivery and would need to speak with the Recreation department about what happens to mail on Saturday. The Medical Services Coordinator stated that on they go with their colleague to the Security desk, collect the mail, separate it, return resident's mail to security and the Recreation will pick it up from there. On 12/19/24 at 02:17 PM, an interview was conducted with the Health Information Supervisor who stated that they work at the facility Monday to Friday from 8AM to 4PM. The Health Information Supervisor also stated that Security will call Administration when the mail arrives, and they would go there and sort the mail, place it in the resident bin and the call Recreation to collect it. The Health Information Supervisor further stated that on Saturday someone from Recreation handles resident's mail as they are responsible to handle weekend mail. The Health Information Supervisor stated that they and the Medical Services Coordinator are only responsible for week day mail. On 12/19/24 at 02:27 PM, an interview was conducted with the Administrator who stated that on weekdays the Health Information Supervisor and the Medical Services Coordinator sort all the mail, and once completed contact the Recreation who then delivers it to the residents. The Administrator also stated that on weekends Recreation deliver and will remove only residents mail out of the bin at Security and deliver it to the residents. The Administrator further stated that they were not aware that this process was not being followed. 10 NYCRR 415.3(e)(2)(i)

Based on observations and interviews conducted during the Recertification Survey from 12/12/2024 to 12/19/204, the facility did not ensure that the Nurse Staffing Information was posted appropriately. Specifically, the posting of daily nurse staffing information was not posted in a prominent area which was readily accessible to residents, families, and visitors. The finding is: The facility did not provide a policy and procedure regarding posting of the Daily Nurse Staffing Information . During observations conducted on 12/13/2024, 12/16/2024 and 12/17/2024, the State Surveyor located the postings of the Daily Nurse staffing levels for each shift at the side of the vestibule in the Information Lobby and was not readily visible or accessible to visitors, families, or residents. Furthermore, there were no signage posted on any of the 8 resident units describing where this information could be located. On 12/18/24 at 05:11 PM, the Staffing Coordinator was interviewed and stated that the daily Nurse Staffing was posted in the vestibule near the Survey Report and the Residents' Right Manual. The Staffing Coordinator also stated that they are responsible for placing the posting on weekdays and the Registered Nurse Supervisor is responsible for the postings on weekends. On 12/18/2024, the Associate Director of Nursing was interviewed and stated that in the past the posting was placed right in front of the Receptionist desk, and they would correct this issue. 10 NYCRR 415.13

Based on observation, record review, and interviews conducted during the Recertification and Abbreviated (NY00350202) survey from 12/12/2024 to 12/19/2024, the facility did not ensure a resident was free from physical abuse. This was evident for 1 (Resident #173) of 3 residents reviewed for Abuse out of 38 total sampled residents. Specifically, Resident #173 reported that on 08/03/2024, at approximately 04:00 AM, Certified Nurse Aide #1 was rough with them while providing care, and Certified Nurse Aide #1 did not stop their actions, continued with the task while Resident #173 continued to express their discomfort, and then Certified Nurse Aide #1 yelled at Resident #173. The finding is: The facility policy titled Abuse Prevention/Prohibition dated 08/16/22 stated that all residents will be screened for potential abuse, an investigation will be conducted, the Administrator is responsible for completing the investigation report. The policy also stated that any person having reasonable cause to believe that an older adult is in need of protective services may report such information to the local provider, and all interventions will be documented in the resident's medical record. Resident #173 had diagnoses which include Quadriplegia, Chronic Respiratory Failure, Depression, and Tracheostomy Dependency. The Annual Minimum Data Set assessment dated [DATE] documented that Resident #173 was cognitively intact and was dependent and required 2 person assist when performing Activities of Daily Living. The Occurrence Report dated 08/3/2024 documented that, on 08/03/24 around 10:00 AM, the resident's husband, who was visiting stated that the Certified Nurse Aide treated the resident roughly and yelled at the resident while they were providing care. The Social Worker and the Nurse Manager met with the resident and the resident communicated the same complaint. Resident was assessed and there were no physical signs of injury. Emotional support was provided, and the resident was assured that the Certified Nurse Aide #1 will no longer provide care to the resident. Certified Nurse Aide #1 was immediately removed from assignments and the New York State Department of Health was notified. The facility concluded that the complaint was thoroughly investigated and concluded that resident's plans of care were to be two person assist and needed two person when staff are providing care, but the Certified Nurse Aide #1 did not follow the plan of care for the resident. The report also documented that there was probable evidence of abuse, neglect or mistreatment and the Department of Health was notified. The Social Services note dated 08/3/2024 documented that they were notified by another social worker that the resident complained that during night care, the Certified Nurse Aide #1 was rough and yelled at her. The Social Services note also documented that they interviewed the resident via computer communication device, and the resident re-stated that during care the Certified Nurse Aide #1 was rough while turning her and yelled at her to not stiffen her legs up. The Social Worker evaluated the resident with the resident's spouse at the bedside along with the primary nurse. The entire body was examined, no visible sign of injury was noted (redness, swelling, bruising or abrasions). The resident denied pain or discomfort. The resident was crying and said they were upset about the incident. Emotional support and comfort provided to the resident and spouse. Resident also re-assured that Certified Nurse Aide #1 will no longer be assigned to their care, resident became calm and was thankful. On 12/13/24 at 04:28 PM, Resident #173 was observed in their room, alert and awake. Resident #173 was not able to verbalize and communicated via a computer communication device. During interview Resident #173 stated that at around 4:00 AM on that day, Certified Nurse Aide #1 appeared angry during care and seemed angry with Resident #173 and began to turn them roughly and slammed their right leg up and down. Resident #173 also stated that Certified Nurse Aide #1 was rough as they changed their incontinence brief and despite them trying to communicate that they were very uncomfortable during care, the Certified Nurse Aide #1 did not stop what they were doing. Resident #173 further stated that they felt so terrible, and they began to cry and the following morning they told their spouse what had occurred. Resident #173 stated that they had been cared for by Certified Nurse #1 in the past, and while they did not want Certified Nurse Aide #1 to get into any trouble, they spoke up because they did not want this situation to happen to someone else who may not be able to speak up for themselves. The Resident Certified Nurse Aide Documentation History Detail dated July 2024 to August 2024 documented Resident #173 received dependent care with bathing, bed mobility, dressing, personal hygiene, turning and positioning and that Certified Nurse Aide #1 provided care for Resident #173 on 08/02/2024. The Comprehensive Care Plans Behavior and Abuse/Victim initiated on 10/15/2022, revised on 8/3/2024 documented that the resident will be free from abuse/neglect and will not exhibit aggressive behavior to others and the resident will not be afraid to report abuse. Interventions included observe resident for physical findings, unusual skin marks, discoloration, ecchymosis, and report promptly, provide emotional support, re-educate staff on abuse/neglect and behavior management as needed. On 12/17/24 at 03:41 PM, an interview was conducted with the Director of Nursing, who stated that all staff are given training on abuse annually and as needed. The Director of Nursing also stated that they always do reminders and re-education about abuse. The Director of Nursing stated that they did not speak directly to Resident #173 as Resident #173 cries easily cry so they limit care to regular staff who are familiar with her. The Director of Nursing further stated that they did not view the incident as abuse and recommended that 2 persons should provide care for Resident #173 as it might be challenging and place the resident at risk of injury with only one staff person. The Director of Nursing stated that there was no sign of injury however Resident #173 was very fearful and fragile. The Director of Nursing further stated that Certified Nurse Aide #1 did not go there with the intent to cause harm, but they did not follow the plan of care for Resident #173. On 12/18/24 at 09:53 AM, an interview was conducted with Certified Nurse Aide #1 who stated that they have provided care to Resident #173 for over a year. Resident #173 is nonverbal however, they can make facial gestures and one can tell if Resident #173 is happy or not. Certified Nurse Aide #1 also stated that throughout the night on 08/03/24, they visited Resident #173 on several occasions, and around late midnight they cleaned and changed the resident's brief. Certified Nurse Aide #1 stated that they performed care alone and Resident #173 is not able to turn themselves, so they used the bed sheet and placed a pillow on Resident #173's upper back to turn them. Certified Nurse Aide #1 also stated that they did not make eye contact with Resident #173 during care and did not see any signs that Resident #173 was experiencing any discomfort. Certified Nurse Aide #1 further states that they were suspended for 8 days and received in-services. On 12/18/24 at 10:42 AM, an interview was conducted with Registered Nurse #2 who stated that they work per diem, had provided care for Resident #173 in the past, and had not received any complaints about staff from them. Registered Nurse #2 also stated that they assessed Resident #173 after the incident, and Resident #173 communicated with them using a computer device and stated that Certified Nurse Aide #1 was rough on them while providing care. Registered Nurse #2 further stated that Resident #173 was crying, and it took a while for Resident #173 to stop crying. 10 NYCRR 415.4 (b)(1)(i)

Based on observation, interview, and record review conducted during the Recertification and Complaint survey (NY00325467) from 12/12/2024 to 12/19/2024, the facility did not ensure that food was served at an appetizing temperature during meal service. This was evident for 1 (Resident #103) of 8 residents reviewed for Food out of 38 total sampled residents. Specifically, food served during lunch meal service was not maintained at palatable and appetizing temperatures. The findings are: The facility's policy and procedure titled Food Distribution and Service to Residents revised 11/20/2024 stated that each resident would be provided with a nourishing, palatable, diet at proper temperature that meets the dietary needs of each resident. Resident #103 was admitted to the facility with Diabetes Mellitus, Hyperlipidemia, and Hypertension. The Quarterly Minimum Data Set, dated dated dated [DATE] documented that Resident #103 had intact cognition and was independent with eating. On 12/13/2024 at 2:15 PM, Resident #103 stated that staff does not serve food immediately on the floor, so food is consistently served cold. Resident #103 also stated that they were told that there is no microwave on the unit and that staff is not allowed to heat up foods due to a safety issue. On 12/16/2024 from 12:35 PM to 12:50 PM, the food cart arrived in the dining room and dietary staff prepared for the meal service on Unit 2 South. On 12/16/2024 from 12:50 PM to 1:29 PM, dietary and nursing staff assembled the trays and distributed the trays to residents in the dining room and delivered to residents in their room. On 12/16/2024 at 1:29 PM, test trays were conducted on Unit 2 South. The food temperatures were mashed potato 145.8 degrees Fahrenheit, diced carrots 114 degrees Fahrenheit, baked chicken leg 140 degrees Fahrenheit, cream of wheat 153 degrees Fahrenheit, ground chicken 117 degrees Fahrenheit, ground green bean 128 degrees Fahrenheit, coffee 116 degrees Fahrenheit and coffee 116 degrees Fahrenheit. On 12/18/2024 at 11:09 AM, the Food Service Director was interviewed and stated that the food temperatures measured on 12/16/2024 were inconsistent and below the optimal temperature for hot foods. The Food Service Director also stated that hot foods are held at least a desirable temperature of 135 degrees Fahrenheit to ensure foods are served hot when residents receive their meal. The Food Service Director further stated that they are always checking temperatures and quality of meals during observations on the units during meal service. On 12/19/2024 at 12:33 PM, the Administrator was interviewed and stated that the meal delivery process was changed earlier this year to ensure residents are provided communal dining service. Residents are gathered and served meals in the dining room. The Administrator also stated that the Food Service Director has been monitoring/checking temperatures and food quality on the units during meal service. The Administrator further stated they have not heard of any issues before now and that there is a microwave in the staff dining cafeteria that can be used for heating up foods if needed. 10 NYCRR 415.14(d)(1)(2)

Based on observation, interview, and record review conducted during the Recertification and Complaint survey (NY00325467) from 12/12/2024 to 12/19/2024, the facility did not ensure that resident menus and dietary preferences were followed. This was evident for 1 (Resident #103) of 8 residents reviewed for Food out of 38 total sampled residents. Specifically, portion sizes were not consistently followed, and were not provided to Resident #130. The findings are: The facility's policy and procedure titled Resident Food Services revised 1/2024 documented residents will be offered menu choices for all meals, beverages, snacks and are based on their prescribed diet, food preferences, and choices accommodating their allergies, intolerances, preferences and consistent with their plan of care. Resident #103 was admitted to the facility with Diabetes Mellitus, Hyperlipidemia, and Hypertension. The Quarterly Minimum Data Set, dated dated dated [DATE] documented that Resident #103 had intact cognition and was independent with eating. During an interview on 12/13/2024 at 2:15 PM, Resident #103 stated they are often served small portion and missing protein on their meal tray. The Comprehensive Care Plan for Nutrition dated 7/16/2024 reviewed 12/12/2024 documented interventions which included to monitor weight, labs, provide diet per physician order, and evaluate needs, eating habits, and preferences. The Dietary note dated 7/23/2024 documented Resident #103 complained they did not receive a protein at lunch yesterday. The Dietary note dated 8/12/2024 documented Resident #103 informed the Registered Dietitian that they were to receive double portion at meals and that their trays are sometimes inconsistent. Resident #103 was upset that their lunch tray today did not have a protein. Registered Dietitian told the resident that this meal ticket reflects no main entree item most likely because of the dislikes regarding an item served for lunch. Resident #103 reported that they will order food in because of these occurrences. During an observation on 12/17/2024 at 1:07 PM, Resident #103's lunch meal ticket documented 1 serving size for all items: 1 salad greens, 1 cranberry juice, 1 peanut butter cookie, 1 apple juice, 1 bowl of chicken noodle soup, 1 portion of eggplant parmesan, 1 portion of corn, red pepper, and green beans, 1 portion of penne pasta. The lunch meal ticket also documented to provide Double Protein as per dietary preference. Resident's plate was observed with 1 slice of eggplant parmesan along with 1 serving size of penne pasta, and corn, red pepper, green beans. There was no double protein observed on Resident #103's tray for the meal. On 12/19/2024 at 11:28 AM, the Clinical Nutritional Director was interviewed and stated there has been ongoing communication with Resident #103 because of a history of not complying with their therapeutic diet. Resident #103 provided their preference for double protein on specific menu items; therefore, it should be reflected on the serving size. The Clinical Nutritional Director also stated they were not able to locate resident's menu preferences in their medical record or meal care system and did not know if double protein was reflected in the serving size and served to Resident #103. The Clinical Nutritional Director further stated that the meal care system prints out resident meal tickets with resident's dislikes/allergies and replaced with other items, however, review of the tickets did not reflect that items were replaced. On 12/18/2024 at 11:09 AM, the Food Service Director was interviewed and stated that Resident #103's lunch menu documented double protein as a dietary preference, but this was not reflected in the serving size of eggplant parmesan served on 12/17/2024. The Food Service Director also stated that the nurse would just call for the double protein when Resident #103's meal tray is being assembled during meal service. The Food Service Director further stated that this has been the practice and so double protein is not reflected in the serving size specification for Resident #103. On 12/19/2024 2:03 PM, the Director of Nursing stated that the Food Service Director has been conducting audits without any issues since they have implemented the new dining process. The Director of Nursing further stated that they were not aware that there were issues related to resident's meals. 10 NYCRR 415.14(c)(1-3)

Based on observation, record review and interviews conducted during the recertification survey from 12/12/2024 to 12/19/2024, the facility did not ensure individual resident financial records were made available to resident or their representative through quarterly statements. This was evident for 1 (Residents #36) of 2 residents reviewed for Personal Funds out of a sample of 38 residents. Specifically, there was no documented evidence that Resident #36, or their representative had been provided with quarterly statements in writing within 30 days after the end of the quarter. The findings are: The undated facility policy and procedure titled Resident Personal Accounts documented that the Finance Department will distribute quarterly statements to residents or other responsible party on a timely basis. The Resident Statement Landscape printed 12/18/2024 documented that Resident #36 and had an active account and funds being held by the facility. The Quarterly Minimum Data Set 3.0 assessment dated [DATE] documented that Resident #36 had intact cognition and participated in assessment and goal setting. The undated document titled Quarterly Statement for Statement Date: July 2024-[DATE] was not signed or dated by Resident #36, their designee, or the Finance Department. There was no documented evidence provided that Resident #36 or their representative had been provided with copies of their quarterly statements. On 12/19/24 at 09:29 AM, an interview was conducted with the Patient Account Coordinator who stated that they recently started working at the facility and is in the process of implementing a system for documenting how statements are delivered where a copy would be provided to the resident and a copy to the home address if family is involved. The recipient would be instructed to sign the statement and return it to the facility. The Patient Account Coordinator also stated that they did not know where the documentation regarding delivery of statements to Resident #36 was located. The Patient Account Coordinator further stated they had not yet been able to follow-up on statements that had been mailed for which no signed copy had been received. On 12/19/24 at 03:38 PM, an interview was conducted with the Administrator who stated that statements are mailed or given to residents on a quarterly basis based on the resident's cognitive status. The Administrator also stated that if there is no family involvement, statements still have to be delivered to the resident. The Administrator further stated that inhouse delivery of statements is done by either Recreation or the Patient Account Coordinator who is expected to get acknowledgement from the resident and file the statement. In a subsequent interview on 12/19/24 at 04:11 PM, the Administrator stated that the facility had a change in Medicaid Coordinator, and they did not transfer all of their files to the facility before they left, so some documentation is unavailable for review. The Administrator also stated that the process that was in place is that the Coordinator mails statements out to all residents whether they reside in the facility or not. On 12/19/24 at 04:20 PM, the Patient Account Coordinator provided copies of six Quarterly Statement for Statement Date: July 2024-[DATE] that had been received and returned by residents in the facility which did not include a statement for Resident #36. 10 NYCRR 415.26(h)(5)(i)

Based on interview and record review conducted during the Recertification and Complaint survey (NY00325467) from 12/12/2024 to 12/19/2024, the facility did not ensure that it promoted and facilitated resident self-determination through the support of resident choice. This was evident for 1 (Resident #103) of 5 residents reviewed for Choices. Specifically, bathing preference was not obtained and not provided in accordance with Resident #103's wishes. The findings are: The facility's policy and procedure titled Performing Activities of Daily Living (ADL) revised 9/1/2022 documented all residents will be provided a shower or bath, with assistance as necessary as least twice per week, unless otherwise specified by resident's plan of care. Resident #103 was admitted to the facility with Diabetes Mellitus, Hyperlipidemia, and Hypertension. The Annual Minimum Data Set, dated dated dated [DATE] documented that it was very important for Resident #103 to choose between tub bath, shower, bed bath or sponge bath. The Quarterly Minimum Data Set, dated dated dated [DATE] documented that Resident #103 had intact cognition, was independent with eating, and required substantial assistance for showering. On 12/13/2024 at 2:02 PM, Resident #103 stated they have been in the facility for about 4 years and had only been receiving bed baths. Resident #103 also stated that they requested to be showered multiple time but was still receiving bed baths. The Comprehensive Care Plan titled Activities of Daily Living dated 12/1/2023 reviewed 10/2/2024 documented that Resident #103 required substantial assistance for shower/bathing. The care plan did not document Resident #103's bathing preferences. The Resident Nursing Instructions revised 7/15/2024 documented Resident #103's bathing type was bed bath or shower, and the bathing schedule was Wednesdays and Saturdays during the 3:00 PM to 11:00 PM shift. The Social Services note dated 9/17/2024 documented that Resident #103 reported not having a shower in 4 years and that the Administrator was made aware of it. Review of progress notes dated 9/17/2024 to 12/16/2024, there was no documentation that resident's shower preference was addressed. The Certified Nursing Assistant Documentation Record for 11/1/2024 to 12/16/2024 documented Resident #103 received a bed bath on 3 (11/2/2024, 11/9/2024, 11/27/2024) out of 9 opportunities in November of 2024. Bathing was not performed for Resident #103 on 11/6/2024, 11/13/2024, 11/16/2024, 11/20/2024, 11/23/2024 and 11/30/2024. Resident #103 received a bed bath on 3 (12/4/2024, 12/7/2024, 12/11/2024) out of 4 opportunities in December of 2024. Bathing was not performed on 12/14/2024. Review of the medical record from 11/1/2024 to 12/16/2024 contained no documented evidence that Resident #103 refused bathing on the other scheduled bathing days. On 12/19/2024 at 3:24 PM, Certified Nursing Assistant #6 stated that Resident #103 had been in the facility for a long time and had always received bed baths on Wednesday and Saturdays during the 3 PM to 11 PM shift. Certified Nursing Assistant #6 also stated that Resident #103 required a special bariatric shower chair which was not available. Certified Nursing Assistant #6 further stated that all staff including nurses knew Resident #103 needed a special bariatric shower and there was no chair yet. On 12/19/2024 at 4:25 PM, Certified Nursing Assistant #7 stated that Resident #103 was admitted to the facility about 4 years ago and was having a lot of pain initially and was not able to get out of bed so received bed baths at that time. Certified Nursing Assistant #7 also stated that there was no shower chair that was appropriate for Resident #103's size; therefore, giving a shower was not an option. Certified Nursing Assistant #7 further stated that Resident #103 was only getting bed baths due to lack of equipment and them not being able to get out of bed. On 12/16/2024 at 4:21 PM, Social Worker #2 stated Resident #103 has a wheelchair that they utilize for ambulation, but the chair was not able to fit through the entryway to the shower room. Social Worker #2 also stated that they had planned to purchase a special chair that is appropriate for Resident #103's size and able to fit through the entry. Social Worker #2 further stated that they did not know the status of the shower chair and did not know whether or not the chair was ordered. On 12/17/2024 at 9:31 AM, Resident #103's wheelchair was measured at 36 inches wide and was not able to fit through the entry to shower room. On 12/19/2024 at 1:00PM, the Administrator stated that a shower chair Resident #103's was ordered immediately on 12/03/2024 after they were made aware of the problem and they are currently waiting for it to be delivered. On 12/19/2024 at 2:03 PM, the Director of Nursing stated Resident #103 has a history of refusing shower and has been getting bed bath twice weekly as per their staff. The Director of Nursing Resident also stated that upon admission residents select the bathing preferences with showers scheduled twice weekly or bed bath only which can be changed any time as per resident's request. The Director of Nursing was not able to explain why Resident #103 was only provided bed baths. 10 NYCRR 415.5 (b)(1-3)

Based on observation, record reviews, and interviews, conducted during an abbreviated survey NY00334448), the facility failed to ensure that a resident right to be informed, in advance, of changes to their plan of care. This was evident for 1 out of 6 residents (Resident #2) sampled. Specifically, a Nursing Progress Note dated 05/19/2024 at 9:16pm documented Resident #2 was an elopement risk, and a wander-guard (elopement prevention system transmitter) was placed on the left side of Resident #2's motorized wheelchair. During an interview on 08/01/2024 at 2:30pm, Resident #2 stated that they were not aware that the facility had placed a wander-guard device on their motorized wheelchair until 06/07/2024 when they attempted to exit the main entrance door in the lobby. Resident #2 stated, at no time where they notified that they were an elopement risk and that they did not consent to wearing a wander-guard device. The findings are: The facility's Policy for Residents Rights and Responsibilities dated 09/01/2021, documented all residents/patients/designated representatives will be given a copy of the Resident's [NAME] of Rights (Attachment 1) prior to or upon admission, and as indicated thereafter. In addition, they will receive and explanation of these rights and be fully advised of their rights and responsibilities as residents/patients of the facility. Attachment I (9) of the policy documents that Resident to be treated with courtesy, fairness, consideration, respect and full recognition of his dignity and individuality including privacy in treatment and in care for their personal needs. An Elopement and Wandering Policy last dated 11/10/2022 was reviewed. Section 2 mentioned placing an electronic elopement prevention system transmitter (bracelet) on resident. Placed on wheelchair only if placement on body is not possible. Resident #2 was admitted to the facility with diagnoses including Spinal Cord Injury, Quadriplegia, Anxiety, and Pressure Ulcer. The Minimum Data Set (an assessment tool) dated 12/12/2023 documented Resident #2 had a Brief Interview of Mental Status (used to determine attention, orientation, and ability to recall information) and scored of 15 associated with intact cognition. A Care plan for Resident/Family Education dated 04/20/2021 was reviewed. The care plan was last updated on 03/12/2024. There was no documented evidence that Resident #2 or their family member was educated on changes in Resident #1's plan of care on 05/19/2024. A Psychiatry Progress Note dated 02/23/2024 documented Resident #2 does not have full capacity to make sounds complex medical care decisions. Resident #2 was guarded, paranoid, and jeopardizing their (Resident #2) health. An Exit Seeking/Wandering Evaluation form dated 05/19/2024 documented that Resident #2 was not disoriented to place and had no impairment in decision-making. A Physician's Order dated 05/19/2024 documented Elopement Precautions, wander-guard in place. A nursing progress note dated 05/19/2024 at 9:16 pm documented elopement risk, wander-guard to left side motorized wheelchair. An Elopement and Wandering Care Plan dated 05/19/2024 documented Resident #2 was at risk for elopement related to verbalized intent and left facility without permission. Resident #2 was followed by staff for about 45minutes. A Secure Care Transmitter placed on wheelchair. There was no documented evidence that Resident #1 was notified of their elopement status or that a Secure Transmitter bracelet would be placed on their wheelchair. During a telephone interview on 08/01/2024 at 2:30 pm, Resident #2 stated that they were not aware that they were an elopement risk and that a wander guard was hidden on their motorized wheelchair. Resident #2 stated that they became aware of the wander guard on 06/07/2024 when they attempted to exit the main entrance door in the lobby. Resident #1 went on to say that the alarm was activated, and the door was locked. Resident #2 stated that they did not receive any education on the wander-guard or consented to wearing one. Resident #1 stated that their rights to move about freely was restricted. Resident #2 stated that they did not receive any education on the wander-guard and how the wander-guard works. During an interview on 08/01/2024 at 3:00 pm, Registered Nurse Supervisor #2 stated that prior to 06/07/2024, Resident #2 was deemed at risk for elopement and a wander-guard was placed on Resident #2's motorized wheelchair. Registered Nurse Supervisor #2 stated that it is facility's protocol that when a resident is deemed an elopement risk, an elopement assessment is performed, the Medical Doctor is notified, a physician's order is obtained, and a wander-guard is placed on the resident. Registered Nurse Supervisor #2 stated that on 05/19/2024, Resident #2 left the facility unsupervised and staff members had to follow Resident #2 into the community and brought Resident #2 back into the facility. Registered Nurse Supervisor #2 stated that Resident #2 was assessed and deemed at risk for elopement. Registered Nurse Supervisor #2 went on to say that Resident #2's behavior was erratic and unsafe, and that Resident #2 was not given a choice to wear a wander-guard. Registered Nurse Supervisor #2 stated that Resident #2 was evaluated by telehealth Psychiatrist, who stated that Resident #2 has no capacity for decision-making. Registered Nurse Supervisor #2 stated that Resident #2 was told that a wander-guard would be placed on their motorized wheelchair to alert the facility staff when Resident #2 is leaving the facility. During an interview on 08/01/2024 at 3:28 pm, the Director of Nursing stated that Resident #2 has behavioral issues and has attempted to leave the facility without supervision. The Director of Nursing stated that Resident #2 was assessed to be at risk for leaving the facility and was at high risk for being a danger to themself. The Director of Nursing stated that a wander-guard was applied to Resident #2's motorized wheelchair for Resident #2's protection, and to alert the staff. The Director of Nursing stated that Resident #2 was not given a choice to wear a wander-guard because of Resident #2's erratic behavior. The Director of Nursing stated that Resident #2 instructed the facility not to inform their family on any matters that related to them and did not consent to wearing a wander guard. 10 NYCRR 415.3

Based on observation, record review, and interviews conducted during the Recertification Survey, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan and the resident's choices. This was evident in 1 (Resident #243) of 5 residents reviewed for Activities of Daily Living out 38 total sampled residents. Specifically, Resident #243 did not a Sequential Compression Device (SCD) applied as ordered. The findings are: Resident #243 had diagnoses of cardiovascular disease and atherosclerosis. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #243 was severely cognitively impaired and required total assistance from staff to perform activities of daily living. On 11/28/22 at 11:52 AM and 11/29/22 12:14 PM, Resident #243 was observed in bed without the SCD in place. The SCD was hanging on the foot of the bed. The Physician's Order (PO) dated 09/23/2022 documented a SCD should be applied to Resident #243 at 10:00 AM and removed at 9:00 PM for Deep Vein Thrombosis (DVT) prophylaxis. The Comprehensive Care Plan (CCP) related to cardiovascular condition initiated 2/3/22 documented Resident #243 was at risk for chest pain as evidenced by elevated cholesterol level, elevated blood pressure, physical inactivity, and smoking. The CCP did not include the SCD as an intervention. The Treatment Administration Record (TAR) for November 2022 documented removal of SCD from Resident #243 at 9PM daily from 11/15/22 to 11/28/22. The TAR did not document instructions to apply the SCD after morning care. On 11/29/22 at 12:20 PM, Certified Nursing Assistant (CNA) #2 was interviewed and stated they provided care to Resident #243 at 9AM. CNA #2 had never seen the SCD before, and the device was not listed on the CNA's tasks for Resident #243. On 11/29/22 at 12:14 PM, Registered Nurse (RN) #3 was interviewed and stated they were the medication nurse on 11/28/22 and 11/29/22. The unit nurse or medication nurse is responsible for the application and removal of the SCD. The CNA can also apply the SCD to the resident. RN #3 knew Resident #243 should have the SCD applied daily. RN #3 stated they usually apply the SCD after the resident receives morning care. RN #3 could not explain the reason the SCD was not applied to Resident #243 on 11/28/22 and 11/19/22. 415.22(a)(1-4)

Based on record review and staff interview conducted during the Recertification survey from 11/28/2022 to 12/06/2022, the facility did not ensure a resident's Comprehensive Care Plan (CCP) was reviewed and revised to reflect the resident's changing needs. This was evident in 1 (Resident #243) of 5 residents reviewed for Activities of Daily Living of 38 total sampled residents. Specifically, Resident #243's CCP related to cardiovascular condition was not reviewed and revised to reflect a Physician Order (PO) for a Sequential Compression Device (SCD). The findings are: The facility's policy titled CCP last revised 10/10/22 documented all disciplines will review and revise each resident's care plan to remains current and in the event a change in resident condition occur. Resident #243 had diagnoses of cardiovascular disease and atherosclerosis. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #243 was severely cognitively impaired and required total assistance from staff to perform activities of daily living. PO dated 09/23/2022 documented Resident #243 receive a SCD, a Deep Vein Thrombosis (DVT) prophylaxis, to be applied at 10:00 AM and removed at 9:00 PM daily. The CCP related to cardiovascular condition initiated 2/3/22 documented Resident #243 is at risk for chest pain as evidenced by elevated cholesterol level, elevated blood pressure, physical inactivity, and smoking. There was no documented evidence the CCP related to cardiovascular condition was reviewed and revised to include PO for daily SCD application to Resident #243. On 11/29/22 at 12:14 PM an interview was conducted with the unit Registered Nurse (RN) #3 who stated that any on-duty RN is responsible for updating resident CCPs. Resident #243's cardiovascular CCP was developed because the resident is at risk for a blood clot, and this is the reason the Physician ordered the SCD. RN #3 stated they missed updating the CCP and adding the SCD as an intervention. 415.11(c)(2)(i-iii)

Based on record review and interviews conducted during the Recertification and Abbreviated (NY00305196) Survey from 11/28/22 to 12/06/22, the facility did not ensure a resident received adequate supervision to prevent accidents. This was evident for 1 (Resident #660) of 4 residents reviewed for Wandering/Elopement out of 38 total sampled residents. Specifically, Resident #660 was identified as an elopement risk and did not receive adequate supervision to prevent elopement. The finding is: The facility policy titled Elopement and Wandering last revised on 11/10/22 documented the Interdisciplinary Care Plan Team (ICPT) will conduct an elopement risk assessment for every resident during admission, readmission, and as needed and develop a Comprehensive Care Plan (CCP). Interventions include the Certified Nursing Assistant (CNA) conducting a headcount at the beginning of each shift and monitoring residents every 30 minutes. Resident #660 had diagnoses of dementia and schizophrenia. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #660 was severely cognitively impaired, was independent in transfers, and required supervision when walking in the room and off the unit. A Physician Order (PO) initiated 11/13/2021 and last renewed 7/08/2022 documented visual checks of Resident #660 every 30 minutes on every shift. Physician Orders initiated 1/21/22 and last renewed 9/20/22 documented Resident #660 required elopement precautions and wanderguard (WG) in place. The Comprehensive Care Plan (CCP) related to elopement and wandering initiated 1/21/2022 documented Resident #660 was at risk for elopement, verbalized intent to leave the facility, verbalized intent to go home, had memory impairment, and had a history of elopement prior to admission to the facility. The Exit Seeking Elopement/Wandering assessments dated 02/20/22, 04/19/22 and 07/17/22 documented Resident #660 was at high risk for elopement due to the increased wandering, frequent expressions of desire to leave, and attempts to leave facility. PO dated 09/26/22 documented WG discontinued for Resident #660. Nursing Note (NN) dated 09/26/22 documented Resident #660 was at risk for elopement, refused to wear the WG, usually signed the logbook when exiting and entering the unit, and did not go outside of the facility. NN dated 10/3/22 documented Resident #660 handed Registered Nurse (RN) #4 their WG device, refused to wear the WG, and stated they do not want it. RN # 2 and Physician made aware. NN dated 10/3/22 documented the Associate Director of Nursing (ADNS) and Director of Nursing (DNS) were notified Resident #660 refuses to wear their WG and the resident was placed on monitoring every 30 minutes. The CCP related to elopement and wandering was revised 10/03/2022 and documented Resident #660 had a WG to the right ankle but removed their WG and will be placed on monitoring every 30 minutes. The Resident Nursing Instructions initiated 10/19/22 documented the CNA monitor Resident #660 every 30 minutes. Facility security video footage dated 11/08/2022 at 1:46 PM was viewed and Resident #660 was observed walking past a security guard who was looking down at their desk. Resident #660 then walked out the front door of the facility unescorted. The Resident CNA Documentation History Detail (RCDHD) dated 11/08/2022 at 2:06 PM documented a visual check of Resident #660 at 2:00 PM. At 2:07 PM the RCDHD documented Resident #660 was visually checked at 2:30 PM and 3:00 PM. Nursing Note dated 11/08/2022 documented at 7:15 PM, CNA #6 noticed Resident #660's dinner tray was untouched and reported to the nurse Resident #660 could not be found. The Occurrence Report Statement dated 11/08/22 documented a search of facility and surrounding neighborhood for Resident #660 was performed and a police report was filed. Resident #660 remained missing. A statement by Resident #660's assigned CNA on the 7AM to 3PM shift, CNA #7, documented the CNA last saw Resident #660 on the unit at 1:46PM. On 12/01/22 at 11:16 AM, an interview conducted with the RN #4 who stated they discontinued the WG order for Resident #660 because supervisor, RN #2, instructed them to do so. Resident #660 kept refusing the WG, used to go out of the unit and come back on time, and there was never an attempt to leave the unit even without the wander guard. On 12/01/22 at 12:12 PM, an interview conducted with the RN #2 who stated Resident #660 was at high risk for elopement since admission to the facility. Resident #660 performed daily activities without any problems and always removed the WG. The resident never attempted to leave the unit, so the WG was discontinued. A wandering/elopement assessment was not conducted but NN documented the resident's refusal. On 12/01//22 at 12:55 PM and 12/05/22 at 03:07 PM, the DNS was interviewed and stated Resident #660 was on 30-minute monitoring. Elopement assessments are completed quarterly and as needed. On 9/26/22, Resident #660 was readmitted from the hospital, was found to be compliant, and the WG was discontinued. RN #1 approached the DNS, stated they felt like someone was going to come to the facility and try to pick up Resident #660, so the WG was placed on the resident again. The Physician should have been informed. There was no documentation of this communication by RN #1. Resident #660 refused to wear the WG and should have been placed on 30-minute monitoring. Residents with WGs are unable to leave the unit because an alarm sounds. The WG was discontinued for Resident #660 in October so the resident could attend off-unit activities. Resident #660 eloped from the facility and staff were not aware until 7:15PM because CNA #7 failed to monitor and continued to document visual checks of the resident. CNA #6 was assigned to Resident #660 on the 3PM to 11PM shift but was unable to conduct visual checks of the resident because they were in inservice for several hours during their shift. A head count was not performed. 415.12(h)(2)

Based on observations, record review, and interviews conducted during the Recertification survey, the facility did not ensure food was prepared and served in accordance with professional standards for food service safety to prevent foodborne illness. This was evident during Dining Observation on the 3 South Unit. Specifically, a Certified Nursing Assistant (CNA) was observed serving breakfast trays without performing hand hygiene in between residents. The findings are: The facility policy titled Hand Hygiene last revised 7/06/2022 documented pathogens can contaminate the hands of staff during direct contact with residents or contact with contaminated equipment and environmental surfaces within close proximity of the resident. Failure to clean contaminated hands can result in the spread of these pathogens to residents, staff (including the person whose hands were contaminated) and environmental surfaces. The resident zone is defined as an area that contains the resident and their immediate surroundings (ex. resident room). This typically includes the skin of the resident and all inanimate surfaces that are touched by or in direct/indirect physical contact with the resident. This includes bedrails, bedside table, bed linen and other medical equipment/supplies. On 11/30/2022 at 08:50 AM, CNA #1 was observed without gloves on in Resident #65's room offering the resident a handwipe and paper apron. CNA #1 adjusted the height of Resident #65's bed, assembled meal items on the breakfast tray, and touched the bedside table. No hand hygiene was performed, and CNA #1 exited the room, picked up another breakfast tray from a meal cart in the hallway, and entered Resident #40's room. CNA #1 placed the breakfast tray on Resident #40's bedside table, assisted the resident to clean their hands with a handwipe, spread margarine and jelly on a slice of bread, opened a milk carton, and prepared a packet of oatmeal. CNA #1 exited the room without performing hand hygiene, picked up a breakfast tray and apron from the meal cart, entered Resident #42's room, and placed the breakfast tray at the foot of the resident's bed. No hand hygiene was performed by CNA #1 before they exited Resident #42's room, took another breakfast tray and apron from the meal cart, and entered Resident #82's room. CNA #1 placed Resident #82's breakfast tray on their bedside table, adjusted the resident's bed sheet, shirt, and head, cleaned the resident's hands with a hand wipe, opened and poured milk in coffee and cereal, opened salt and pepper packet and sprinkled contents on eggs, and spread jelly and margarine on a slice of bread. No hand hygiene was performed by CNA #1 prior to exiting Resident #82's room. On 11/30/2022 at 09:52 AM, CNA #1 was interviewed and stated hands must be sanitized when placing a bib on a resident. If the CNA touches any items in a resident's room, touches food, or if they get something on their hands, their hands should be washed. Hand hygiene is important to prevent contamination from bacteria that could be on the bed rails or bedside tables. CNA #1 stated they did not perform hand hygiene between serving residents breakfast trays. On 11/30/2022 at 09:57 AM, the Licensed Practical Nurse (LPN) #1 was interviewed and stated staff wash their hands before distributing the meal trays and should wear gloves when opening food items to prevent their hands from touching the food. If their hands become soiled, the staff can wash or sanitize their hands before leaving the resident's room. Hand hygiene should be done before serving food to the residents in their rooms and prior to exiting the resident's room. On 11/30/2022 at 10:18 AM, the Infection Preventionist (IP) was interviewed and stated staff distributing meal trays should wash hands or use hand sanitizer in between serving each resident their tray. Most staff wear gloves during meal service. Staff should wash their hands if touching something and then moving on to a different task to prevent spread of infection. 415.14 (h)

Based on record review and interviews conducted during the Recertification and Abbreviated (NY00305196) Survey from 11/28/22 to 12/06/22, the facility did not ensure that medical records were accurate. This was evident for 1 (Resident #660) of 4 residents reviewed for Wandering/Elopement out of 38 total sampled residents. Specifically, the medical record documented Resident #660 was visually checked by the Certified Nursing Assistant (CNA) every 30 minutes after the resident eloped from the facility. The findings are: Resident #660 had diagnoses of dementia and schizophrenia. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #660 was severely cognitively impaired, was independent in transfers, and required supervision when walking in the room and off the unit. A Physician Order initiated 11/13/2021 and last renewed 7/08/2022 documented visual checks of Resident #660 every 30 minutes on every shift. The Comprehensive Care Plan (CCP) related to elopement and wandering initiated 1/21/2022 was updated 10/03/2022 and documented Resident #660 removed their wanderguard and will be placed on monitoring every 30 minutes. The Resident Nursing Instructions initiated 10/19/22 documented the CNA monitor Resident #660 every 30 mintues. Facility security video footage dated 11/08/2022 at 1:46 PM was viewed and Resident #660 was observed walking past a security guard who was looking down at their desk. Resident #660 then walked out the front door of the facility. The Resident CNA Documentation History Detail (RCDHD) dated 11/08/2022 at 2:06 PM documented CNA #7 visually checked Resident #660 at 2:00 PM. At 2:07 PM the RCDHD documented CNA #7 visually checked Resident #660 at 2:30 PM and 3:00 PM. Nursing Note dated 11/08/2022 documented at 7:15 PM, CNA #6 noticed Resident #660's dinner tray was untouched and reported to the nurse Resident #660 could not be found. On 12/01//22 at 12:55 PM, the Director of Nursing was interviewed and stated CNA #7 was assigned to Resident #660 on the 7AM to 3PM shift and responsible for Resident #660's elopement going unnoticed until 7:15 PM on 11/08/2022 because they continued to document Resident #660 was visually checked every 30 minutes even though the resident had already exited the building. CNA #7 no longer works at the facility. 415.22(a)(1-4)

Based on observation, record reviews and interviews during an abbreviated survey (NY 063) conducted on 12/28/2021, the facility did not ensure that each resident was offered the Pneumococcal Immunization, unless the immunization is medically contraindicated or the resident has already been immunized; the resident or the resident's representative had the opportunity to refuse immunization; and the resident's medical record includes documentation that indicates, at a minimum, the following: (A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of Pneumococcal Immunization; and (B) That the resident either received the Pneumococcal Immunization or did not receive the Pneumococcal Immunization due to medical contraindication or refusal. The was evident in 3 out of 5 residents sampled (Resident #1, Resident #3, and Resident #5). 1) Specifically, Resident #1, Resident #3 and Resident #5 were not offered the Pneumococcal Immunization. 2) Record review revealed that Resident #1, Resident #3, and Resident #5 were not provided with education regarding the benefits and potential side effects of the Immunization. The findings are: The facility policy dated 12/14/1998 and last revised 10/07/2021 documented that All residents will be immunized with Pneumococcal Vaccine unless the resident or designated representative refuses the vaccine in writing. The policy also states that All residents and/or designated representatives will receive education about Pneumococcal disease as a part of the preadmission process and during the admission process. The policy documents that a Licensed Nurse evaluates the resident's eligibility to receive the Pneumococcal Vaccine as a part of the admission process. The policy documents that the Primary Care Provider (PCP) orders the Pneumococcal Vaccine as indicated according to current Centers for Disease and Control (CDC) and Advisory Committee on Immunization Practices (ACIP) guidelines. Resident #1 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS, a resident assessment tool) dated 11/07/2021 documented that Resident #1 had a Brief Interview of Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) and scored 15/15 associated with intact cognitive response. Resident #1's medical record from 09/01/2021 - 12/28/2021 revealed no documentation indicating that the Pneumococcal Vaccine was offered to Resident #1 prior to 12/28/2021. There was no documentation that Resident #1 received education on the vaccine. Resident #1's Physician's Admission assessment dated [DATE] documented that Resident #1's [MEDICATION(S)] VACCINE DATE was unknown and that there was no known drug allergy. Resident #1's MDS dated [DATE], Section O, documented that Resident #1 was not up to date with the Pneumococcal Vaccine and that it was not offered. Resident #1's Immunization Record revealed that Resident #1 received the Pneumococcal Vaccine on 12/28/2021 while New York State Department of Health surveyor was onsite conducting the investigation. 2) Resident #3 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented that Resident #3 had a BIMS score of 15/15 associated with intact cognition. Resident #3's Immunization Record revealed that there was no documented evidence that Resident #3 received the Pneumococcal Vaccine. Resident #3's medical record from 12/14/2021 - 12/28/2021 revealed there was not documented evidence that the Pneumococcal Vaccine was offered to Resident #3. There was no documented evidence that Resident #3 was educated on the Pneumococcal Vaccine or that Resident #3 refused the vaccine. A review of the Physician Admission assessment dated [DATE] documented that Resident #3's [MEDICATION(S)] VACCINE DATE was unknown and that there was no known drug allergy. A review of the MDS dated [DATE], Section O, documented that Resident #3 was not up to date with the Pneumococcal Vaccine and that it was not offered. 3) Resident #5 was last admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented that Resident #5 had a BIMS score of 15/15 associated with intact cognitive response. Resident #5's Immunization Record revealed that there was no documented evidence that Resident #5 received the Pneumococcal Vaccine. Resident #5's medical record from 09/22/2021 - 12/28/2021 revealed that there was no documented evidence that the Pneumococcal Vaccine was offered to Resident #3. There was no documented evidence that Resident #5 was educated on the Pneumococcal Vaccine or that the resident refused the vaccine. Resident #5's Physician Admission assessment dated [DATE] documented that Resident #5's [MEDICATION(S)] VACCINE DATE was unknown and that Resident #5 had no known drug allergy. The MDS dated [DATE], Section O, documented that Resident #5 was not up to date with the Pneumococcal Vaccine and that it was not offered. During an interview on 12/28/2021 at 01:35 PM, Resident #1 stated that he/she received the Pneumococcal Vaccine today 12/28/2021. Resident #1 also stated that he/she had been asking about the Pneumococcal Vaccine since him/her admission to the facility and that the vaccine was not offered to him/her prior to 12/28/2021. During an interview on 12/28/2021 at 02:12 PM, Registered Nurse (RN) #1 stated that the residents are offered the Pneumococcal Vaccine upon admission. RN #1 stated Resident #1 asked him/her to check the system and see if Resident #1 had received the vaccine. RN #1 stated that he/she spoke to the doctor today (12/28/2021) and received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The vaccine was administered 12/28/2021. RN #1 stated that he/she was not sure why Resident #1 did not receive the vaccine earlier. During an interview on 12/28/2021 at 02:28 PM, Resident #3 stated that he/she was never offered the Pneumococcal Vaccine and did not receive education about the vaccine. During an interview on 12/28/2021 at 02:38 PM RN #2 stated that the admission nurse is required to ask the residents if they receive the Pneumococcal Vaccine. RN #2 also stated that a nurse should have followed up the next day with the resident and the vaccine status. RN #2 stated if a resident did not receive the vaccine, the doctor is notified and if the resident agrees, the vaccine would be offered to the resident. RN #2 stated that education related to the vaccine would be provided at the time that the vaccine is offered. During an interview on 12/28/2021 at 03:45 PM, MD #1 stated that the Pneumococcal Vaccine is usually given by the hospitals to residents during their stay. MD #1 stated he/she was not sure why Resident #1 was not given the Pneumococcal Vaccine. MD #1 could not state why Resident #3 and Resident #5 were not offered the Pneumococcal Vaccine and why there were no documentation regarding the Pneumococcal Vaccine. During an interview on 12/28/2021 at 04:22 PM, the Medical Director stated that Residents are offered the Pneumococcal Vaccine upon admission by anyone - nurses, nurse practitioners, or physician. The Medical Director stated, for Resident #1, there might have been a focus on other issues during the admission. The Medical Director stated that he/she was not sure why Resident #1 was not given or offered the Pneumococcal Vaccine prior to today (12/28/2021). The Medical Director stated he/she believed that Resident #1 only requested the vaccine within the last week. During an interview on 12/28/2021 at 05:12 PM, The Director of Nursing (DON) stated that Resident #1 never refused the Pneumococcal Vaccine. The DON stated that Resident #1 asked for the vaccine, but he/she was not sure when the resident requested the vaccine. The DON stated that Resident #1 received the vaccine today (12/28/2021) after the nurse from the unit came down to the office stating that Resident #1 had requested the vaccine. The DON stated that the nurse was informed that he/she should call the physician and obtain an order, which was done. The DON stated that the Pneumococcal Vaccinations are a known issue in the facility as based on their quality measures reports. The DON stated that the facility has one of the lowest scores for the Pneumococcal Vaccine. The DON stated that they have had discussions, about the vaccine, with the Medical Director and the team. The DON stated that this issue is on their Quality Assurance and Policy Improvement plan to address in year 2022. The DON stated that the process should be that - on admission, the record should be received from the hospital. Once a resident is admitted , they should be asked about the Pneumococcal Vaccine and provided with education. The DON stated if the resident agrees to the Pneumococcal Vaccine at admission, an order should be made. The DON stated that if a resident declines the vaccine, this should then be indicated in the medical record. The DON stated that if there is information that the vaccine was given in the hospital or the community, it should be reflected in the immunization record. 415.19(a)(1)

Based on observation, interviews and record review conducted during an abbreviated survey (NY 511), the facility did not develop and implement a comprehensive person-centered care plan to meet a resident medical and nursing needs. This was evidence for 1 out of 3 residents sampled (Resident #1). Specifically, on 05/18/2020, the Physician ordered Intravenous Fluids (IVF) for Resident #1. A person-centered care plan with interventions to monitor the IV site and to prevent Resident #1 from pulling out the Hep-Lock was not initiated. The facility policy entitled Comprehensive Care Plan revised 08/31/2020 documented that it is the facility' policy that all residents will have an individualized Electronic Medical record (EMR) baseline care plan and comprehensive care (CCP). Each CCP will be a profile of the resident's current medical condition, skilled nursing needs, and activities of daily living (ADL). The CCP must be reviewed and revised as indicated by the interdisciplinary care plan (ICP) team. Intermittent care plans must be developed to address episodic events and must be reviewed and resolved within the specified time frame. A facility document entitled Peripheral Intravenous (IV) Access/Therapy, PC4.1 revised 01/27/2011, documented that Intravenous Therapy may be administered using an appropriate administration set or an infusion pump. All peripheral IV sites are changed every 72-96 hours and as needed. In addition, all IV tubing are changed every 72 hours and as needed and labeled with the date changed. Also documented, the Licensed Nurse should evaluate IV site each shift for signs and symptoms of infection, and/or infiltration and document the following in the progress notes section of the EMR. The document did not mention implementing a care plan with interventions. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Give 60 Milliliters by intravenous route continuously for poor intake. A Nurse ' s Progress Note dated 05/26/2020 documented that Resident #1 was alert with periods of confusion and was resistive to care. D5.45 Normal Saline running at 60ml/hour to dorsum of right forearm. Seen with infiltrating. IV Fluid stopped and removed. Pressure gauze applied and the right arm elevated. A 24g IV insert via aseptic technique to dorsum of left hand. A Nurse's Progress Note dated 05/27/2020 at 8:08 PM documented that Resident #1 was confused. Resident #1 pulled IV on the left hand and it was reinserted. A Nurse's Progress Note dated 05/29/2020 at 10:50 PM documented that IVF continues via Hep-Lock to right arm for hydration. Site dry and intact with swelling and redness still visible to the left arm. Review of the Care Plan Activity Report for Resident #1 revealed no documented evidence that a person-centered care plan with interventions developed and implemented for Resident #1's Peripheral Intravenous Access/Therapy. During an interview on 11/01//2021 at 2:09 PM, the Registered Nurse (RN) stated that when Intravenous fluid or antibiotics is ordered via Hep-Lock access, the RN inserts the Hep-Lock and creates an individualized care plan. the RN stated that the access site is also documented in the medical record. During an interview on 11/01/2021 at 2:30 PM, the Director of Nursing (DNS) stated that the RN is responsible for initiating episodic care plans. The DON stated that the RN is responsible for initiating the care plan, after an IV access insertion, to monitor the access site. 415.11

Based on observation, interviews and record review conducted during an abbreviated survey (NY 511), the facility did not ensure that a resident was free from physical restraint imposed for purposes of convenience and not required to treat resident's medical symptoms. This was evidence for 1 out of 3 residents sampled (Resident #1). Specifically, on 05/24/2020, Resident #1 was observed with a plastic bag tied to Resident #1's left wrist and the resident's left wrist tied to the left siderail of Resident #1's bed. Resident #1 was unable to untie the plastic bag and there was no doctor's order for the restraint. The findings include: The Facility's Policy and procedure entitled Restraints revised 11/28/2016, documented that it is the facility policy to be committed to a restraint free environment. Through the interdisciplinary team (IDT) will assess the potential need for restraints, identify alternatives to restraints, evaluate need for current restraints, and continually reassess residents to reduce and discontinued restraints when present. Plastic bags as restraint were prohibited. The Facility Investigation summary dated 05/26/2020 documented that on 05/24/2021 at 8:15 AM, Resident #1 was observed physically restrained in bed. A Certified Nursing Assistant (CNA) on the 7-3 shift, assigned to Resident #1, observed the resident's left wrist tied with a plastic bag and tied to the siderail. It was documented that no staff members were identified as being responsible for applying the restraint. The CNA and Licensed Practical Nurse (LPN) that were on duty (11-7 shift) were terminated. Resident#1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS, a resident assessment tool) dated 05/09/2020 documented that Resident #1 had impaired cognition. Resident #1 required total assistance in most or all areas of Activities of Daily Living (ADL). Review of Resident #1 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nurse ' s Progress note dated 05/24/2020 documented that Resident #1 was observed with his/her left wrist restraint. The restraint was immediately removed. The resident was assessed and observed with no injuries. Observation was done for changes in neuromuscular function on the left wrist. A Nurse Practitioner's Progress Note dated 05/24/2020 documented that Resident #1 was evaluated for left hand. Resident #1 had [CONDITION(S)]. The skin was cool and dry to touch. Resident #1's left hand was slightly cooler than the right hand. Pulses were palpable with sensation. The motor function was intact, and no injuries noted. During an interview on 10/08/2021 at 10:30 AM, Certified Nursing Assistant (CNA) #2, who worked on 05/24/2020 on the 7-3, stated that he/she went to take Resident #1's temperature and observed that Resident #1 had a brown grocery plastic bag tied to his/her left wrist. The handles of the plastic bag were coiled twice and tied to the left siderail of Resident #1's bed. Resident #1's left hand was in alignment with the siderail. CNA #2 reported that he/she notified the nurse, and the nurse removed the plastic bag. During an interview on 10/08/2021 at 10:50 AM, CNA #1, assigned to Resident #1 on the 11-7 shift, stated that he/she did not tie the plastic bag to Resident #1's left wrist and to the siderail of Resident #1's bed. CNA #1 stated that he/she provided incontinent care to Resident #1 but did not see a plastic bag on the siderail or tied to Resident #1's left wrist. During an interview on 10/08/2021 at 11:30 AM, Licensed Practical Nurse (LPN) #1, who worked on the 11-7 shift on 05/23/2020, stated that he/she administered medications to Resident #1 on 05/24/2020 at 2:00 AM and at 6:00 AM. LPN #1 stated that he/she did not observe any restraint on Resident #1's left wrist and that he/she did not apply the restraint to Resident #1's left wrist. LPN #1 reported that Resident #1 was receiving intravenous therapy (IV) on the right arm and that he/she only checked the IV site on Resident #1's right arm. Review of LPN #1's written statement to the facility dated 05/24/2020, documented that he/she observed that a brown plastic bag loosely tied to the left siderail of Resident #1's bed. During an interview on 10/08/2021 at 1:00 PM, the Assistant Director of Nursing (ADNS) stated that all restraints must have a doctor's order and that there are protocols to follow before applying any restraint. The ADNS stated that the facility is restraint free and that it was inappropriately for staff to restraint Resident #1. During an interview on 10/18/2021 at 1:40 PM, the Director of Nursing Service (DNS) stated that restraints are only used for medical reasons. 415.4 (a) 2-7

Based on observations, staff interviews and record reviews conducted during an abbreviated and partial extended survey (NY 372), the facility failed to initiate Cardiopulmonary Resuscitation (CPR) to an unresponsive resident who had Full Code status with Advance Directives in place. This was evident for 1 out of 10 residents sampled (Resident #1). Specifically, on [DATE] Resident #1's advanced directive status was changed from a DNR (Do Not Resuscitate) order to a Full Code (CPR to be performed) order. The facility failed to ensure the resident's paper medical record was updated to reflect the change in code status. On [DATE], the resident was found unresponsive, facility staff failed to check the Electronic Medical Record (EMR) for the physician's orders [REDACTED]. Cardio-Pulmonary Resuscitation (CPR) was not initiated, and the resident expired. This resulted in actual harm and the potential for serious harm to the health and safety of all residents in the facility that is Immediate Jeopardy and Substandard Quality of Care. The findings are: The facility Policy and Procedure titled: CODE 99-Basic Life Support (BSL) with a review date of [DATE] documented the facility will provide basic life support for individuals (patient /resident, visitor or staff) who develop a sudden change in medical condition affecting the cardiovascular, [MEDICAL CONDITION] or [MEDICAL CONDITION] system or any other life -treating emergency. Procedure included: All Clinical Staff/BLS Certified Staff verify DNR status: check for purple armband indicating DNR status of the resident; check the physician orders. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, an assessment tool) dated [DATE] documented Resident #1 had a Brief Interview of Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) indicating severe impairment in cognition. A Nursing Note dated [DATE] at 12:10 PM, documented ADVANCE DIRECTIVE: during Comprehensive Care Plan Meeting Resident #1's Health Care Proxy (HCP) asked that the Do Not Intubate (DNI) and DNR order be rescinded. Order was canceled. A Physician order [REDACTED]. An Occurrence Investigation Summary Report dated [DATE], documented on [DATE] at approximately 7:00 AM, the Respiratory Therapist (RT) #1, observed that Resident #1 was not responsive. RT#1 called for assistance and the Medical Emergency Rapid Response Team was called and emergency care initiated per facility protocol. One of the Registered Nurse's (RN), #1, who responded, went to verify the advanced directives of the resident. RN#1 returned to the staff providing care and informed them that the resident was DNR. Resident #1 was assessed to be unresponsive, no pulse, no audible breath sounds and no palpable blood pressure. Resident #1 was pronounced deceased by RN #1 and RN #2 at 7:03 AM. During observation on [DATE], it was noted Resident #1's spine of the Paper Medical Record contained purple (DNR) label with Resident's name, room number and Medical Doctor (MD) name. During an interview on [DATE] at 2:07 PM, the Licensed Practical Nurse (LPN) #1 who worked 11 PM-7 AM shift on [DATE], stated that RT#1 ran out of Resident #1's room to the nursing station and called her and RN #3 to come and see the resident. LPN #1 stated Resident #1 did not have a wrist band, and RT #1 told her to call Rapid Response while RN#1 went to check the resident's code status in the chart. LPN #1 stated RN #1 returned and said Resident #1 had a DNR order. LPN #1 stated if the resident was noted unresponsive, she should check the wrist band and the MD order in the Electronic Medical Record (EMR). During an interview on [DATE] at 2:50 PM, RN #1, who worked on the 7 AM -3 PM shift on [DATE] stated RT#1 came out of Resident #1's room and asked nurses to assess the Resident. RT #1 and RT #2 were in the room. RN #3 was checking vital signs and RT#1 was using the Ambu bag (artificial manual breathing unit) on the resident. RN #1 stated she went to check Resident #1's chart for advanced directives because the resident did not have a wrist band. She checked the paper chart, saw a purple paper on the side of the chart and inside the chart there was a DNR order from the hospital dated [DATE]. RN#1 stated she did not check the resident DNR status in the EMR. RN#1 stated she informed the team that the resident was a DNR. During an interview on [DATE] at 3:20 PM, the Social Worker #1 (SW) stated that Resident #1 came from the Hospital with a HCP and a DNR order. A conference call care plan meeting was held with the HCP on [DATE] and the DNR order was rescinded by the family as Resident #1 was doing better in the facility. The MD was notified and the DNR order was discontinued. The SW stated he sent an email to the facility staff which included the Unit Clerk, Nurse Manager and Nurse Supervisor to alert them of Resident #1's change in code status. The SW also stated the Unit Clerk should have changed the purple (DNR) chart insert to a white (Full Code) chart insert. During an interview on [DATE] at 8:30 AM, RT#1, who worked the 12 AM -8 AM shift on [DATE], stated he was assigned to Resident #1. At approximately 7:00 AM, he heard the alarm go off in Resident #1's room. The RT #1 stated he responded and saw the ventilator indicated Low Minute Volume. RT#1 stated he put some air in the cuff of the [MEDICAL CONDITION] and the alarm stopped. The resident was ok and not in respiratory distress. RT#1 stated he left the room and after a few minutes the alarm went off again. He returned to the room, put more air in the cuff and pressed the cuff to see if it held the air. RT#1 stated the cuff did not hold the air. RT#1 concluded that the pilot balloon (tubing that inflates the cuff at the base of the [MEDICAL CONDITION] to hold it in place within the trachea) was defective. RT#1 stated in a situation like this, the [MEDICAL CONDITION] would need to be changed. RT#1 stated Resident #1 was stable at this point in time. RT#1 called second RT#2 for assistance and went to the supply room to obtain a new [MEDICAL CONDITION] kit. RT#1 stated he returned to the room with RT#2 and noted the resident was unresponsive. They took off the inner cannula (inner tube of [MEDICAL CONDITION]) and saw it was plugged with mucus. RT #2 applied a new cannula and suctioned the resident. RT# 1 stated he checked the vital signs and Resident #1 had no pulse and no respirations, so he ran outside to call for help, and the resident's bed was lowered in preparation for CPR. RT#1 stated while he was waiting for Resident #1's code status he started a manual ventilation via Ambu-bag. The resident was not wearing a wrist band. RT#1 stated the nurses came to the room and a nurse (RN #1) went back to check the Advanced Directives in the EMR and call Rapid Response team. RT#1 stated when RN #1 came back, she told the team the resident had a DNR order and all interventions were stopped. During an interview on [DATE] at 11:00 AM, the Associate Director of Nursing (ADNS) stated she was informed at approximately 8:00 AM on [DATE], by the Performance Improvement Director who was reviewing the chart of Resident #1 that the resident had a Full Code order. The ADNS stated she informed the Administrator immediately and started an investigation. The ADNS stated when a resident is noted to be unresponsive, the nurse should verify the Advanced Directives in the EMR. During an interview on [DATE] at 1:39 PM, the Unit Clerk (UC) stated she did not see the email dated [DATE] that Resident #1's code status was changed from DNR to full code and nobody verbally told her about any changes. The UC stated the SW or RN Supervisor must tell her the resident had a change in status. She would remove the MOLST form from the front of the chart and put in back of the paper chart. The UC stated it is her responsibility to print a wrist band, give it to the nurse and update the color of the spine on the paper chart. During an interview on [DATE] at 5:26 PM, the Medical Director stated he was informed by the ADNS via email, that an investigation was ongoing regarding Resident #1, who had a Full Code order and did not receive resuscitation. The Medical Director stated he reviewed the chart and it was clear Resident #1 should have been resuscitated. During an interview on [DATE] at 5:57 PM, the Administrator stated the ADNS notified him in the morning of [DATE] about the incident and ADNS had started the investigation. The Administrator stated they were doing a root cause analysis; staff were suspended and the policy on Advanced Directives was changed. The Administrator stated the nurse should have checked the MD order in the EMR, not in the paper chart. Immediate Jeopardy was removed on [DATE], during the onsite abbreviated survey based on the following corrective actions taken by the facility: The Administrator was immediately informed, and all staff involved were interviewed and statements collected. All staff involved were immediately suspended pending the outcome of the investigation. A house-wide audit of all residents (census 253) was completed on [DATE] to ensure the correct armband was in place for every resident. An audit was performed on all discontinued DNR orders from [DATE] to [DATE] to ensure all residents with a discontinued DNR status was reflected on the paper chart. The Code 99 policy and procedure was reviewed and revised to include: (1) taking the computer to the location of the medical emergency to view the DNR/code status; (2) two clinicians will need to verify the DNR/code status by checking the physician's orders [REDACTED]. Staff was in-serviced on revised policy starting on [DATE] which included 44 of 70 RNs, 13 of 24 RTs, and 20 of 38 LPNs and ongoing. Policy revision was completed on [DATE]. The facility revised the Rapid Response and Code 99 EMAR progress note template and form to include the new 2 clinician verification of Advanced Directives on [DATE]. 415.3 (e)(2)(iii)