Every finding on record at St Margarets Center

Based on records review and interviews during the recertification survey, the facility did not ensure each resident's drug/medication regimen was managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being for 10 (Resident #s 1, 6, 10, 45, 46,48, 54, 62, 68, and 79) of 19 residents reviewed for unnecessary medications. Specifically, for Resident #s 1, 6, 10, 45, 46, 48, 54, 62, 68, and 79, as-needed psychotropic medication orders did not include end dates. This is evidenced by: A facility policy titled, Medication Management dated 12/10/2024, documented that as needed orders for psychotropic drugs were limited to 14 days. The use of psychotropic medication to treat an emergency situation must be consistent with the requirements regarding as needed orders for psychotropic medications. Resident #1 Resident #1 was admitted to the facility with the diagnoses of spastic quadriplegic cerebral palsy (movement disorder which include poor coordination, stiff muscles, and tremors), gastro-esophageal reflux disease, and neuromuscular scoliosis (a type of spinal curvature that results underlying neurological or muscular disorders). The Minimum Data Set (an assessment tool) dated 10/18/2024 documented the resident was rarely/never understood by others, rarely/never understood others, and was severely cognitively impaired. An order dated 7/24/2024 documented diazepam (a psychotropic medication) 10 milligrams per 0.1 milliliter 1 spray in nostril as needed for seizures 5 minutes or greater or 3 or more cluster seizures in 1 hour. There was no end date documented. Resident #46 Resident #46 was admitted to the facility with the diagnoses of spastic diplegic cerebral palsy (movement disorder which include poor coordination, stiff muscles, and tremors), seizures, and autistic disorder (a lifelong developmental disability that affects how people communicate and interact with the world). The Minimum Data Set, dated dated dated [DATE] documented the resident was rarely/never understood by others, rarely/never understood others, and was severely cognitively impaired. An order dated 10/02/2023 documented diazepam (a psychotropic medication) 10 milligrams per 0.1 milliliter 1 spray in nostril as needed for seizures 5 minutes or greater or 3 or more cluster seizures in 1 hour. There was no end date documented. Resident #79 Resident #79 was admitted to the facility with the diagnoses of cervical spinal cord injury, anxiety disorder, and acute stress reaction (a short-term psychological response to a traumatic event). The Minimum Data Set, dated dated dated [DATE] documented the resident was understood by others, could understand others, and was cognitively intact. An order dated 1/10/2025 documented diazepam 1 milligram via gastrostomy tube every 8 hours as needed for anxiety. There was no end date documented. During an interview on 2/14/2025 at 10:22 AM, Consultant Pharmacist #1 stated the facility was provided with a list of all residents who had their medications reviewed and the recommendations made. Consultant Pharmacist #1 stated they informed the physicians that as needed psychotropic medications required end dates, even if prescribed for seizures. During an interview on 2/14/2025 at 1:05 PM, Medical Director #1 stated they did not put end dates on psychotropic medications prescribed for seizure disorders. There should be a rationale in the medical provider notes, but the notes 'probably weren't present' because they think of the psychotropic (specifically diazepam) as an anticonvulsant and not a psychotropic medication. During an interview on 2/14/2025 at 1:19 PM, Medical Doctor #1 stated the nurses would give the prescriber a list of medications for renewal and they would renew the medications as needed. The Medical Doctor #1 was not able to state why there were no end dates for as needed psychotropic medications, but stated they understood the rationale behind the regulation. During an interview on 2/18/2025 at 12:25 PM, Director of Nursing #1 stated they were aware of the need for as needed psychotropic medications to have end dates. 10 New York Codes, Rule and Regulations 415.18 (c)(2) 51958

Based on record review and interviews during a recertification survey, the facility did not establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infection. Specifically, the facility water management and sampling plan did not include a simple schematic that visually described the building water system and the identification of areas where Legionella could grow and spread. This is evidenced by: There was no documented evidence that the facility water management and sampling plan included a simple schematic that visually described the building water system and the identification of areas where Legionella could grow and spread. During an interview on 02/11/2025 at 11:46 AM, Senior Regional Director of Facilities #1 stated that the facility Legionella Management Plan would be updated to include a flow chart that described the building water system and the identification of areas where Legionella could grow and spread. 10 New York Codes, Rules, and Regulations 483.80(a)(1)(2)(4)(e)(f)

Based on observation, record review, and interviews during a recertification and abbreviated survey (Case #s NY00311240, NY00320508, NY00321961, and NY00329555), the facility did not ensure residents were free from neglect for 4 (Resident #s 1, 5, 6, and #45) of 19 residents reviewed for abuse and neglect. Specifically, (a.) Resident #1, was provided personal care by Certified Nurse Aide #2 instead of two staff members as their care plan indicated, and Resident #1's bed was not set up as the care plan required, subsequently, the resident hit their head and sustained a small injury to their forehead; (b.) Resident #5 sustained a fall from a mechanical lift due to improper technique; (c.) Resident #6 sustained a fractured left great toe with evidence of improper transfer found; and (d.) Resident #45 was being readied to be transferred from their wheelchair, but the Certified Nurse Aide #3 did not buckle the resident's seatbelt causing the resident to fall from their wheelchair to the floor. This is evidenced by: The facility policy titled, Abuse Prevention and Prohibition Policy, dated [DATE], documented that it was the policy of the facility to prohibit and protect residents from any form of abuse, exploitation, mistreatment, misappropriation and neglect. The policy further defined abuse as the willful inflection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Neglect was defined as the failure to provide timely, consistent, safe, adequate, and appropriate services, treatment, and/or care to a resident, while such resident was under the supervision of the facility. Neglect may include but was not limited to failure to carry out physician orders, medications omission, treatment omission or failure to follow the care plan or provide emergency services; failure to adequately supervise whereabouts and activities of residents; and /or failure to provide adequate hydration and nutrition. A facility policy titled, Using the Care Plan, dated [DATE], documented under policy interpretation and implementation that failure to follow a resident's care plan as written could pose safety risks to the resident. Disregard for and failure to follow a care plan, in some cases, could be deemed neglectful. Disciplinary actions imposed by family and State licensing agencies could be imposed. Resident #1 Resident #1 was admitted to the facility with the diagnoses of profound intellectual disabilities (a level of intellectual disability characterized by having an average mental age of 3 years and below), disorder of bone density and structure (a medical condition where there is an abnormality in the density and structure of bones), and spastic quadriplegic cerebral palsy (a severe form of cerebral palsy that affects all four limbs, trunk, and the face characterized by severe muscle stiffness and spasticity). The Minimum Data Set (an assessment tool), dated [DATE], documented that the resident had severe cognitive impairment, and rarely or never could be understood or understand others. Per the facility investigation, on February 18, 2023, Resident # 1 was in their bed on the North Unit. Certified Nurse Aide #2 reported that they went into Resident #1's room to do care by themselves and did not seek out assistance from another staff although they knew that Resident #1 required the assistance of two staff. Certified Nurse Aide #2 stated that they did not know why they did not seek assistance and there was no excuse. During the care given, Resident #1 rolled over and hit the wall, injuring their forehead. Resident #1's care plan and Kardex documented that the resident's bed should not have been against the wall, mats should have been on the floor on either side of the bed, and Certified Nurse Aide #2 should have had a second care giver with them. Resident #5 Resident #5 was admitted to the facility with the diagnoses of microcephaly (a condition where the head is much smaller than expected often due to abnormal brain development), dysphagia (difficulty swallowing food or liquids), and myoclonus (a sudden and involuntary muscle spasm). The Minimum Data Set, dated dated [DATE], documented that the resident had severe cognitive impairment, and rarely or never could be understood or understand others. Facility's Investigation dated [DATE], Certified Nurse Aide #4 transferred Resident #5 from the bed to the wheelchair with a full mechanical lift. During the transfer, Resident #5's bottom half slid out of the mechanical lift sling and landed on the floor. Certified Nurse Aide #4 was aware that a full mechanical lift required 2 staff members but attempted the transfer without assistance. Resident #5 was transferred to the hospital for evaluation and returned to the facility with no injuries from the incident. During an interview on [DATE] at 12:21 PM, Director of Nursing #1 stated that Certified Nurse Aide #4 was let go following their care plan violation of not using two people for resident care. Resident #6 Resident #6 was admitted to the facility with the diagnoses of epilepsy (a brain condition that causes recurring seizures), scoliosis (a sideways curvature of the spine that can cause a prominent shoulder blade, uneven waist, and back pain), and anoxic brain damage (a condition that occurs when the brain is deprived of oxygen for an extended period of time). The Minimum Data Set, dated dated [DATE], documented that the resident had severe cognitive impairment, and rarely or never could be understood or understand others. Facility's Investigation dated [DATE], Resident #6 was found with discoloration to their left great toe. Certified Nurse Aide #1 stated they had noticed the bruise the shift before. Certified Nurse Aide #1 stated they had completed multiple transfers of Resident #6 independently (scoop transfers) that were not appropriate as the resident was care planned for fully assisted transfers with at least 2 staff members. It was determined that the independent scoop transfers put the resident at risk for injury. During an interview on [DATE] at 12:21 PM, Director of Nursing #1 stated the investigation into the resident's fractured toe showed the care plan for transfers was violated and this put the resident at risk and probably caused the fracture. Resident #45 Resident #45 was admitted with the diagnoses of diagnoses of asthma with exacerbation (a worsening of asthma symptoms, including coughing, wheezing, chest tightness, and shortness of breath), congenital hydrocephalus (a condition where there's too much cerebrospinal fluid in the baby's brain at birth that can cause brain damage and long term problems), and spastic quadriplegic cerebral palsy (a severe form of cerebral palsy that affects all four limbs, trunk, and the face characterized by severe muscle stiffness and spasticity). The Minimum Data Set, dated dated [DATE], documented that the resident had severe cognitive impairment, and rarely or never could be understood or understand others. Facility's Investigation dated [DATE], Certified Nurse Aide #3 reported that they had been preparing to transfer Resident #45 from their wheelchair to bed. Certified Nurse Aide #3 unbuckled the resident's seatbelt to place the sling for the Hoyer lift under them. Certified Nurse Aide #3 reported that when they went to turn to Resident #45 on to their side to slide sling under them, Certified Nurse Aide #3 needed to tilt the resident's wheelchair. Certified Nurse Aide #3 did not re-buckle the seatbelt and Resident #45 fell to the floor onto their knees and hit their head on the floor. During an interview on [DATE] at 12:21 PM, Director of Nursing #1 stated Certified Nurse Aide #2 was let go following their care plan violation of not using two people for resident care. Director of Nursing #1 could not speak to what happened to Certified Nurse Aide #3, but they did not believe Certified Nurse Aide #3 was employed by the facility anymore. They stated the injuries were considered abuse or neglect, cut and dry if it was a care plan violation. Each staff member was precepted for 10 days and if the staff still could not follow a care plan, then there was a problem, and the staff would not be kept on. Abuse and neglect were part of ongoing education with the staff. There was a safe handling review done house wide after the care plan violation/safe handling incidents occurred. 10 New York Codes, Rules, and Regulations 415.4 (b)(1)(i) 48744

Based on record review and interviews conducted during recertification and abbreviated survey (case #NY00329555), the facility did not ensure that the development and implementation of comprehensive person-centered care plans included measurable objectives and timeframes to meet residents' medical, nursing, mental and psychosocial needs for 3 (Resident #s 4, 59, and 62) of 19 residents reviewed for comprehensive care plans. Specifically, (a.) for Resident #s 4 and 59 , the Comprehensive Care Plan did not include the use of medications with specific indication for use; (b.) for Resident #62, intervention of floor mat on the floor was not implemented to ensure safety while at play. This is evidenced by: A facility policy titled, Care Plans, dated 4/01/2019, documented under Policy Interpretation and Implementation: 1. Each resident's care plan was designed to: a. Incorporate identified problem areas; f. Identify the professional services that are responsible for each element of care; i. Reflect currently recognized standards of practice for problem areas and conditions. A facility policy titled, Using the Care Plan, dated 4/01/2013, documented under policy interpretation and implementation. Failure to follow a resident's care plan as written could pose safety risks to the resident. Disregard for and failure to follow a care plan, in some cases, could be deemed neglectful. Disciplinary actions imposed by family and State licensing agencies could be imposed. Resident #4 Resident #4 was admitted to the facility with diagnoses of septo-optic dysplasia of brain (a rare congenital malformation syndrome that features a combination of the underdevelopment of the optic nerve, pituitary gland dysfunction, and absence of the midline part of the brain), cardiomegaly (an enlarged heart), expressive language disorder (a communication disorder characterized by difficulty using expressive spoken language that is below the appropriate level for the mental age). The Minimum Data Set (an assessment tool) dated 10/13/2024, documented the resident had severe cognitive impairment, and rarely or never could be understood or understand others. A physician order dated 1/21/2020 at 3:45 PM documented an order for zinc oxide cream 22.5% - apply to buttocks/peri area topically as needed for diaper rash. Apply as needed at each brief/incontinence change. Contact medical director if no improvement within 48 hours of initiation. A physician order dated 3/16/2016 at 7:00 AM documented an order for albuterol sulfate u-d 2.5 milligrams per 3 milliliter vial nebulizer - 1 vial inhale orally every 4 hours as needed for wheezing. A physician order dated 9/14/2022 at 4:30 PM documented an order for Propranolol HCl Tablet 10 milligrams - give 1 tablet via gastric tube every 6 hours as needed for heart rate over 90. Hold for systolic blood pressure less than 110. There was no documented care plan focuses related to using creams after episodes of incontinence, giving respiratory treatments when Resident #4 required them for wheezing, or monitoring blood pressures to determine the need for blood pressure medication. Resident #59 Resident #59 was admitted to the facility with the diagnoses of cerebral palsy (a group of disorders that affect movement, muscle tone, balance, and posture), profound intellectual disabilities (the most severe category of intellectual disability characterized by the inability to live independently, being in need of close supervision, limited communication, and physical restrictions), and intestinal malabsorption (a digestive health condition in which the gastrointestinal tract is unable to absorb one or more nutrients). The Minimum Data Set, dated dated dated [DATE] documented the resident had severe cognitive impairment, and rarely or never could be understood or understand others. A physician order dated 11/23/2023 at 10:15 AM documented an order for albuterol sulfate inhalation nebulization solution (2.5 milligrams per 3 milliliters) 0.083% - 1 vial inhale orally via nebulizer as needed for wheezing. There was no documented care plan focuses related to giving respiratory treatments when Resident #59 required them for wheezing or difficulty breathing. Resident #62 Resident #62 was admitted with the diagnoses of extreme immaturity of newborn, gestational age 24 completed weeks, bronchopulmonary dysplasia originating in the perinatal period, congenital tracheomalacia. The Minimum Data Set, dated dated dated [DATE] documented the resident had severe cognitive impairment, and rarely or never could be understood or understand others. Resident #62's Comprehensive Care Plan for Activities of Daily Living Self-Care Performance deficit related to impaired cognition, dated 5/10/2021, documented interventions of out of bed environment (3) floor mat with supervision to play on the mat, caregiver on the mat to assist if nearing edge of the mat, to avoid toys (self-hitting with toys) or other residents, and to maintain safety as they quickly rolled, crawled, sat and pulled to tall kneel. The facility reported incident dated 1/19/2023 at 11:50 AM, documented that Resident #62 was left alone on the floor mat, not attended to by staff on the mat with them, and was not engaged per the comprehensive care plan interventions. During an interview on 2/14/2025 at 12:20 PM, Licensed Practical Nurse #3 stated that care plans were updated by the charge nurses or the social workers. It was their expectation that if a resident was on respiratory treatments, there would be a respiratory care plan for the resident. Licensed Practical Nurse #3 stated that medical interventions required care plan interventions. During an interview on 2/14/2025 at 12:24 PM, Registered Nurse #1 stated they would not expect that a resident receiving albuterol treatments would be guaranteed to have a respiratory care plan, if that was the only thing that needed to be done. For example, if the resident could clear their own secretions and had no other respiratory issues, they would not necessarily expect that there would be an active respiratory care plan. Registered Nurse #1 stated that not every medication required a care plan. During an interview on 2/18/2025 at 12:21 PM, Director of Nursing #1 stated that medications did not need to be specifically care planned for. Director of Nursing #1 confirmed that resident Kardex information was generated from the information in care plans. Director of Nursing #1 eventually stated that they could see why care planning based on medications and medical issues would be important for all the information to be contained in one place. Director of Nursing #1 stated care plan interventions for supervision and behavioral management should be followed. They would expect the Certified Nurse Aides to follow and implement the care plan as written 10 New York Codes, Rules, and Regulations 483.21(b)(1) 48744 51958

Based on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure drugs and biologicals were stored properly and labeled in accordance with professional standards of practice. Specifically, opened medications had no open and/or expiration dates for 2 out of 5 medication carts reviewed for medication storage. This is evidenced by: The Facility's Medication Storage Policy, revised on 1/10/2024, documented under Medication Storage section that the nursing staff was responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner; medications were stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems; medications were stored separately from food and were labeled accordingly. Under Medication Labeling section, the policy documented that labeling of medication and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices; multi-dose vials that have been opened would be dated and discarded within 28 days unless the manufacturer's label specified a shorter or longer duration of use once opened. During an observation on 2/13/2025 at 9:41 AM, South Unit, medication Cart #1 contained an opened bottle of Famotidine, an opened bottle of Valproic Acid, and an opened bottle of Levetiracetam Solution. None of the opened bottles had open or expiration dates. During an observation on 2/13/2025 at 10:05 AM, North Unit, medication Cart #1 contained an opened bottle of Glycopyrrolate, 2 opened bottles of Levetiracetam Solution, and an opened bottle of Centra Vite. None of the opened bottles had open or expiration dates. During an interview on 2/13/2025 at 9:41 AM, Licensed Practical Nurse #1 stated that the opened medications should have been labeled when they were opened. During an interview on 2/13/2025 at 10:05 AM, Licensed Practical Nurse #2 stated they knew medications should be labeled with the date opened. When asked if the carts were checked for storage issues, Licensed Practical Nurse #2 stated that they only worked 3 days a week so they could not speak for other shifts. During an interview on 2/18/2025 at 12:21 PM, Director of Nursing #1 stated that nursing staff was responsible for checking medication storage areas for expired medications or medications requiring dates opened. Director of Nursing #1 stated that there were plenty of staff in the building, and there was no reason that they believed the staff could not maintain proper medication storage. 10 New York Codes, Rules, and Regulations 415.18(d)

Based on record review and interviews during an abbreviated survey (Case #NY00323346), the facility did not ensure that alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 resident (Resident #1) of 22 residents reviewed for abuse. Specifically, the facility did not ensure they reported the alleged sexual abuse of Resident #1 to the New York State Department of Health (DOH) within 2 hours of learning about it when the hospital discharge summary dated 8/24/2023 was reviewed that documented the allegation of sexual abuse or following the resident's representative call to the facility who voiced concerns regarding the alleged abuse. This was evidenced by: The Policy and Procedure titled, Incident Reporting Policy reviewed 4/6/2022, documented for allegations involving abuse, the incident must be reported to DOH no later than 2 hours after the allegation was discovered. Resident #1 Resident #1 was admitted to the facility with diagnoses of obstructive hydrocephalus (fluid buildup on the brain that cannot drain on its own), quadriplegia (paralysis of all 4 limbs plus the torso), and severe hypoxic ischemic encephalopathy (brain damage caused by lack of oxygen to the brain). The Minimum Data Set (an assessment tool) dated 6/26/2023, documented the resident had severe cognitive impairment, was rarely/never understood, and could rarely/never understand others. The Hospital Discharge Summary dated 8/24/2023 at 7:14 AM, documented the resident's discharge diagnoses included traumatic injury to the genital area. It documented when the bedside Registered Nurse attempted to catheterize the resident on 8/18/2023, they had concerns regarding cuts to the labial (genital) area. The Medical team also assessed and expressed concern. The SANE examiner (a nurse trained specifically in rape investigation) was called and had low concern for sexual assault. The Admission/Readmission Medical Doctor Visit note dated 8/24/2023 at 4:28 PM, documented urethral trauma (injury to the duct urine passes through when going to the bathroom) was noted on exam. A SANE (rape) exam had been completed. The suspicion for sexual abuse was low but was reported. A Social Services Note dated 9/1/2023 at 11:10 AM, documented Social Worker #1 (SW) returned a phone call from the family representative who was very concerned about what was discovered at the hospital. The SW stated they would look into it and talk with the Administrator before calling them back to discuss further details of the event. There was no further documentation from the SW regarding reporting it to the Administrator or a call back to the resident representative. During an interview on 9/21/2023 at 10:27 AM, SW #1 stated they spoke with Resident #1's resident representative who told them the hospital notified them they had concerns there were cuts and abrasions in the resident's genital area, so they spoke with their Supervisor (the Administrator). The SW stated Administrator was very shocked they had not received a phone call from the hospital. During an interview on 10/4/2023 at 9:28 AM, the Director of Nursing (DON) stated they knew the resident's representative called upset about what the hospital had reported and wanted to discuss it. They stated since the hospital reported it, they were not sure what their responsibility for reporting the alleged incident was. The DON stated abuse must be reported within 2 hours once an allegation became known. During an interview on 10/4/2023 at 11:47 AM, the Administrator stated they could not recall a date they first found out about the alleged incident. They stated the resident's representative had called and voiced concern. The Administrator stated they had read the hospital discharge summary and at the time they did not feel they needed to report the alleged abuse because the hospital had investigated. The Administrator stated abuse needed to be reported within 2 hours of receiving an allegation. 10 NYCRR 415.4(b)

Based on record review and interviews during an abbreviated survey (Case #NY00323346), the facility did not ensure in response to allegations of abuse the facility must have evidence that all alleged violations were thoroughly investigated for 1 resident (Resident #1) of 22 residents reviewed for abuse. Specifically, the facility did not ensure it investigated the allegation of sexual abuse for Resident #1 when the hospital discharge summary dated 8/24/2023 that documented it was reviewed, or following the resident's representative call to the facility who voiced concerns regarding the alleged abuse. This was evidenced by: The Policy and Procedure titled, Incident Reporting Policy reviewed 4/6/2022, documented the licensed nurse or supervisor shall promptly initiate a thorough investigation regarding the alleged incident to determine whether it is reportable in accordance with this policy. The investigation must be thorough and complete. Resident #1 Resident #1 was admitted to the facility with diagnoses of obstructive hydrocephalus (fluid buildup on the brain that cannot drain on its own), quadriplegia (paralysis of all 4 limbs plus the torso), and severe hypoxic ischemic encephalopathy (brain damage caused by lack of oxygen to the brain). The Minimum Data Set (an assessment tool) dated 6/26/2023, documented the resident had severe cognitive impairment, was rarely/never understood, and could rarely/never understand others. The Hospital Discharge Summary dated 8/24/2023 at 7:14 AM, documented the resident's discharge diagnoses included traumatic injury to the genital area. It documented when the bedside Registered Nurse attempted to catheterize the resident on 8/18/2023, they had concerns regarding cuts to the labial (genital) area. The Medical team also assessed and expressed concern. The SANE examiner (a nurse trained specifically in rape investigation) was called and had low concern for sexual assault. The Admission/Readmission Medical Doctor Visit note dated 8/24/2023 at 4:28 PM, documented urethral trauma (injury to the duct urine passes through when going to the bathroom) was noted on exam. A SANE (rape) exam had been completed. The suspicion for sexual abuse was low but was reported. During an interview on 10/4/2023 at 9:28 AM, the Director of Nursing (DON) stated there was not an investigation done. The DON stated they probably should have started an investigation when the resident's representative called and expressed concern about what the hospital had reported to them. During an interview on 10/4/2023 at 11:47 AM, the Administrator stated they could not recall a date they first found out about the alleged incident. They stated the resident's representative had called and voiced concern. They stated they read the hospital discharge summary and spoke with the resident's representative, but no further investigation was done. They stated at the time, they did not feel they needed to report the incident or investigate it because the hospital had investigated. The Administrator stated if the hospital had reported the resident may have been sexually abused to the facility, they would have done a full investigation. 10 NYCRR 415.4(b)(3)

Based on record review and interviews during an abbreviated survey (Case #s NY00305353 and NY00316934), the facility did not ensure respiratory care, including tracheostomy care, was provided consistent with professional standards of practice for 7 (Resident #s 6, 7, 8, 9, 10, 11, and 12) of 7 residents reviewed. Specifically, the facility did not consistently provide tracheostomy (surgical procedure to create an opening through the neck into the trachea (windpipe) tube (TT) changes as ordered from August through October 2022 for (Resident #'s 6, 7, 8, 9, 10, and 11). Also, for Resident #s 8 and 9, the facility did not develop and implement a tracheostomy care plan. Care plans were not initiated until 6/15/2023. For Resident #12, the facility did not follow their procedure for emergent TT reinsertion following accidental extubation (unintentional and uncontrolled removal of the TT) on 5/19/2023, when staff did not use the obturator (component of a TT used upon insertion and consists of a thin, rigid, and curved rod that passes inside the TT to make insertion easier) to reinsert the TT. Additionally, Resident #12's tracheostomy care plan did not document emergency interventions for unplanned extubation. This is evidenced by: The Policy and Procedure (P&P) titled Changing the Tracheostomy Tube Scheduled and Emergent Changes last revised 11/10/2022, documented it was the facility's policy to change the tracheostomy tube (TT) monthly, as needed and as ordered by the physician and documented changes may also be required in an emergent situation. The purpose of the P&P documented to maintain a stable airway and to direct nursing staff on how to handle an emergent need to change a TT. It documented the following equipment was to be used: TT with outer cannula, inner cannula (if applicable) and obturator. In an emergent situation full dislodgement of the TT, the TT should only be replaced by a Registered Nurse, Respiratory Therapist, or MD. The P&P documented full dislodgement referred to the actual TT being out of the resident's stoma (surgically created opening). The P&P documented the procedure for a TT change and included instructions for using the obturator. Per the State Operations Manual (SOM) Rev. 211, 02-03-23, an extubation creates an emergency situation that requires that an obturator be readily available that can be used by competent staff for reinsertion. The P&P titled Care Plans last revised 4/1/2019, documented that upon admission, comprehensive care plans would be initiated within 48 hours and would contain healthcare information necessary to properly care for a resident. The P&P documented each resident's care plan was designed to incorporate risk factors associated with identified problems; reflect the treatment goals, timetables, and objectives in measurable outcomes; and would reflect currently recognized standards of practice for problem areas and conditions. It documented that the Care Planning/Interdisciplinary Team was responsible for the review and updating of care plans. Resident #6: Resident #6 was admitted to the facility with diagnoses of tracheostomy status, quadriplegia (paralysis from the neck down, including the trunk, legs, and arms) , and persistent vegetative state. The Minimum Data Set (MDS - an assessment tool) dated 8/12/2022, documented the resident received tracheostomy care while a resident of the facility and within the last 14 days. The Comprehensive Care Plan (CCP) for Tracheostomy related to reactive airway disease, last revised on 4/17/2023, documented the resident would have no signs and symptoms of infection through the review date. Review of the Treatment Administration Record (TAR) dated August, September, and October, documented a physician order dated 5/17/2022 for tracheostomy (tube) change every four weeks by the Registered Nurse (RN) and as needed. The TAR did not document the TT change was signed as being done for the months noted above. The CCP did not document an intervention for TT changes. The North-West unit Trach Change List documented that Resident #6's TT change was due monthly and was not completed in August, September, and October 2022. The facility's Final Summary Report for Resident #6 dated 11/2/2022, documented the Director of Nursing (DON) #1 was made aware that the resident had not had their ordered TT change completed on 11/1/2022. The facility initiated an investigation and determined that Resident #6 had not had their TT changed as ordered for the months of August, September, and October of 2022. On 11/2/2022, the TT was changed without difficulty by a Respiratory Therapist (RT) in the presence of the physician (MD). Resident #11: Resident #11 was admitted to the facility with diagnoses of tracheostomy status, obstructive sleep apnea (OSA), and asthma. The MDS dated [DATE], documented the resident received tracheostomy care while a resident in the facility and within the last 14 days. The CCP for Tracheostomy related to OSA and asthma, last revised 9/14/2021, documented the resident would have no signs and symptoms of infection through the review date. Review of the TAR dated August, September, and October, did not document a physician order for routine TT changes. The CCP did not document an intervention for TT changes. The North-West unit Trach Change List documented that Resident #11's tracheostomy (tube) change was due monthly and was not completed in August, September, and October 2022. Review of the facility's Final Summary Report for Resident #6 dated 11/2/2022, documented the facility's audit concluded that one other resident (#11) had missing signatures for all 3 months (August, September, October). It documented that on 11/3/2022, Resident #11 was assessed, and the TT change was completed. During an interview on 5/8/2023 at 9:26 AM, the Administrator (ADMIN) #1 stated they identified a problem with Resident #6's TT not being changed per physician order and investigated other residents. The ADMIN #1 stated they identified 6 residents and then reported to the New_York State Department of Health (NYSDOH). The ADMIN #1 stated they later identified an additional 11 residents, for a total of 17 residents that did not have TT done as ordered by the physician. The ADMIN #1 stated the former Registered Nurse Educator was responsible for ensuring the TT changes were done and for care planning related to the tracheostomy. The ADMIN #1 stated staff were reeducated about the importance of correct tracheostomy care via In-Service in November 2022. The ADMIN #1 stated there were no negative outcomes to any of the residents. During an interview on 5/12/2023 at 2:14 PM, the Infection Preventionist/MDS Coordinator (IP/MDS) #1 stated they saw on the 24-hour report that the change was not done on Resident #6 and in investigation was initiated. The facility did an August through September 2022 look back and found 17 residents from various units that did not have TT changes as ordered. The IP/MDS #1 stated the facility's policy was an MD order needed to be followed. The IP/MDS #1 stated they identified an issue with orders in the electronic medical record not being automatically carried over into the next month and were showing with a status of discontinued. The IP/MDS #1 stated when an order discontinues, it no longer appears on the TAR and the nurse would not know it had to be done. The IP/MDS #1 stated the nurse educator was responsible for monitoring the TT changes and no longer works in the facility. The IP/MDS #1 stated the DON #1 was currently doing the auditing of the TT changes. During an interview on 5/12/2023 at 4:03 PM, the DON #1 stated the issue with the TT changes not being done was identified during the morning meeting. The DON #1 stated TT changes were usually done once a month or every 4 weeks, depending on the physician order. The DON #1 stated the facility identified a problem with their electronic ordering system and said there were times when the order for the TT was discontinuing automatically, and also identified staff were not doing the TT when the order was on the TAR. The DON #1 stated it was their understanding that the RN educator was responsible for ensuring the TT changes were done and that the tracheostomy care plans were updated. The DON #1 stated the RN educator was terminated. Resident #12: Resident #12 was admitted to the facility with diagnoses of respiratory failure, tracheostomy status, and dependence on respirator (ventilator) status. The MDS dated [DATE], the resident received oxygen therapy, suctioning, tracheostomy care, and invasive mechanical ventilator while a resident of the facility and within the last 14 days. The CCP for Tracheostomy related to impaired breathing mechanics, last revised 11/16/2022, documented CCP interventions to monitor/document respiratory rate, depth, and quality. The CCP for Ventilator Dependent related to diaphragmatic weakness, last revised 11/16/2022, documented a CCP intervention for routine TT change by respiratory care. The CCP did not document emergency interventions for unplanned extubation. The Nursing Progress Note dated 5/19/2023 at 11:00 AM by Registered Nurse Manager (RNM) #1, documented RNM #1 entered the room and found the RT #1 trying to establish an airway as the TT was dislodged. The resident was unresponsive and cyanotic (a bluish color in the skin, lips, and nail beds caused by a shortage of oxygen in the blood) and had a thready pulse (weak and difficult to detect). The Progress Note dated 5/19/2023 at 2:41 PM by RT #2, documented they responded to a code blue alarm. The resident had decannulated (inadvertent removal of the TT out of the stoma). The Respiratory Care Note dated 5/19/2023 at 3:54 PM by RT #1, documented they were called into the room by the Certified Nurse Aide (CNA). RT #1 was not able to pass the suction catheter (through the TT). The resident was returned to bed where it was evident that they had become decannulated. RT #1 documented that a number of failed replacement attempts were made with the old and the new downsized TT and the resident was sent out to the hospital. The Incident Report dated 5/19/2023 at 10:45 AM by RNM #1, documented they responded to the ventilator alarm and desat (oxygen saturation level was decreasing) on the monitor. RNM #1 was advised by Certified Nurse Aide (CNA) #2 that the TT was out. The Final Report Summary for a code blue on the Vent unit on 5/19/2023, documented Resident #12 was tracheostomy status and required a ventilator to breathe at all times. On 5/19/2023, the resident was noted to have decreasing oxygen saturations and it was discovered that their TT was not in place. Attempts to reinsert the TT were unsuccessful and a code blue was called. Resident #12 was bagged per the advance directives in their MOLST until EMS arrived and brought the resident to the hospital. During an interview on 5/22/2023 at 1:46 PM, CNA #2 stated they told RT #1 they believed the TT was out because the TT ties looked loose where the gauze and TT were located. RT #1 then adjusted the TT ties and was going to try to suction the resident and then CNA #2 told RT #1 they really needed to get the resident into the bed because the resident's color was turning, and they looked pale. Once the resident was in bed, the ventilator started alarming and RT #1 saw that the TT was out. RT #1 then tried to put the TT back in. Shortly after, RNM #1 then came into the room. CNA #2 stated RT #1 told RNM #1 the TT was out and RNM #1 asked CNA #2 for the obturator. During a subsequent interview on 5/23/2023 at 1:09 PM, CNA #2 stated that when RNM #1 asked for the obturator, CNA #2 took it off the wall where it was always taped and handed it to RNM #1. During an interview on 5/22/2023 at 4:51 PM, RT #1 stated they were asked by CNA #2 to look at the resident because there was something not right about them. RT #1 saw the resident and CNA #2 told RT #1 they could hear something coming from the TT. RT #1 tried to suction the resident but could not pass the catheter through the TT. RT #1 stated the CNAs put the resident in the bed and then RT #1 saw that the TT was out. RT #1 then stated they tried to put the TT back in but when it was inserted it was false tract, which meant instead of going into the trachea, the TT goes in between the trachea and the outer tissues. RT #1 stated RNM #1 came into the room at that point. During a subsequent interview on 5/24/2023 at 3:25 PM, RT #1 stated the resident's TT was totally out of the stoma. RT #1 stated they did not use the obturator to reinsert the resident's TT when it first came out because RT #1 thought they could slip it right in. During an interview on 5/22/2023 at 2:46 PM, RNM #1 stated a code blue was called and when they walked into the resident's room, they heard CNA #2 say the TT was out. RNM #1 stated RT #1 had made an attempt to put the TT in without using the obturator but that did not work because it went into a false tract and the resident had no breath sounds. RNM #1 then asked for the obturator and CNA #2 handed it to them. During an interview on 5/23/2023 at 10:30 AM, LPN #5 stated the resident's face was obviously blue and RT #1 was trying to establish an airway by placing the TT but was having difficulty because the TT was going into a false tract, which meant it was not going into the trachea but was going into a different space. LPN #5 stated inserting the TT in a false tract was a risk of putting the TT in. LPN #5 stated they did not know if RT #1 used the obturator to reinsert the TT because things were already in motion when LPN #5 entered the room. LPN #5 stated the obturator was used to help guide the TT during insertion. LPN #5 stated the resident's TT obturator was kept in a bag at the bedside. LPN #5 stated that it was not standard practice to insert the TT without the obturator. LPN #5 stated they have seen the obturator being used during the TT changes that they have observed. During an interview on 5/23/2023 at 12:09 PM, RT #2 stated they heard the code blue announced and went into the resident's room. RT #2 stated RT #1 was in the room and said the TT was out and they attempted to put it back in. RT #2 stated that in an emergency situation it was a standard of practice to put the original TT back in. RT #2 did not know if RT #1 used the obturator to reinsert the TT. RT #2 stated the obturator for the TT was normally kept in a bag above the resident's bed and helped to keep the TT to stay rigid, so the TT was not bending when it was being inserted. RT #2 stated that during an emergency they might try to pop it (the TT) in really quick but would still want to use the obturator. RT #2 could not think of an instance where they would not have used it. RT #2 stated staff were assuming the TT was in false tract, which meant it is not where it was supposed to be and shifts somewhere else, because the TT was in but the resident had no breath sounds. During an interview on 5/23/2023 at 2:24 PM, RT Manager (RTM) #3 stated Resident #12 has always been a hard TT change because the resident's stoma did not line up with the opening in the trachea. RTM #3 stated staff would have to pull the stoma over to line it up before the TT was inserted. RTM #3 stated the obturator for the resident's TT was kept on the wall above their bed. RTM #3 stated if the TT was dislodged, the obturator would be inserted inside the TT to make it sturdier because the TT was kind of floppy. RTM #3 stated the obturator was used as a guide and was generally used during TT insertion. RTM #3 stated if the resident's TT was close to the stoma and only partially out, you might try to get it in at that second without using the obturator. RTM #3 stated a false tract was created when the TT got inserted between the trachea and the skin. During an interview on 5/25/2023 at 2:31 PM, the Director of Nursing (DON) #1 stated they responded to the code blue that was announced. The DON #1 asked what was happening and staff said the resident lost their TT and they thought it was in a false tract, which the DON #1 stated meant the TT was not in the trachea and air was going down the esophagus. The DON #1 told staff they wanted the resident on the floor so they could hyperextend the resident's neck to get better access to the trachea. The DON #1 stated the TT was not in the trachea because when staff were bagging the resident, the resident's face was blowing up and had swelling to their chest under their neck, that was hard when touched. The DON #1 stated it was called subcutaneous emphysema that was caused by trapped air in the tissue. The DON #1 stated the TT was removed and then the DON #1 attempted to put the TT in without using the obturator and it went into a false tract. The DON #1 stated RT #1 should have used the obturator and did not follow proper procedure. The DON #1 stated they were not familiar with the facility's policy for emergency TT replacement. During an interview on 6/9/2023 at 1:33 PM, RN #3 stated they were focused on bagging the resident and did not know if RT #1 used the obturator to reinsert the TT. RN #3 stated the TT was kind of [NAME] and the obturator was used to keep the TT more solid for easier insertion. RN #3 stated the resident's TT kept going into a false tract, which meant instead of going into the airway, the TT gets inserted around it and into the tissue. During an interview on 6/9/2023 at 2:00 PM, the Medical Director (MD) #3 stated the goal of accidental decannulation was to get the TT back in as quickly as possible. MD #3 stated it was a Nursing protocol and the facility's emergency protocol for each resident to have a replacement TT which includes an obturator in their room. MD #3 stated a false tract meant that air was not going into the lungs but was going into a space between the skin and the trachea, and as a result the resident developed what is called subcutaneous emphysema. During an interview on 6/20/2023 at 11:39 AM, the DON stated it was the responsibility of the RN Educator to ensure residents with tracheostomy had care plans in place with interventions for tube out procedures. The DON stated that everyone knew the tube out procedure that was based on the facility's emergency policy for TT reinsertion. The DON stated the RN Educator no longer worked at the facility. During an interview on 6/27/2023 at 1:00 PM, MD #2 stated they had not participated in the development of the facility's policies and procedures. MD #2 stated the obturator was a tool that was used to enable the insertion of the TT into the stoma that acts as a tract into the trachea, and then into the trachea. MD #2 stated a false tract does not exist. MD #2 stated the false tract was created with the introduction of the TT into tissue fascia (fibrous connective tissue that envelops, separates, or binds together muscles), which creates a blind pouch. MD #2 stated it was a traumatic placement of the TT. MD #2 stated if the TT was in a false tract, they would not have been able to oxygenate or ventilate the resident. MD #2 stated air would go into the tissues instead of the trachea and into the lungs. MD #2 stated the physical aspect of placing the TT could cause a false tract and it was a risk of TT placement. 10 NYCRR 415.12(k)(5(4)

Based on record review and interviews during an abbreviated survey (Case #NY00315997), the facility did not ensure that it provided pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for 1 (Resident #2) of 4 residents reviewed. Specifically, for Resident #1, the facility did not ensure an emergency anti-seizure medication prescribed as needed was available to administer on 4/15/2023, when the resident was having back- to-back seizures. The physician (MD) was notified and advised to send the resident to the hospital. This is evidenced by: Resident #2: Resident #2 was admitted to the facility with diagnoses of cerebral palsy, anoxic brain injury (caused by a complete lack of oxygen to the brain), and convulsions (rapid involuntary muscle contractions that occur during seizures). The Minimum Data Set (MDS - an assessment tool) dated 2/17/2023, documented the resident rarely/never made self-understood and rarely/never understood others. The undated document titled Seizure Protocol documented the MD along with nursing staff would help to identify residents who had a history of seizures or epilepsy and residents who were receiving antiepileptic and other medications for seizures or epilepsy. It documented seizures may occur in residents not diagnosed with epilepsy (repeated unprovoked seizures) and acute seizures may occur due to a metabolic disturbance, acute illness, stroke, head injury and other neurological congenital diseases. If a resident was having a seizure, the nurse would implement medication inventions per the resident's order (i.e. Diastat rectal gel, Valtoco nasal spray). If a new or recurrent seizure was identified or suspected, the nurse would notify the MD, who would evaluate the need for further interventions such as the need to transfer the resident to a hospital for further evaluation and treatment. It documented hospital transfer might not be necessary if the resident had a known seizure disorder, and the seizure could be readily controlled. The Comprehensive Care Plan (CCP) for Seizure Disorder, last revised 11/29/2022, documented a CCP intervention to give seizure medication as ordered by the doctor. The Order Summary Report for active orders as of 4/1/2023, documented an order for Diazepam 2 Systems 5-7.5-10 mg kit (Diastat); insert 10 mg rectally as needed for seizure greater than 5 minutes or 3 cluster seizures in 1 hour; may repeat x1 in 20 minutes. The Nursing Progress Note dated 4/15/2023 at 5:45 PM by Licensed Practical Nurse (LPN) #8, documented the resident was noted to be having back-to-back seizures, all less than 120 seconds. The resident had an order for the Diastat, but none was on hand. LPN #8 called and notified the supervisor of the situation and called the MD to make them aware. The MD advised to send the resident to the hospital. LPN #8 documented the resident all together had more than 10 seizures before EMS arrived. LPN #8 called the pharmacy to get a STAT order for the Diastat and left a message on their outside hours line. The Medication Administration Record (MAR) dated 4/15/2023, did not document Diazepam 2 Systems 5-7.5-10 mg kit was signed as being administered. During an interview on 5/12/2023 at 2:37 PM, the Infection Preventionist/MDS Coordinator (IP/MDS) #1 stated they were on call on 4/15/2023. The IP/MDS stated Diastat was available in the fcility's named medication dispensing system. The Licensed Practical Nurse Supervisor (LPNS) #7 called them and said they were trying to get the Diastat out of the system, but it required a Registered Nurse (RN) to cosign and there was no RN available. The IP/MDS #1 stated they were concerned about status epilepticus (a continuous state of seizure, which is a medical emergency) because LPNS #7 said the resident continued to have seizures and the resident was not one who had seizures like that. The IP/MDS #1 stated that out of concern, the resident was sent to the hospital. The IP/MDS #1 stated the Diastat was not given. The IP/MDS #1 stated nurses could now get narcotics out of their dispensing system with a PIN (personal identification number) provided by the pharmacy. During an interview on 5/12/2023 at 3:41 PM, the Director of Nursing (DON) #1 stated the Diastat was given but the resident continued to have seizures. The resident needed another dose but there was none in the medication cart for the resident. The DON #1 stated the facility had a named medication dispensing system for emergency medications and the Diastat was in there. The DON #1 stated the nurse could not access the system and called the IP/MDS #1, who was on call. The IP/MDS #1 was concerned about status epilepticus (a continuous state of seizure, which is a medical emergency) and the MD wanted the resident transported to the hospital. The DON #1 suggested the surveyor talk to the IP/MDS #1 about it because they were more familiar with the outcome. During an interview on 6/22/2023 at 8:45 AM, LPN #8 stated Resident #2 had an order for Diastat to be given for seizures greater than 5 minutes and if they were having multiple seizures. LPN #8 stated the Certified Nurse Aide (CNA) reported to them that the resident was having seizures. LPN #8 stated they went to see the resident and made an observation of the seizures and timed them. LPN #8 stated the seizures stopped for a few minutes and then the CNA reported the resident was having them again. LPN #8 stated they then went to the medication cart to get the Diastat but there was none in the narcotic box located in the cart. LPN #8 then went to medication room and found no Diastat in the narcotic box. LPN #8 stated they notified the supervisor and then called the pharmacy to get an emergency order. LPN #8 stated that to their knowledge, the medication was in the facility's named medication dispensing system, but the supervisor needed a second person with access to the system to dispense the medication, and they did not have another person with access in the building. LPN #8 stated they did not give any Diastat to the resident and did not sign off on the MAR because they did not give it. LPN #8 stated that after they called the pharmacy, they called the MD and the MD told them to send the resident to the hospital. 10 NYCRR 415.18(a)

Based on record review and interviews during an abbreviated survey (Case #NY00303903), the facility did not ensure residents are free of any significant medication errors for 1 (Resident #1) of 3 residents reviewed. Specifically, the facility did not ensure LPNS #1 followed the facility's policy and standard of practice for medication administration when LPNS #1 did not check three times to ensure the right physician ordered medication (Tuberculin PPD solution 5 unit/0.1 ml, inject 0.1 ml intradermally (within the skin) one time only for PPD screening) was to be administered to Resident #1. LPNS #1 injected Resident #1 intradermally with the wrong medication (COVID-19 vaccine). This was evidenced by: Resident #1: Resident #1 was admitted to the facility n [DATE], with diagnoses of herpes viral meningitis (an infection of the brain and brain covering caused by the herpes simplex virus), tracheostomy (surgical procedure to create an opening through the neck into the trachea (windpipe) status, dependence on respirator (ventilator) status. The Minimum Data Set (MDS - an assessment tool) dated [DATE], documented the resident rarely/never made self-understood and rarely/never understood others. The Policy and Procedure (P&P) titled, Medication Administration revised [DATE], documented the purpose of the P&P was to provide clear guidelines for the administration of medications and treatments to ensure physicians' orders were followed and the risk of medication related errors was minimized. The P&P documented it was the responsibility of [named licensed staff] to administer medications as ordered by the physician and the five rights of medication administration must occur: right resident, right medication, right dose, right time, right route. A Medication Administration Incident Report must be completed for any deviation. Prior to administering the resident's medication, the nurse must check the electronic medication administration record (eMAR) against the label on the medication three times; when removing the medication from the medication cart; when pouring the medication; and when returning the medication to the medication cart. Prior to administering the resident's medication, the nurse should compare the drug dosage and schedule on the resident's eMAR with the drug label. The Comprehensive Care Plan (CCP) for Altered Respiratory Status related to pulmonary edema, prematurity, bronchopulmonary dysplasia (BPD), tracheostomy/ventilator dependence and age/weight, last revised [DATE], documented a CCP intervention to administer medications as ordered. The Medication Order Summary Report for orders as of [DATE], documented an order dated [DATE] for Tuberculin PPD solution 5 unit/0.1 ml, inject 0.1 ml intradermally (within the skin) one time only for PPD screening. The Medication Error/Discrepancy Report dated [DATE] by Licensed Practical Nurse Supervisor (LPNS) #1, documented wrong medication and drug administered without a physician order. The date/time of the error was [DATE] at 2:00 AM, and Tuberculin 0.1 ml was ordered to be given intradermally. The description of the actual error documented COVID-19 vaccine 0.1 ml was administered. It was documented the error occurred because LPNS #1 took wrong vial from the refrigerator. LPNS #1 documented they did not complete the 5 rights; did not complete the 3 checks; and did not follow accepted professional standards. The Director of Nursing (DON) #1 documented LPNS #1 was provided with verbal retraining and was to do medication pours with the educator. The incident was reported to the New_York State Department of Health (NYSDOH). The Facility Final Report Summary for date of event [DATE] by the DON #1, documented that on [DATE] at approximately 2:00 AM, LPNS #1 went into Resident #1's room to place a 0.1 ml of tuberculin test PPD per MD order. LPNS #1 retrieved the vial from the office of the Registered Nurse Educator (RNED) #1. LPNS #1 stated they did not read the vial at the time to assure they had the correct vial. LPNS #1 stated they were unaware that other vaccines were ever kept in the refrigerator. LPNS #1 then stated they drew up 0.1 ml into the TB syringe and placed it intradermal into Resident #1's left forearm. Immediately after placing the injection, the vaccine bottle fell on to the floor. LPNS #1 picked it up and at that time noted that the bottle read COVID-19 vaccine. The DON #1 and MD on call were immediately notified. The MD advised to observe Resident #1 for any negative reaction. The Pharmacist was notified. A Vaccine Adverse Event Reporting System (VAERS) report was filed. It was documented there was no adverse reactions to this resident. -Conclusion: Resident #1 was due to have a PPD test administered. LPNS #1 failed to follow nursing protocols, including reading the label of vial, and did not use tuberculin serum to administer the PPD test. LPN #1 immediately identified their error and notified the DON #1, MD, and Pharmacist for direction. There was no adverse reaction to the resident as a result of the nurse's action. During an interview on [DATE] at 12:37 PM, LPNS #7 stated they always performed the 5 rights, which was the right person, time, dose, route, and medication, before they administered any medication. LPNS #7 stated they would always look at the vial before they administered the medication. During an interview on [DATE] at 12:46 PM, LPN #5 stated the vials with the TB solution were stored in a special refrigerator in the RNED #1's office. LPN #5 stated COVID-19 and Influenza vaccine were also kept in that refrigerator. LPN #5 stated that before they administered any medication, they would verify the order and do the 5 rights check which was the right resident, route, medication, frequency, and dose. LPN #5 stated all nurses are supposed to look at the vial and the order in the eMAR. During an interview on [DATE] at 1:02 PM, the DON #1 stated they were called in the middle of the night by the night supervisor, LPNS #1. The DON #1 stated LPNS #1 was very upset because they had given COVID-19 intradermally, when they were supposed to be giving TB solution for a PPD test. The DON #1 stated LPNS #1 told them they had taken a vial out of the refrigerator. The DON #1 stated in [their] mind PPD was the only thing in the refrigerator. The DON #1 stated there were vials with other solutions in there. The DON #1 stated they were appalled because LPNS #1 walked all the way down the hall with the vial in their hand and did not identify that it was not the TB solution. The DON #1 stated at some point, the vial fell on to the floor and LPNS #1 realized they had administered COVID-19 vaccine. The DON #1 stated LPNS #1 did not follow any procedures or proper protocols for medication administration. The DON #1 stated the facility had medication policies that were in place and included the 5 rights of medication administration and the 3 checks of the medication. The DON #1 stated nothing was followed. The DON #1 stated there was no negative outcome for the resident. The DON #1 stated LPNS #1 had not given any other PPD tests. The DON #1 stated LPNS #1 no longer worked at the facility. During an interview on [DATE] at 3:00 PM, the Infection Preventionist/MDS Coordinator (IP/MDS) #1 stated LPNS #1 gave Resident #1 COVID-19 vaccine instead of TB solution for the PPD test. The IP/MDS #1 stated LPNS #1 did not follow what they needed to do as a nurse for medication administration. The IP/MDS #1 stated LPNS #1 did not follow facility policy or standards of nursing practice. During an interview on [DATE] at 1:34 PM, LPNS #1 stated they were a travel nurse and had been a nurse for [AGE] years. On [DATE], they were the supervisor and was asked to do the TB test on Resident #1. LPNS #1 asked where the solution was and was told it was in the refrigerator in the RNED #1's office. LPNS #1 stated they had never been in the RNED #1's office. LPNS #1 went to the office and found a refrigerator that had TB supplies on top of it. LPNS #1 then opened the refrigerator and saw that the only thing that was in there was a packet of vials and thought it was the TB solution. LPNS #1 grabbed the vial and supplies and then went to the resident's room and placed it in their left forearm. LPNS #1 stated when they were entering the lot number and expiration date into the computer system, the bottle fell on the floor and when they picked it up, they realized the vial had expired on ,d+[DATE]. LPNS #1 stated they thought at that point they had given expired TB solution. LPNS #1 stated they went back to the RNED #1's office, looked inside the refrigerator, and saw a bag that had TB solution vials in it and realized the vial they took out of the refrigerator was COVID-19 vaccine. LPNS #1 stated they then told the RN Supervisor. LPNS #1 then called the MD, DON #1, the Pharmacist, and the RNED #1. LPNS #1 stated the DON #1 told them they just had a COVID-19 clinic at the facility and the Pharmacy was supposed to come and pick up the COVID-19 vaccine vials. LPNS #1 stated the DON #1 and the RNED #1 said nothing else was supposed to be in that refrigerator. LPNS #1 stated they did the right thing by writing themselves up. LPNS #1 stated they should not have assumed it was a TB vial. 10 NYCRR 415.12(m)(2)

Based on record review and interviews during an abbreviated survey (Case #NY00304944), the facility did not ensure that all alleged violations involving abuse are reported immediately but no later than 2 hours after the allegation is made if the events that cause the allegation involve abuse for 2 residents (Resident #'s 1 and 2) of 3 residents reviewed for abuse. Specifically, facility Administration learned of the allegation of abuse for Resident #'s 1 and 2 on 11/4/2022 at 11:45 AM. The incident was not reported to the Department of Health (DOH) until 5:08 PM on 11/4/2022. This was evidenced by: The Policy and Procedure dated 7/25/2022 and titled, Abuse Policy, documented Facility Administration and Nursing Administration will review the allegation and report as needed to DOH via the Health Commerce System reporting system in accordance with applicable regulations. Resident #1 The resident was admitted to the facility with diagnoses of child physical abuse, post traumatic seizures, and traumatic subdural hematoma sequela. The Minimum Data Set (MDS- an assessment tool) dated 9/30/2022, documented the resident had severe cognitive impairment, was sometimes understood, and rarely/never understand others. Resident #2: The resident was admitted to the facility with diagnoses of epilepsy, tetralogy of Fallot, and congenital tracheomalacia. The MDS dated [DATE], documented the resident could sometimes be understood, and could sometimes understand others. The Nursing Home Facility Incident Report Submission form documented the alleged incident that occurred at 11/4/2022 at 11:30 AM was submitted to DOH on 11/4/2022 at 5:08 PM. The Administrator was first made aware of the alleged incident at 11:45 AM. During an interview on 11/9/2022 at 3:54 PM, the Administrator stated abuse needed to be reported within 2 hours of the suspicion of abuse. During an interview on 1/10/2023 at 12:53 PM, the DON stated incidents should be reported to DOH as soon as the facility finds out about it but must be reported no later than 24 hours after learning of an alleged incident. 10 NYCRR 415.4(b)

Based on observation, record review and interviews during the recertification survey and an abbreviated survey (Case #NY 015), the facility did not ensure resident records were maintained in accordance with professional standards of practice for 5 (Resident #'s 32, 38, 76, 77, and #280) of 21 residents reviewed. Specifically, for Resident #32, the facility did not ensure staff documented whether the resident was provided with toileting per their assigned toilet training program between 12/1/2021 - 12/15/2021; for Resident #38, the facility did not ensure that the resident's care plan was updated with a new focus, goals, and interventions following a condition change on 6/16/22 when the resident was diagnosed with COVID-19; for Resident #76, the facility did not ensure documentation of administration and response to treatments and medications provided, change of condition, and test results; for Resident #77, the facility did not ensure facility staff documented whether the resident was toileted per their toileting program; for Resident #280, the facility did not ensure staff documented whether the resident was provided with toileting opportunities per the resident's assigned toilet training program between 12/1/2021 - 12/15/2021. This was evidenced by: The facility policy titled Using the Care Plan, reviewed 12/3/2018, documented that documentation must be consistent with the resident's care plan. The facility policy titled Care Plans, reviewed 4/1/2019, documented assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. Resident #76: Resident #76 was admitted to the facility with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - an assessment tool) dated 5/31/2022, documented the resident was severely cognitively impaired, and could rarely/never be understood or understand. An Occupational Therapy Daily Note dated 6/17/2022, documented; resident was seated in main doorway after getting off school bus. Per nursing report resident required suctioning while on the bus. Noted O2 in low 90's. Reported to floor nurse. Nurse provided respiratory care and cleared resident for OT session. Poor tolerance as indicated by heart rate in high 120's and O2 in low 90's, reported to nursing. Nursing provided respiratory care. Resident transferred to bed vital signs stable. A Physician's Visit Note dated 6/22/2022, documented; reported to have copious thick yellow foul-smelling [CONDITION(S)] ([CONDITION(S)]) secretions. No fever, no respiratory distress. Possible tracheitis, will obtain culture and gram stain. Hold on treatment pending results, given current clinical stability. Resident #76's medical record did not include nursing staff documentation regarding the treatment provided or monitoring of the resident's condition following the incident documented by the Occupational Therapist (OT) on 6/17/2022. A Nursing Progress Note dated 6/27/2022 documented; during physician rounds the floor nurse informed writer and physician that resident had de-sat (low oxygen saturation) episode into 80's. Per nurse resident was suctioned with copious thick white secretions. Resident was given [MEDICATION(S)] and placed on oxygen. Physician evaluated, ordered chest x-ray and RVP (respiratory [CONDITION(S)] panel). Resident #76's medical record dated 6/17/2022 through 6/29/2022, did not include documentation regarding the resident's condition related to their respiratory status. The Treatment Administration Record (TAR) for June 2022 documented an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #76's medical record did not include documentation of the results of the sputum culture and gram stain ordered on 6/22/2022. During an interview on 06/29/22 at 9:11 AM, Licensed Practical Nurse (LPN) #1 stated, if a resident needed suctioning and oxygen for increased secretions or low oxygen saturation, they would write a progress note and notify the nurse manager. During an interview on 06/29/22 at 10:31 AM, the Director of Nursing (DON) stated, the nurses that provided care on 6/17/2022 should have documented a progress note and signed the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurses responsible for the resident's care should have been monitoring the resident's condition and documenting lung assessments and vital signs while awaiting the culture, x-ray, and lab results. During an interview on 06/29/2022 at 10:48 AM, the DON provided the preliminary culture report sent to the facility on [DATE]. The report was signed by the physician, but there was no date indicating when the physician signed. The DON stated, the Doctor was here on 6/24/2022, the date the results were sent to the facility, so it was most likely reviewed and signed that day. The DON stated, the Doctor should have dated it and written a note stating the plan of treatment. The results were not in the electronic medical record (EMR) because the person responsible for scanning test results into the EMR is about a month behind. During an interview on 06/29/22 at 02:37 PM, the facility Administrator reported they were aware of documentation issues and had begun to get a plan in place but the plan had not been implemented yet. Resident #77 Resident #77 was admitted to the facility with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Comprehensive Care Plan titled ADL (activities of daily living) self-care performance deficit last revised on 2/14/2022, documented the resident was to be toileted every 2 hours and as needed. The Documentation Survey Report (CNA (certified nursing assistant) Documentation) for December 2021 documented; place on toilet/commode every 2 hours while awake. There was a place for every shift to document the answer to the question, Was resident placed on toilet every 2 hours during your shift. A response was documented as yes 5 times, no 8 times, and there was no documentation for the remaining 80 opportunities. During an interview on 06/27/22 at 09:37 AM, CNA #1 stated they are trying to potty train with some success. Staff are to take the resident to the bathroom every 2 hours. Upon review of the documentation from December , CNA #1 stated it looks like they were not putting the resident on the toilet as they should have. During an interview on 06/29/22 at 11:45 AM, the DON (Director of Nursing) reviewed the documentation provided and stated if it's not documented, it's not done. The documentation is terrible and hopefully they are doing it and just not documenting, but we can't be sure. Resident #280: The resident was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - a resident assessment tool) dated 10/9/2021, documented the resident was sometimes able to make themselves understood, sometimes able to understand others, and severely cognitively impaired. It documented the resident was always incontinent of bowel and bladder, with both urinary and bowel toileting programs in place. The Comprehensive Care Plan titled 'Activities of Daily Living (ADLs) - Self Care Performance, revised 12/17/2021, documented to provide opportunities for toileting every 1 - 2 hours and upon request, allow the resident to sit on the commode for at least 5 minutes, and to provide fidgets, books, and small toys to play with while seated on the commode. The Care Card dated 12/15/2021, documented to provide opportunities for toileting every 1 - 2 hours and upon request, allow the resident to sit on the commode for at least 5 minutes, and to provide fidgets, books, and small toys to play with while seated on the commode. Toilet training documentation dated 12/1/2021 - 12/15/2021 was reviewed and during this period, assigned toilet training was documented as Not Applicable for this resident on 12/1/2021 at 6:18 PM, 12/2/2021 at 10:00 AM, 12/2/2021 at 9:58 PM, 12/4/2021 at 11:12 AM, 12/5/2021 at 3:54 PM, 12/6/2021 at 6:19 PM, 12/7/2021 at 8:52 PM, 12/8/2021 at 10:39 AM, 12/8/2021 at 6:21 PM, 12/9/2021 at 11:53 AM, 12/9/2021 at 5:36 PM, 12/10/2021 at 8:51 PM, 12/11/2021 at 12:08 PM, 12/12/2021 at 7:17 PM, 12/14/2021 at 8:47 PM, and 12/15/2021 at 4:12 PM. During an interview on 06/29/22 at 10:38 AM, Certified Nurse Aide (CNA) #3 stated that therapy creates the toileting programs, and then nursing takes over responsibility for them when they were determined to be successful. Information related to resident toilet training programs was documented on their care plan and care cards, both of which contained the same information. The CNAs were normally responsible for assisting residents with most of their toilet training and documentation of the results in the Electronic Medical Record (EMR). When residents had toilet training assigned, whether the resident was toileted, and the number of attempts needed to be documented in the EMR; Not Applicable (N/A) should not be documented. During an interview on 06/29/22 at 10:45 AM, Registered Nurse (RN) #4 stated that tasks associated with resident toilet training programs were documented on the care plan and care card and assigned tasks must be documented. Typically, the CNAs performed these tasks, and documented in the EMR. Between 12/1/2021 - 12/15/2021, Resident #280 was on a toilet training program, and had tasks assigned in the EMR. Staff should not have been documenting N/A for their assigned toilet training tasks, they should have been documenting whether the training was performed, the number of attempts made, and how many of the attempts were successful. During an interview on 06/29/22 at 01:00 PM, the Director of Nursing (DON) stated that CNAs perform most of the work related to resident toilet training programs. Information regarding resident toilet training programs was documented on the resident's care plan and care card, which was posted in the resident's room inside their closet. When residents had toilet training assigned, the person assigned to the resident needed to document whether they performed the toilet training, the number of attempts made, and if any of the attempts were successful. When staff documented N/A for toilet training for Resident #280 between 12/1/2021 - 12/15/2021, this was incorrectly documented . NYCRR 415.22(a)(1-4)

Based on record reviews and interviews during the recertification survey dated 6/23/2022 through 6/29/2022, the facility did not ensure the resident, residents' representatives and the Office of the State Long-Term Care Ombudsman were notified in writing of the reason for the transfer/discharge to the hospital in a language and manner they understood for 1 (Resident #46) of 3 residents reviewed for hospitalization s. Specifically, for Resident #46, the facility did not provide a written transfer/discharge notice to the resident, residents representative or the Ombudsman when the resident was transferred to the hospital on 5/31/2022 and again on 6/3/2022. This is evidenced by: The facility Policy and Procedure titled Transfer and Discharges dated 3/28/2019, documented the facility will notify the resident and designated representative of the decision to transfer or discharge and reasons for the move in writing and in a language and manner they understand. The notice will be provided as soon as practicable when an immediate transfer or discharge is required by the resident's urgent medical needs a copy of the Transfer/Discharge Report will be provided in person or via mail within the next business day. Resident #46: Resident #46 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS- an assessment tool) dated 4/29/2022, documented the resident had severe cognitive impairment and unclear speech. The MDS schedule documented the resident was discharged on [DATE] and returned on 6/2/2022 and discharged on [DATE] and returned on 6/7/2022. The medical record did not document that the resident and/or resident representative were notified in writing of the reason for the transfer/discharge in a language they could understood when the resident was transferred to the hospital on 5/31/2022 and 6/3/2022. The medical record also did not document the ombudsman was notified. A nursing progress note dated 5/31/2022 at 11:35 AM, documented the resident's mentation was off baseline; resident non-responsive, pupils' reaction sluggish, vital signs within normal limits, 911 promptly called, and medical doctor (MD) contacted and made aware. A nursing progress note dated 5/31/2022 at 2:35 PM, documented the hospital reported the resident needed urgent surgery to correct shunt failure. A nursing progress note dated 6/3/2022 at 3:31 PM documented the resident was unable to stand and felt lightheaded during therapy. Temperature 102.6 degrees, blood pressure 87/61, and blood oxygen saturation level 80%, MD made aware, and resident transferred to the hospital. During an interview on 6/29/2022 at 11:28 AM, Social Worker (SW) #4 stated the transfer/discharge notices are mailed to the residents' representatives and then documented in the medical record. SW #4 reviewed the medical record and could not provide documentation that the transfer/discharge notices were mailed to Residents #46's representative when the resident was hospitalized on [DATE] and 6/3/2022 and stated, if it was not documented, it was not done. SW #4 also stated they did not notify the Office of the State Long-Term Care Ombudsman because they were not aware of the requirement. During an interview on 6/29/2022 at 12:01 PM, Registered Nurse (RN) # 3 stated the transfer/discharge notices are completed by nursing and a copy of the notice is provided to the social worker. RN #3 stated their understanding was that the SW was responsible to mail the transfer/discharge notice to the resident's representative and to notify the ombudsman. During an interview on 6/29/2022 at 12:53 PM, SW #5 stated when a resident is admitted to the hospital the bed is automatically held for 30 days unless the facility is notified differently. The transfer/discharge notice are mailed to the residents' representative at the time of the transfer and should be documented in the residents' medical record. SW #5 also stated they were not aware of the requirement to notify the Office of the State Long-Term Care Ombudsman. During an interview on 6/29/2022 at 12:17 PM, the Director of Nursing (DON) stated their understanding was that the SW Department was responsible to ensure that the transfer/discharge notices were mailed to the residents' representatives at the time of transfer/discharge but was not sure about the ombudsman notification. The DON said they believed the admissions nurse was tracking this, but the admissions nurse position has been vacant for a while and both social workers are new to the facility within the past 4 months, and this requirement may have been overlooked. The DON stated they plan to review the policy and procedures and ensure compliance with the regulation. NYCRR 415.3(H)(1)(iii)(a-c)

Based on record review and interview during the recertification survey, the facility did not ensure written notice of the facility's bed hold policy was provided to the residents and the resident representatives for 1 (Resident #46) of 3 residents reviewed for hospitalization . Specifically, for Resident #46, the facility did not ensure the resident and the resident representative received written notice of the facility's bed hold policy when the resident was transferred to the hospital. This was evidenced by: The facility Policy and Procedure titled Bed Reservations dated 4/2/2019, documented at the time of admission and again at the time of transfer for any reason, the facility shall inform and provide written information to the resident and the designated representative regarding bed reservation. Resident #46: Resident #46 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS- an assessment tool) dated 4/29/2022, documented the resident had severe cognitive impairment and unclear speech. The MDS schedule documented the resident was discharged on [DATE] and returned on 6/2/2022 and discharged [DATE] and returned on 6/7/2022. The medical record did not include documentation that the resident and/or resident's representative was notified in writing of the reason for the transfer/discharge in a language they could understood when the resident was transferred to the hospital on 5/31/2022 and 6/3/2022. The medical record also did not include documentation the ombudsman was notified. A nursing progress note dated 5/31/2022 at 11:35 AM, documented the resident mentation was off baseline; resident non-responsive, pupils' reaction sluggish, vital signs within normal limits, 911 promptly called, and medical doctor (MD) contacted and made aware. A nursing progress note dated 5/31/2022 at 2:35 PM, documented the hospital reported the resident needed urgent surgery to correct shunt failure. A nursing progress note dated 6/3/2022 at 3:31 PM, documented the resident was unable to stand and felt lightheaded during therapy. Temperature 102.6 degrees, blood pressure 87/61, and blood oxygen saturation level 80%, MD made aware, and resident transferred to the hospital. During an interview on 6/29/2022 at 11:28 AM, Social Worker (SW) #4 stated a copy of the bed hold policy are mailed to the residents' representatives and then documented in the medical record. SW #4 reviewed the medical record and could not provide documentation that the copies of the bed hold policies were mailed to Resident #46's representative when the resident was hospitalized on [DATE] and on 6/3/2022 and stated, if it was not documented, it was not done. During an interview on 6/29/2022 at 12:01 PM, Registered Nurse (RN) #3 stated their understanding was that SW were responsible to mail the bed hold policy to the resident's representative. During an interview on 6/29/2022 at 12:53 PM, SW #5 stated when a resident is admitted to the hospital the bed is automatically held for 30 days unless the facility is notified differently. The bed hold policy is mailed to the residents' representative residents at the time of the transfer and should be documented in the residents' medical record. During an interview on 6/29/2022 at 12:17 PM, the Director of Nursing (DON) stated their understanding was that the SW Department was responsible to ensure that the transfer/discharge notices were mailed to the residents' representatives at the time of transfer/discharge but was not sure who was responsible for mailing the bed hold policy. The DON stated they believed the admissions nurse was tracking this, but the admissions nurse position has been vacant for a while and both social workers are new to the facility within the past 4 months, and this requirement may have been overlooked. The DON stated they plan to review the policy and procedures and ensure compliance with the regulation. 10NYCRR 415.3(h)(4)(i)(a)

Based on observations, record review, and interviews during a recertification survey the facility did not ensure that a resident who needs respiratory care, including [CONDITION(S)] care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 2 (Resident #'s 32 and #76) of 4 residents reviewed for respiratory care. Specifically, for Resident #76, the facility did not ensure that the resident's respiratory status including their response to therapy, and changes in their respiratory condition were consistently assessed, monitored and documented and for Resident #32 the facility did not ensure physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #76: Resident #76 was admitted to the facility with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - an assessment tool) dated 5/31/2022, documented the resident was severely cognitively impaired, and could rarely/never be understood or understand. An Occupational Therapy Daily Note dated 6/17/2022, documented the following; resident was seated in the main doorway after getting off the school bus. Per nursing report the resident required suctioning while on the bus. Noted O2 in low 90's. Reported to floor nurse. Nurse provided respiratory care and cleared resident for OT session. Poor tolerance as indicated by heart rate in high 120's and O2 in low 90's, reported to nursing. Nursing provided respiratory care. Resident transferred to bed, vital signs stable. Resident #76's medical record did not include nursing staff documentation regarding the treatment provided or monitoring of the resident's condition following the incident documented by the Occupational Therapist (OT) on 6/17/2022. A Physician's Visit Note dated 6/22/2022 documented; reported to have copious thick yellow foul-smelling [CONDITION(S)] secretions. No fever, no respiratory distress. Possible tracheitis, will obtain culture and gram stain. Hold on treatment pending results, given current clinical stability. The Treatment Administration Record (TAR) documented the sputum culture and gram stain via tracheal aspirate was obtained on 6/22/2022. A Nursing Progress Note dated 6/27/2022 documented; during physician rounds the floor nurse informed writer and physician that resident had de-sat (low oxygen saturation) episode into 80's. Per nurse resident was suctioned with copious thick white secretions. Resident was given [MEDICATION(S)] (used to prevent and treat wheezing and shortness of breath caused by breathing problems) and placed on oxygen. Physician evaluated, ordered chest x-ray and RVP (respiratory [CONDITION(S)] panel). A Nursing Progress Note dated 6/28/2022, documented; called lab for RVP results, still pending. Chest x-ray results, no pleural effusion or indication of pneumonia. Physician notified. Resident #76's medical record dated 6/17/2022 through 6/29/2022, did not include documentation regarding the resident's condition realted to their respiratory status. Resident #76's medical record did not include documentation of the results of the sputum culture and gram stain ordered on 6/22/2022. During an interview on 06/29/22 at 8:57 AM, OT #1 stated, on 6/17/2022 they went to get the resident off the school bus and the nurse on the bus reported the resident needed care during the ride home, so OT #1 got the floor nurse. The nurse suctioned and checked vitals saying it was okay, so OT #1 proceeded with the therapy session. The resident started de-sating and appeared distressed, so I called the nurse (there was a shift change so it was another nurse the 2nd time) in and the nurse suctioned the resident, put the resident on oxygen, and OT #1 and the nurse put the resident to bed where the resident appeared much more comfortable. This was an unusual event for this resident. OT #1 did not know who the nurses were that provided care. During an interview on 06/29/22 at 9:11 AM, Licensed Practical Nurse (LPN) #1 stated, if a resident needed suctioning and oxygen for increased secretions or low oxygen saturation, they would write a progress note and notify the Nurse Manager. During an interview on 06/29/22 at 10:31 AM, the Director of Nursing (DON) stated, the nurses that provided care on 6/17/2022 should have documented a progress note and signed the Medication Assistance Record (MAR)/TAR. The nurses responsible for the resident's care should have been monitoring the resident's condition and documenting lung assessments and vital signs while awaiting the culture, x-ray, and lab results. During an interview on 06/29/2022 at 10:48 AM, the DON provided the preliminary culture report sent to the facility on [DATE]. The report was signed by the physician, but there was no date indicating when the physician signed the report. The DON stated, the Doctor was here on 6/24/2022, the date the results were sent to the facility, so it was most likely reviewed and signed that day. The DON stated, the Doctor should have dated it and written a note stating the plan of treatment. Resident #32: Resident #32 was admitted to the facility with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS -an assessment tool) dated 4/15/2022, documented the resident was severely cognitively impaired, usually understood and could sometimes understand others. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observations on 06/23/2022 at 11:19 AM, the connector to the nebulizer bottle was dated 6/14/22 and initialed. On 06/28/2022 at 02:16 PM, the connector to the nebulizer bottle date remained unchanged. The Treatment Administration Record (TAR) dated June 2022, documented to change the large volume nebulizer and compressor tubing, be sure to date, time and initial every Tuesday night shift. The TAR included staff initials to indicate the nebulizer and compressor tubing was changed on 6/14/2022 and 6/21/2022. During an interview on 06/28/2022 at 02:50 PM, Licensed Practical Nurse (LPN) #2 stated the tubing should have been changed weekly. LPN #2 stated they didn't know why it was documented on the TAR that the change was completed however it was not because the date on the connector did not reflect the change. LPN #2 stated that the TAR should not have been signed if the treatment was not done. During an interview on 6/28/2022 at 03:01 PM Registered Nurse (RN) #4 stated the compressor tubing and large volume nebulize are supposed to be changed weekly. RN #4 stated they didn't know why it was signed for but not done. RN #4 stated because the connector was dated with a permanent marker it was obvious it wasn't changed as ordered. During an interview on 06/29/22 at 10:27 AM, the Director of Nursing (DON) stated they expected nurses to follow the MD (medical doctor) orders. The DON stated when the connector is changed, the date should be written on the connector. If it was not dated on the ordered date, then it was not changed. 10NYCRR415.12(k)(6)

Based on observation, record review and interviews during a partial extended abbreviated survey (Case #s NY 829, NY 145 and NY 404), the facility failed to ensure the resident environment remained free of accident hazards as possible and each resident received adequate supervision to prevent accidents, for 4 (Resident #'s 1, 4, 5 and 7) of 7 residents reviewed. Specifically, on [DATE], the facility failed to provide Resident #1 with care planned 1:2 supervision that included tilting the wheelchair back if the resident's head fell forward. The Certified Nurse Aide (CNA) was positioned behind the resident talking on their cell phone and failed to tilt the wheelchair back when the resident's head fell forward. Subsequently, Respiratory Therapist #1 observed Resident #1 leaned forward, and not breathing. CPR (cardiopulmonary resuscitation) was initiated, and EMS (emergency medical services) transported the resident to the hospital. - Additionally, Resident #4 was care planned to have 1:2 supervision while awake. On [DATE] there was no staff in the room when the Speech Language Pathologist (SLP) observed Resident #4 in bed with a package of personal cleansing wipes, and pieces of the packaging in their mouth. The facility could not identify who had been assigned to the 1:2 supervision. Also, Resident #5 was care planned to have 1:2 supervision while awake. - On [DATE] at 3:55 PM, a SLP observed Resident #5 in the hallway next to an unattended medication cart, pouring a bottle of medication in their lap. - For Resident #7, the facility did not ensure care planned 15-minute checks of the resident who had impaired motor control and used physical restraints that included a seat belt and chest harness to maintain safety and alignment in the wheelchair and who was at high risk for falls, from 6:50 AM to 8:10 AM on [DATE]. This resulted in Immediate Jeopardy (IJ) and Substandard Quality of Care with the likelihood for serious injury, serious harm, serious impairment, or death for 3 (Resident #'s 1, 4 and 5) residents. IJ began on [DATE] and was called on [DATE] at 4:55 PM. The facility submitted an IJ removal plan on [DATE]. IJ was removed on [DATE]. This was evidenced by: The Policy and Procedure (P&P) titled Using the Care Plan last reviewed on [DATE], documented the care plan would be used in developing the resident's daily routines and would be available to staff personnel who had responsibility for providing care or services to the resident. The P&P documented the Kardex, a card-filing system that allowed quick reference to the particular needs of each resident for certain aspects of nursing care was utilized and was located in each resident's closet. Nurses (Licensed Practical Nurses (LPNs) and Registered Nurses (RNs) were responsible for supervising the CNA's accurate implementation of each resident's care plan. The P&P documented that failure to follow a resident's care plan as written, could pose safety risks to the resident. Disregard for and failure to follow a care plan, in some cases, could be deemed neglectful. During an interview on [DATE] at 2:42 PM, the Administrator stated there was no policy for 1:2 supervision. Resident #1: Resident #1 was admitted to the facility with diagnoses of developmental disorder of scholastic skills, disorder of psychological development, [CONDITION(S)] (an opening surgically created through the neck into the trachea (windpipe) to allow direct access to the breathing tube) ([CONDITION(S)]) status, and dependence on respirator (Mechanical ventilators are machines that act as [NAME] to move air in and out of your lungs. Your respiratory therapist and doctor set the ventilator to control how often it pushes air into your lungs and how much air you get) (ventilator). The Minimum Data Set (MDS-an assessment tool) dated [DATE], documented the resident's cognitive skills for daily decision making were severely impaired. The resident sometimes made themselves understood and was sometimes able to understand others. The Comprehensive Care Plan (CCP) for ADL (activities of daily living) Self-Care Performance Deficit last revised on [DATE], documented the resident required supervision when sitting in their wheelchair and staff were to tilt the chair if the resident's head was falling forward and per request. The CCP for History of Behavior Problem last revised on [DATE], documented the resident's behaviors included pulling off the SPO2 (the amount of oxygenated hemoglobin in the blood) monitor probe, disconnecting vent tubing at [CONDITION(S)] and tubing, pulling on and pulling out tube feed and putting in mouth. The resident required 1:2 supervision from 7:00 AM - 11:00 PM, during waking hours while not in school. The Kardex Report (undated) printed on [DATE], included the following intervention for Positioning/Devices/Equipment: Wheelchair with supervision; tilt chair if head is falling forward and per request and used 1:2 supervision from 7:00 AM - 11:00 PM, during waking hours while not in school. An Incident Report dated [DATE] at 2:45 PM, written by Respiratory Therapist (RT) #1, documented RT #1 saw Resident #1 slumped over, head forward and the resident's arm was a yellow color. RT #1 pulled Resident #1's head back and noted the resident was not breathing and had no pulse. RT #1 called for help and Code Blue (a hospital emergency code used to describe the critical status of a patient), CPR was initiated, and the resident was sent out via EMS. The facility's investigation titled Final Report for a CPR event on [DATE] documented the following: -Background: Resident #1 resided on the Vent (ventilator) Unit and required 1:2 supervision; 1 staff to 2 residents during waking hours. Resident #1 was full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive) status. -Description: On [DATE] at approximately 2:45 PM, Resident #1 was observed unresponsive while seated in their wheelchair in the common area of the Vent Unit. -Summary of Evidence: CNA (certified nursing assistant) #1 was assigned to Resident #s 1 and 2 on [DATE]. RT #1 reported that at about 1:30 PM, staff requested they suction Resident #1. At around 1:30 PM, CNA #1 left the common area. CNA #1 reported they left Resident #1 with two other CNAs. CNA #1 reported that they returned to the common area around 2:00 PM. CNA #1 was playing with Resident #2 and reported that Resident #1 was also in the common area and thought they were sleeping. RT #1 reported that at about 2:45 PM, they were walking by the common area and noted Resident #1 was slumped forward in their wheelchair with arms stretched out in front of them on the wheelchair tray and head resting on their right arm. RT #1 pulled residents head back and yelled for assistance and code. -Conclusion: Resident #1 was care planned for 1:2 (one staff to two residents) supervision. CNA #1 was assigned to Resident #1 and another resident (#2). CNA #1 reported Resident #1 was in the common area and they thought the resident was sleeping. The facility was unable to determine the exact time Resident #1 became unresponsive. A file received from the Attorney General's Office (AG) documented an interview with CNA #1 on [DATE]. CNA #1 admitted to having a phone conversation beginning at 2:34 PM on [DATE]. The call lasted approximately eight minutes. CNA #1 stated they had taken the call in the common room. CNA #1 was asked if their attention could have been diverted from providing supervision to Resident #1. CNA #1 replied probably. CNA #1 stated that Resident #1's chair was in the upright position, and CNA #1 noticed while on the phone I saw [their] head bopping up and down. [Their] chin was resting on [their] chest with [their] head slumped forward. CNA #1 stated that, usually we just let [them] sleep in their chair, it's a common practice. CNA #1 stated Resident #1's head was fully down for a couple of minutes when the RT checked on [them]. The RT came up to Resident #1 and slapped [their] hands to get [their] attention. At this point, the RT began doing CPR on Resident #1. A file received from the AG documented an interview with the Respiratory Therapy Manager (RTM) on [DATE]. The RTM stated that Resident #1 sleeping in the dayroom would not be typical behavior for the resident. The RTM stated that if Resident #1 were to fall asleep in their chair while in the upright position, their head would fall forward, closing off their [CONDITION(S)]. During an interview on [DATE] at 2:31 PM, CNA #3 stated 1:2 supervision meant the aide had two residents that needed 1:1 supervision. The aide had to sit close enough so when they stood up, they could touch the resident. If there were two residents that required 1:1 supervision, they would have to be watched in the common area. During an interview on [DATE] at 11:27 AM, CNA #2 stated CNA #1 was assigned to Resident #s 1 and 2 on [DATE]. CNA #2 stated that was CNA #1's only assignment. CNA #2 stated when an aide had to watch two residents, it would have to be done in the common area. CNA #2 said they always maintained eye contact with residents who required 1:1 supervision because they wanted to be able to see their face. CNA #2 stated Resident #1 was non-verbal and used facial expressions and hand gestures to make their needs known. CNA #2 stated Resident #1 had never fallen asleep in the common area. CNA #2 stated if they saw the resident was sleeping, they would have tilted their chair back or put them to bed. During an interview on [DATE] at 4:30 PM, CNA #4 stated they were not clear as to what the facility's policy was for 1:1 supervision. CNA #4 stated their understanding was that it meant sitting really close to the resident for safety. CNA #4 stated they watched Resident #1 in the common area on [DATE] from 1:30 PM to 1:45 PM, and then from 2:05 PM to 2:15 PM. CNA #4 said they had to watch Resident #1 because all three aides, including the assigned aide, went to lunch at the same time on that day. CNA #4 stated they had taken care of Resident #1 before. CNA #4 said the resident was very calm during the time they watched them on [DATE]. CNA #4 said they never saw Resident #1 sleeping in the common area. During an interview on [DATE] at 4:13 PM, CNA #5 stated that for 1:1 supervision they had to be within arms-reach of the resident. CNA said Resident #1 would grab you and let you know that they needed suctioning. During an interview on [DATE] at 4:46 PM, CNA #7 stated they were familiar with Resident #1 and most of the time they would sit in front of the resident at arms-length. CNA #7 said the 1:1 supervision would take place in the dayroom in front of the nurse's station and that a float aide would get the 1:1 assignment because they were not familiar with the unit, and it was easier to watch two residents. During an interview on [DATE] at 3:19 PM, Licensed Practical Nurse (LPN) #1 stated they were assigned to Resident #1 on [DATE]. LPN #1 stated they were in the medication room when they heard the code blue announced. LPN #1 said the aide thought the resident was sleeping. LPN #1 said that was not something the resident would usually do in the common area. LPN #1 said if staff saw the resident's head/body slumped they should have checked on the resident to make sure they were ok. During an interview on [DATE] at 12:09 PM, Registered Nurse (RN) #3 stated Resident #1 needed 1:1 supervision at all times wherever the resident was. RN #3 said on [DATE], there was 1:2 supervision on the unit which meant there were two residents who needed 1:1 supervision, and one staff was watching both residents. During an interview on [DATE] at 1:03 PM, RT #1 stated when they were making their rounds, they saw Resident #1 in their wheelchair facing the TV, and one CNA that was about five to seven feet away from the resident, more than arms-length and was sitting in a chair. RT #1 said the resident was slumped forward and was in full arrest when they found them. RT #1 said if the resident was leaned backwards, they should have been able to sleep safely in the chair, but not if slumped forward. RT #1 said if staff were in direct view of the resident they would have been able to visualize that the resident was in respiratory distress. RT #1 said that the way Resident #1 was positioned in their wheelchair was what made them initially check on the resident. During an interview on [DATE] at 1:45 PM, RT #2 stated Resident #1 needed 1:1 supervision, which meant one staff member supervised one resident. RT #2 said 1:2 supervision meant one staff member supervised two residents and it was being done often. RT #2 said there was usually one aide assigned to the common area so that residents could come out of their rooms. RT #2 said a lot of the long-term aides were good at identifying what looked right with a resident. During an interview on [DATE] at 2:41 PM, RT #3 stated Resident #1 needed 1:1 supervision at the time of the incident. RT #3 said it took a lot of a familiarity to understand Resident #1 and their needs. RT #3 said the staff member doing the 1:1 supervision was not familiar with the resident. RT #3 said Resident #1 was very, very active and would never fall asleep in the common area. RT #3 said Resident #1 only slept at night. RT #3 stated that if the staff that were supposed to be paying attention to the resident, were paying attention to them, the incident would never have happened. RT #3 said Resident #1 needed to be eyes on at all times. RT #3 said the physician came to the unit after the incident and they discussed that they should never let floaters, staff who were not familiar with the residents, do the 1:1 supervision. During an observation of the common area of the Vent Unit on [DATE] at 12:28 PM, the Director of Nursing (DON) reenacted where Resident #1 and staff were at the time of the incident. The DON said both CNA #1 and LPN #1 were sitting in a chair and were facing the TV. The surveyor estimated the distance to be about eight to ten feet away from the resident and the DON agreed. The DON stated staff would not be able to adequately visualize the resident from where they were sitting and in the direction the resident was facing. They were sitting in back of the resident and would have been unable adequately visualize the resident. The DON said it was the facility's policy to not use cell phones during working hours and said the focus should have been on the resident. During an interview on [DATE] at 2:42 PM, the Administrator stated they reviewed Resident #1's record and said the resident needed 1:2 supervision, which meant one staff member with two residents who required the same level of supervision. The Administrator said there was no policy for 1:2 supervision. The Administrator stated they did not know if CNAs had received any training for the 1:2 supervision. The Administrator said for 1:2 supervision, staff should have eyes on the resident, be within arms-reach of the resident, and should not be across the room. Staff should be able to visualize the resident and should be engaged with the resident. The Administrator stated staff should not be using their cell phones in resident areas. The Administrator said that they determined through interviews that CNA #1 and LPN #1 were in the common area at the time of the incident. The Administrator said LPN #1 reported they were in the medication room at the time of the code but other staff reported LPN #1 was in the common area. During an interview on [DATE] at 3:46 PM, the Medical Director (MD #3) stated they were in the facility at the time of the incident. MD #3 was familiar with the resident and said Resident #1's medical condition was pretty stable. MD #3 said the aide was there to supervise the resident as a behavior monitor more than a medical one. Resident #4: Resident #4 was admitted to the facility with diagnoses of spastic diplegic (a form of [CONDITION(S)] (CP) that is a chronic neuromuscular condition of hypertonia and [CONDITION(S)]-manifested as an especially high and constant tightness or stiffness-in the muscles of the lower extremities of the human body, usually those of the legs, hips and pelvis), [CONDITION(S)], autistic disorder (a neurological and developmental disorder that affects how people interact with others, communicate, learn, and behave), and congenital dislocation of both hips. The Minimum Data Set (MDS-an assessment tool) dated [DATE], documented the resident rarely made themselves understood and rarely understood others. The Comprehensive Care Plan (CCP) for Safety Care last revised [DATE], documented the resident needed safety monitoring due to decreased safety awareness, and excessive mouthing of many non-food items. The resident was to have 1:2 supervision (one staff member for the resident and their roommate) while awake. The Kardex Report dated [DATE], documented 1:2 supervision (one staff member for the resident and their roommate) while awake. An Incident Report dated [DATE] at 9:27 AM, documented the Speech Language Pathologist (SLP) #2 entered Resident #4's room and observed the resident in bed with a package of personal cleansing wipes. The resident was observed to have pieces of the packaging in their mouth. SLP #2 removed the material from the resident's mouth and removed the wipes. The Nursing Progress Notes did not include documentation about the incident dated [DATE]. During an interview on [DATE] at 1:35 PM, SLP #2 stated that on [DATE] at around 9:30 AM, SLP #2 entered the resident's room and noticed Resident #4 in bed with a package of personal cleansing wipes. There was no other staff in the resident's room. SLP #2 said 3 large pieces of the packaging were in the resident's mouth. SLP #2 was able to remove the pieces with a toothbrush. SLP #2 said the resident had a history of putting non-food items in their mouth, and the resident was not showing any kind of distress. SLP #2 said there was usually an aide assigned to Resident #4, but SLP #2 could not figure out who the assigned aide was, and that Registered Nurse Manager (RNM) #2 could not identify who the assigned aide was. SLP #2 said Resident #4 was care planned to have 1:2 supervision. SLP #2 said that at 10:30 AM, they brought the resident out of their room, was getting ready to leave the unit and wanted to ensure the resident had supervision. SLP #2 said they were told by CNA #10 that Resident #4 was on 15-minute checks. SLP #2 reviewed the Kardex with CNA #10 and it documented 1:2 supervision. CNA #10 said they were not assigned to the resident. During an interview on [DATE] at 2:54 PM, CNA #10 stated they were not Resident #4's aide on [DATE], and did not know who the resident's aide was. CNA #10 told the therapist they thought the resident was on 15-minute checks and the therapist told them they were wrong and that the resident needed 1:1 supervision, meaning direct supervision. CNA #10 said they did check on Resident #4 afterwards, even though they were not assigned to the resident. During a subsequent interview with CNA #10 on [DATE] at 6:02 PM, CNA #10 stated they did check on Resident #4 after the incident and then washed the resident. CNA #10 said they would have documented the care they provided to the resident. The surveyor reviewed their documentation and the assignment sheet dated [DATE], with CNA #10. CNA #10 stated the assignment had been changed from what was originally on the sheet and reiterated that they did not work on Resident #4's unit that day. During an interview on [DATE] at 3:09 PM, the Therapy Director (TD) stated Resident #4 had been on 1:2 supervision for quite a while. The TD said Resident #4 had a mouthing thing and was supposed to be supervised when in their wheelchair because they were independent with mobility, and when they were in bed. The TD said the 15-minute checks of the resident were to be done at night. During an interview on [DATE] at 4:13 PM, RNM #2 stated they were responsible for the South/New South Units. RNM #2 said they recalled looking at the assignment and seeing CNA #10's name next to Resident #4's name on [DATE]. RNM #2 said the nurse on duty was responsible for doing the assignment that day but arrived late. Because the day shift nurse was late, the overnight nurse would have been responsible for the assignment that morning. RNM #2 said SLP #2 approached them and showed them a half dollar piece of plastic and described it as being part of the package of personal cleaning wipes. RNM #2 said they assessed Resident #4. RNM #2 said SLP #2 expressed concern about who was watching Resident #4. RNM #2, SLP #2, CNA #10, and LPN #2 all reviewed the assignment, and decided CNA #10 would be supervising Resident #4 at that point because they were already assigned to the New South Unit. When asked who was assigned to Resident #4 prior to the incident, RNM #2 stated they did not know who was assigned, and it was possible that no one was assigned. RNM #2 then stated they did not know what fell apart at the time of the incident. RNM #2 said they were not familiar with Resident #4's care plan but knew that the resident was not always aware of safety limitations and needed oversight because of that. RNM #2 said if Resident #4 was being supervised at the time of the incident, someone would have intervened. During an interview on [DATE] at 12:18 PM, the Director of Nursing (DON) stated Resident #4 was supposed to be supervised while awake. The DON said Resident #4 would put things in their eyes, ears, and mouth. The DON said a CNA was supposed to be assigned to the residents to provide supervision and if they were being supervised 1:1, it would not have happened. During an interview on [DATE] at 2:42 PM, the Administrator stated if Resident #4 was awake, the expectation was the supervision would be provided. Resident 4 needed some level of direct supervision. The Administrator said there should always be someone assigned to Resident #4. and they were currently investigating the incident. During an interview on [DATE] at 11:42 AM, Physician (MD) #2 stated they were not surprised the incidents occurred because Resident #4 is very active and mobile in their wheelchair. Resident #5: Resident #5 was admitted to the facility with diagnoses of [CONDITION(S)], autistic disorder, and congenital deformities of the hip. The Minimum Data Set (MDS-an assessment tool) dated [DATE], documented the resident rarely made themselves understood and rarely understood others. The resident resided on the New South Unit. The Comprehensive Care Plan (CCP) for Elopement Risk/Wanderer last revised [DATE], documented the resident was at risk related to impaired safety awareness and independent with wheelchair mobility with decreased safety skills/cognition/impulsivity. The resident was to have 1:2 supervision (one staff member for the resident and their roommate) while awake. The Kardex Report dated [DATE], included 1:2 supervision (one staff member for the resident and their roommate) while awake. Resident #5 was a wander risk as they were able to independently move in their wheelchair. An Incident Report dated [DATE] at 3:55 PM, documented Speech Language Pathologist (SLP) #2 discovered Resident #5 pouring a medication bottle onto their lap. The resident was removed from the medication cart and was moved to a safe place with supervision. The Nursing Progress Notes did not include documentation of the incident. During an interview on [DATE] at 1:35 PM, SLP #2 stated they went out into the hall, and observed Resident #5 pouring liquid medication from a medication cart in their lap. SLP #2 said they removed the medication and noticed the resident also had two unopened bottles in their lap. SLP #2 stated they yelled for the nurse. During an interview on [DATE] at 4:55 PM, CNA #11 was sitting in Resident #4's room. CNA #11 stated they were floated to the unit to do the 1:2 supervision for Resident #'s 4 and the resident's roommate (Resident #5) on [DATE]. CNA #11 stated both residents did not need to be on 1:2 supervision because they really did not do anything. CNA #11 was unaware of the incidents with Resident #'s 4 and Resident #5. During an observation of the New South Unit on [DATE] at 11:39 AM, CNA #13 was in the community room/common area of the unit and was supervising Resident #5. At 11:45 AM, Resident #5 self-propelled in their wheelchair out of the common area and into the hallway. Resident #5 threw their ball down the hallway. CNA #13 left the common area to retrieve the ball and to bring Resident #5 back to the common area. CNA #12 said there was no Charge Nurse and no Nurse Manager on the unit and that every day, the aides would put their name on the assignment sheet next to the residents they were going to provide care for. During an interview on [DATE] at 12:18 PM, the Director of Nursing (DON) stated Resident #5 was supposed to be supervised while awake, and there should never be medication on a medication cart when the cart was unattended. The DON stated the incident should not have happened because staff should have been watching the resident. The DON stated they did not know how or when 1:2 supervision was established and implemented in the facility and did not have a policy for the 1:2 supervision. The DON said they were not sure if staff understood the meaning of 1:1 and 1:2 supervision. The DON said the aides had not received any formal training about the expectation of the 1:1 supervision in the last year and it was hard to train when you are not sure about the definition. The DON said Therapy determined if the resident needed 1:1 supervision and said the hope was they would discuss it with the interdisciplinary team (IDT). During an interview on [DATE] at 2:42 PM, the Administrator stated Resident #5 was supervised when they were awake. Resident #5 could be grabby, could wander in their wheelchair to look for something to do. The Administrator said medications should not be on an unattended medication cart. During an interview on [DATE] at 3:56 PM, the Administrator stated the facility did not maintain a safe environment for Resident #5 when medication was left on the unattended medication cart. During an interview on [DATE] at 11:42 AM, Physician (MD) #2 stated they were not surprised the incidents occurred because Resident #5 is very active and mobile in their wheelchair. During an interview on [DATE] at 3:46 PM, the Medical Director (MD #3) stated RNM #2 was new, and training had not been organized to the level they strived for. MD #3 said they had 1:2 supervision in the facility and the goal was to keep all the residents safe. Resident #7: Resident #7 was admitted to the facility with diagnoses of [CONDITION(S)], [CONDITION(S)] (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain), and acute necrotizing hemorrhagic [CONDITION(S)] (a rare type of brain disease that occurs following a [CONDITION(S)] infection such as the flu). The Minimum Data Set (MDS-an assessment tool) dated [DATE], documented the resident rarely/never made themselves understood and was rarely/never able to understand others. The resident resided on the South Unit. The Comprehensive Care Plan (CCP) for Physical Restraints last revised [DATE], documented Resident #7 used physical restraints that included a seat belt and chest harness to maintain safety/and alignment in the wheelchair and the CNA was to ensure the resident was positioned correctly with proper body alignment while restrained. The CCP for At Risk for Falls and Injury last revised [DATE], documented 15-minute checks by the CNA. The Kardex Reports dated [DATE], and [DATE], documented the resident utilized a seat belt and chest harness in the wheelchair and was on 15-minute checks A Point of Care Audit Report (completed care plan tasks)) for Resident #7 dated [DATE] to [DATE], documented that on [DATE] at 7:38 AM, safety check every 15 minutes were completed by CNA #20. The Point of Care Audit did not include documentation that 15-minute checks were completed for the resident from 6:50 AM to 8:10 AM on [DATE]. A Nursing Progress Note dated [DATE] at 12:37 PM by LPN #9, documented that at approximately 8:10 AM, they were called into Resident #7's room by the therapists (Therapy Aide #1). Resident #7 was unresponsive. The resident had slid down in their wheelchair and their head was on the seat of the wheelchair. The resident had no respirations and no pulse. The resident was lowered to the floor and CPR was initiated. A written statement dated [DATE] by CNA #21 (the assigned day shift aide) documented they were on the unit at 7:20 AM that morning. CNA #21 documented they saw Resident #7 sitting in their chair. During interview on [DATE] at 2:23 PM, CNA #20 stated that when they documented that on [DATE] at 7:38 AM, it was for what they did for the resident during the night. CNA #20 stated they last saw Resident #7 in their wheelchair at 6:50 AM and did not go back into the room. During interview on [DATE] at 8:00 AM, CNA #21 stated they were not aware the resident was care planned for 15-minute checks and did not see and/or check on the resident on [DATE]. CNA #21 stated that when they wrote their statement, they were panicked and crying and thought they would get in trouble for not checking the resident, and so they wrote that they saw the resident. A written interview with the Therapy Aide (TA) #1 dated [DATE] documented that at 8:10 AM, TA #1 entered Resident #7's room and noted the resident was unresponsive and slouched in their wheelchair, with the chest harness under their chin. TA #1 was unable to detect a pulse and yelled for help. During an interview on [DATE] at 2:01 PM, CNA #20 stated they were assigned to Resident #7 on [DATE] during the 11:00 PM - 7:00 AM shift. CNA #20 said they could not recall if the resident was care planned for 15-minute checks. CNA #20 said they dressed the resident and put them in their chair before 7:00 AM on [DATE] and then helped Resident #7 with a video call to their mother around 6:35 AM. CNA #20 stated they left the room after the call. CNA #20 said they gave a verbal report about the resident to the oncoming day shift aide, CNA #12. CNA #20 said the assignment was then changed and given to CNA #21. CNA #20 said they told CNA #21 that Resident #7 was already dressed and up in their chair. During a subsequent interview on [DATE] at 2:23 PM, CNA #20 stated they called the resident's mother at 6:34 AM on [DATE], and the call was about 5 to 10 minutes long. CNA #20 said Resident #7 was in their chair and they left the resident's room at 6:50 AM. CNA #20 told them that Resident #7 was in the chair and CNA #12 would then have been responsible for the resident. CNA #20 said Resident #7 was usually on CNA #12's assignment. CNA #20 said they did not go back in the resident's room because their shift was over. During an interview on [DATE] at 11:07 AM, CNA #12 stated CNA #20 had the resident during the night. When CNA #12 arrived on the unit on the morning of [DATE], CNA #20 told them that Resident #7 was up in the chair. CNA #12 said they were not assigned to Resident #7 that day. CNA #12 stated aides did not show up for work on time. The day shift started at 7:00 AM but the aides come in late at 7:30 AM, 8:00 AM, or 9:00 AM. CNA #12 said CNA #20 would have been responsible for Resident #7 until the assigned aide, CNA #21, arrived on the unit, even though CNA #20 had given them a verbal report about the resident. CNA #12 stated they did not see and/or check on Resident #7 prior to the incident. CNA #12 stated they did not k [TRUNCATED]

Based on record review and interviews during an abbreviated survey (Case #'s NY 829, NY 145, and NY 404), the facility did not ensure provision of sufficient nursing staff with the appropriate competencies and skills sets 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 throughout the facility for 3 (Resident #s 1, 4 and 5) of 7 residents reviewed. Specifically, for Resident #1 on the ventilator) unit, the facility did not ensure adequate staffing to provide nursing and respiratory care on 1/19/2022. For Resident #4 on the New South Unit, the facility did not ensure staff were assigned to provide the resident with the care planned 1:2 supervision on 3/4/2022. For Resident #5, the facility did not ensure adequate staffing was assigned to provide the resident with the care planned 1:2 supervision on 3/1/2022. This was evidenced by: Refer to F689 The facility did not have a policy for staffing. Resident #1: Resident #1 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - an assessment tool) dated 1/7/2022, documented the resident's cognitive skills for daily decision making were severely impaired. The resident sometimes made themselves understood and was sometimes able to understand others. The Comprehensive Care Plan (CCP) for ADL Self-Care Performance Deficit last revised 12/30/2021, documented the deficit was related to severe congenital [CONDITION(S)], neurodevelopmental delay, chronic ventilator support, limited mobility, altered safety awareness/impulsivity and aggressive behavior at times. The resident required supervision when sitting in their wheelchair and staff were to tilt the chair if the resident's head was falling forward and per request. The CCP for History of Behavior Problem last revised 12/17/2021, documented the resident's behaviors included pulling off the SPO2 monitor probe, disconnecting vent tubing at [CONDITION(S)] and tubing, pulling on and pulling out tube feed and putting in mouth, as well as scratching, grabbing and hair pulling towards others related to boredom and lacking attention. The resident required 1:2 supervision from 7:00 AM - 11:00 PM, during waking hours while not in school. A Staffing Sheet dated 1/19/2022, documented Registered Nurse (RN) #3, Licensed Practical Nurse (LPN) #1 and Certified Nursing Aide (CNA) #s 1, 2, 3 and 4 were assigned to the ventilator (Vent) Unit. A Vent Unit 7-3 Assignment sheet dated 1/19/2022, documented CNA #1 was assigned to provide 1:2 supervision for Resident #s 1 and 2. The document titled 2 Unit January Respiratory Schedule dated January 2022, documented Respiratory Therapist (RT) #1 and RT #3 were scheduled to work on the Vent Unit on 1/19/2022. During an interview on 3/1/2022 at 2:41 PM, RT #3 stated that on 1/19/2022, they had to go out on an appointment, leaving RT #1 as the only RT on Vent Unit. During an interview on 2/22/2022 at 2:31 PM, CNA #3 stated there was usually two Respiratory Therapists (RTs) and two RNs, one LPN, and five CNAs on the Vent Unit during the day shift. On 1/19/2022, an RT and a RN left the facility with a resident who had an appointment, leaving RT #1, RN #2 and LPN #1 on the unit. CNA #3 said there were four CNAs assigned on 1/19/2022 but CNA #1, was assigned to do the 1:2 supervision for Resident #s 1 and 2. CNA #3 said there were 3 CNAs on the floor on 1/19/2022 and they would have been assigned five to six residents each. CNA #3 stated that on 1/19/2022, they saw the Respiratory Therapy Manager (RTM) on the Unit but most of the day it was only RT #1 who was on the Unit. During an interview on 3/1/2022 at 4:13 PM, CNA #5 stated staffing on the Vent Unit was hit or miss depending on the day. CNA #5 said one day there could be four CNAs, and the next day there could be two. CNA #5 said the 3:00 PM to 11:00 PM shift was the worst. CNA #5 said they worked 7:00 AM - 3:00 PM and often worked the 3:00 PM to 11:00 PM in addition to their shift. CNA #5 stated that all the CNAs would do that. CNA #5 said that there used to be two RTs, two RNs, and one LPN but now there was one RN and one LPN or just two RNs. CNA #5 said that since the vents had been moved downstairs, they have three RTs and said there used to be one or two RTs. CNA #5 said they definitely needed two RTs on the unit and one additional RT to go out on appointments. CNA #5 said when there were only two RTs on the unit and one had to go out on an appointment, it was very stressful on the floor, especially when there not enough nurses. CNA #5 said the nurses would have to answer vent alarms while they passed medication. During an interview on 3/1/2022 at 1:45 PM, RT #2 stated that on 1/19/2022, there were two Vent Units, Peds C upstairs and the Vent Unit downstairs. RT #2 said that the following week, they merged into one unit. RT #2 stated they had been requesting for quite a while that the units merge because of staffing issues with RTs and RNs. RT #2 said that typically there were two RNs on the Vent Unit and one LPN on the medication cart. RT #2 said that often times there was one RN and one LPN, and they both had medication carts. RT #2 said there was a shortage of CNAs on all shifts and stated it was hit or miss. During an interview on 3/1/2022 at 2:41 PM, RT #3 stated that on 1/19/2022, they had to go out on an appointment, leaving RT #1 as the only RT on Vent unit. RT #3 stated there always needed to be at least two RTs on the Vent unit. RT #3 stated the Respiratory Therapy Manager (RTM) was supposed to be covering for them while they were out on the appointment. During interview on 3/4/2022 at 2:53 PM, RN #2 stated they were the charge nurse on the Vent Unit and on 1/19/2022 they had to cover for a nurse who went out on an appointment. RN #2 stated that the CNA staffing was a joke and said they were told that having three CNAs on the Vent Unit was a good number. RN #2 said there were two residents who needed 1:1 supervision, which meant there were only two CNAs for the floor if there were 3 CNAs working. During an interview on 2/11/2022 at 3:09 PM, the RTM stated that they have called the Nursing Supervisor because there was not enough staff on the Vent Unit. The RTM said there was no staff around at night from 7:00 PM - 7:00 AM and said it had been crazy for a while. The RTM said the staffing situation at night would cause the RTM to go into Resident #1's several times in response to their vent alarm and would interfere with the RTM needing to go into other rooms to assist them. The RTM said that at night, there was usually one nurse on the Vent Unit and one supervisor in the building. The RTM said the RTs had complained about staffing problems that were mostly on the 7:00 PM - 7:00 AM shift. During an interview on 2/22/2022 at 3:13 PM, the Registered Nurse Manager (RNM) #1 stated that at the time of the incident on 1/19/2022, they had two ventilator (vent) units, the Vent Unit and the Peds C Unit, and both were very busy. RNM #1 said that shortly after the incident with Resident #1 on 1/19/2022, they combined the units to make one vent unit. RNM #1 said there were typically two RTs, two RNs, and an LPN on the Vent Unit. RNM #1 said that on 1/19/2022, there was one RT, one RN and one LPN on the unit because an RT and an RN left the facility for a resident appointment. RNM #1 said the RTM would sometimes accompany the resident on the appointment or would cover for the RT and on 1/19/2022, the RTM covered the RT. RNM #1 said that an RN could also cover for an RT. RNM #1 said they had problems staffing CNAs on the Vent Unit. RNM #1 said there were days when there were only two CNAs on the unit during the day shift. RNM #1 said that staffing was not so good during the evening shift and they would frequently have one or two CNAs on the unit, after begging, borrowing and stealing. RNM #1 said that during the night, they sometimes had one CNA. RNM #1 said they supposed to have three nurses on the unit and minimally one of the nurses had to be a RN. RNM #1 said that a charge nurse worked on the Vent Unit, Monday to Friday, and on 1/19/2022 it was RN #2. RNM #1 said the night shift was the worst and there had been many nights having one or two LPNs on the Vent Unit and one RN in the building. RNM #1 said that the RN in the building might be supervising, working a unit, or both. RNM #1 said there were many residents on the Vent Unit with behaviors that included pulling out their [CONDITION(S)]. RNM #1 said that from 7:00 PM to 11:00 PM, staffing was bare minimum. RNM #1 stated they would never leave the unit unstaffed, but it was not adequately staffed with the appropriate number of staff. Resident #4: Resident #4 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE], documented the resident rarely made themselves understood and rarely understood others. The CCP for Safety Care last revised 5/6/2020, documented the resident needed safety monitoring due to developmental delay, decreased safety awareness, and excessive mouthing of many non-food items. The resident was to have 1:2 supervision (one staff member for the resident and their roommate) while awake. The Kardex Report dated 3/10/2022, included the following intervention for Resident Care/Monitoring: 1:2 supervision (one staff member for the resident and their roommate) while awake. The South/New South CNA 5 CNA Assignment Sheet dated 3/4/2022 for the 7:00 AM to 3:00 PM shift, documented three CNAs were assigned. The assignment sheet did not include an assigned CNA for Resident #4. During an interview on 3/7/2022 at 1:35 PM, SLP #2 stated they were on the New South Unit on 3/4/2022 at around 9:30 AM, and they noticed Resident #4 was in bed and had a package of personal cleansing wipes, and there were 3 large pieces of the packaging in the resident's mouth. SLP #2 was able to remove the pieces with a toothbrush. SLP #2 said the cleansing wipes were usually kept in the resident's room for the CNA to use when providing care. SLP #2 said the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . SLP #2 showed Registered Nurse Manager (RNM) #2 what they had removed and RNM #2 assessed the resident's mouth, and Resident #4 showed no distress. SLP #2 said there was usually a CNA assigned to Resident #4, but SLP #2 could not figure out who the assigned CNA was because they did not see any staff on the unit. RNM #2 could not identify who the assigned CNA was. SLP #2 stated Resident #4 was care planned to have one staff supervise two residents. SLP #2 said that at 10:30 AM, they brought the resident out of their room, was getting ready to leave the unit and wanted to ensure the resident had supervision. SLP #2 said they had been told by CNA #10 that Resident #4 was on 15-minute checks. SLP #2 reviewed the Kardex with CNA #10 and it documented 1:2 supervision. CNA #10 said they were not assigned to the resident. SLP #2 said RNM #2 got the assignment book and started reviewing it to see who was assigned to the resident. During an interview on 3/8/2022 at 2:54 PM, CNA #10 stated they were not Resident #4's CNA on 3/4/2022. CNA #10 stated SLP #2 came out of Resident #4's room and told a CNA and a nurse that the resident was eating something. CNA #10 said that CNA was not assigned to Resident #4 either. CNA #10 said they did not know who the resident's CNA was. CNA #10 told the therapist they thought the resident was on 15-minute checks and the therapist told them they were wrong and that the resident needed 1:1 supervision, meaning direct supervision. CNA #10 said they did check on Resident #4 afterwards, even though they were not assigned to the resident. During an interview on 3/8/2022 at 5:55 PM, the Administrator stated CNA #10 was assigned to residents in room (identified room number) on the New South Unit on 3/4/2022 and was also assigned to Resident #4, on the New South Unit. The Administrator provided documentation that CNA #10 provided care to Resident #4 on 3/4/2022. During a subsequent interview with CNA #10 on 3/8/2022 at 6:02 PM, CNA #10 stated they did check on Resident #4 after the incident and then washed the resident. CNA #10 said they would have documented the care they provided to the resident. CNA #10 reviewed their documentation and the assignment sheet dated 3/4/2022 and stated the assignment had been changed from what was originally on the sheet and reiterated that they did not work on Resident #4's unit that day. During an interview on 3/8/2022 at 4:13 PM, RNM #2 stated they were responsible for the South/New South Units. RNM #2 stated that going by memory CNA #10 was assigned to Resident #4 on 3/4/2022. RNM #2 said they recalled looking at the assignment and seeing CNA #10's name next to Resident #4's name. RNM #2 said SLP #2 approached them and showed them a half dollar size piece of plastic and described it as being part of the package of personal cleaning wipes. RNM #2 stated SLP #2 expressed concern about who was watching Resident #4. RNM #2, SLP #2, CNA #10, and LPN #2 all reviewed the assignment, and it was discussed that CNA #10 would be supervising Resident #4 at that point because they were already assigned to the New South Unit. When asked who was assigned to Resident #4 prior to the incident, RNM #2 stated that it was their impression that CNA #10 would take Resident #4 at that moment to keep the resident safe. RNM #2 stated it was a possibility no one was assigned to the resident prior to the incident, and that they truthfully did not know who was assigned. When asked how CNA #10 would be able to supervise Resident #4 and provide care to their other assigned residents, RNM #2 stated it was very hard but it seems that they manage. RNM #2 said Resident #4 was not always aware of safety limitations and needed oversight because of that. RNM #2 stated that, if Resident #4 was being supervised at the time of the incident when the resident put something in their mouth, someone would have intervened just like SLP #2 did. Resident #5: Resident #5 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE], documented the resident rarely made themselves understood and rarely understood others. The CCP for Elopement Risk/Wanderer last revised 2/10/2020, documented the resident was at risk related to impaired safety awareness, independent wheelchair mobility with decreased safety skills/cognition/impulsivity, and ability to scoot/crawl independently. The resident was to have 1:2 supervision (one staff member for the resident and their roommate) while awake. The Kardex Report dated 3/1/2022, documented Resident #5 was to receive 1:2 supervision (one staff member for the resident and their roommate) while awake. Resident #5 was a wander risk as they were able to independently move in their wheelchair and could scoot/crawl when on the mat/floor. The South/New South unit 4 CNA Assignment Sheet dated 3/1/2022 for the 3:00 PM - 11:00 PM shift, documented there were three CNAs assigned. The CNA assigned to Resident #5 was also assigned seven additional residents, including Resident #4. During an interview on 3/4/2022 at 1:35 PM, SLP #2 stated they were treating someone on the unit and when they went out into the hall, they observed Resident #5 pouring liquid medication from a medication cart onto their lap. SLP #2 removed the medication and noticed the resident also had two unopened bottles in their lap. SLP #2 yelled for the nurse. SLP #2 said the nurse told them it was heartburn medication. During an interview on 3/7/2022 at 4:55 PM, CNA #11 stated that, if they were assigned residents in addition to 1:2 assignment, they could not provide care in another resident's room and supervise Resident #s 4 and 5 in the hall or common areas at the same time. During an observation of the New South unit on 3/9/2022 at 11:39 AM, CNA #13 was in the community room/common area of the unit and was supervising Resident #5. Resident #4 was in the room and was receiving treatment from a therapist. Three other residents were noted in the common area. CNA #13 stated they were assigned 5 residents in addition to being assigned to do the 1:2 supervision of Resident #s 4 and 5. CNA #13 said 5 of their assigned residents were currently in the common area. CNA #13 said they had personally talked to the DON about it on Thursday. At 11:45 AM, Resident #5 self-propelled in their wheelchair out of the common area and into the hallway. Resident #5 then threw their ball down the hallway. CNA #13 left the common area to retrieve the ball and to bring Resident #5 back to the common area. At 11:46 AM, the therapist left the common area and while they were walking down the hallway, CNA #13 yelled to them and asked if they could watch Resident #s 4 and 5 while they assisted another CNA with a resident who required the assistance of two staff members. The therapist returned to the common area. At 11:55 AM, CNA #12 entered the common area and stated there were only two CNAs on the unit, and two of the residents required 1:1 supervision. CNA #12 said there was no charge nurse and no nurse manager on the unit. CNA #12 said that every day, the CNAs would put their name on the assignment sheet next to the residents they were going to provide care for. During an interview on 3/9/2022 at 12:18 PM, the Director of Nursing (DON) stated Resident #4 and their roommate Resident #5, were supposed to be supervised while awake. The DON said one CNA was supposed to be assigned to both residents and that would be the CNA's only assignment. The DON stated that if the daily assignment needed to be altered because they were low on staff or the census was low, the nurse manager or charge nurse was expected to adjust the assignment accordingly. The DON said they would not expect the CNA to have additional residents to care for when they had a 1:2 assignment. The DON stated they were not aware that the CNA assigned the 1:2 supervision was also assigned additional residents to care for. The DON stated that if it was happening, it was because of how residents were being assigned on the unit. During an interview on 3/9/2022 at 2:42 PM, the Administrator stated both Resident #s 4 and 5 needed some level of direct supervision. The Administrator said there should always be staff assigned to Resident #s 4 and 5. The Administrator stated they were not aware of staff being assigned the 1:2 assignment along with additional residents. The Administrator stated During an interview on 3/11/2022 at 3:56 PM the Administrator stated the 1:2 supervision was not being done due to a staffing shortage. 10 NYCRR 415.13(a)(1)(i-iii)

Based on record review and interview during a partial extended abbreviated survey (Case #s NY 829 and NY 145), the facility did not ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 3 (Resident #s 1, 4, and 5) of 3 residents reviewed. Specifically, Administration did not develop and implement a policy and procedure for 1:2 supervision. Subsequently, Resident #s 1, 4, and 5 were care planned for 1:2 supervision. This was evidenced by: Refer to F689 During an interview on 3/9/2022 at 2:42 PM, the Administrator stated there was no policy and procedure for 1:2 supervision. Resident #1: Resident #1 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - an assessment tool) dated 1/7/2022, documented the resident's cognitive skills for daily decision making were severely impaired. The resident sometimes made themselves understood and was sometimes able to understand others. The CCP for History of Behavior Problem last revised on 12/17/2021, documented the resident's behaviors included pulling off the SPO2 (the amount of oxygenated hemoglobin in the blood) monitor probe, disconnecting vent tubing at [CONDITION(S)] and tubing, pulling on and pulling out tube feed and putting in mouth. The resident required 1:2 supervision from 7:00 AM - 11:00 PM, during waking hours while not in school. Resident #4: Resident #4 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - an assessment tool) dated 11/19/2021, documented the resident rarely made themselves understood and rarely understood others. The Comprehensive Care Plan (CCP) for Safety Care last revised 5/6/2020, documented the resident needed safety monitoring due to decreased safety awareness, and excessive mouthing of many non-food items. The resident was to have 1:2 supervision (one staff member for the resident and their roommate) while awake. Resident #5: Resident #5 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE], documented the resident rarely made themselves understood and rarely understood others. The resident resided on the New South unit. The CCP for Elopement Risk/Wanderer last revised 2/10/2020, documented the resident was at risk related to impaired safety awareness, independent wheelchair mobility with decreased safety skills/cognition/impulsivity, and ability to scoot/crawl independently. The resident was to have 1:2 supervision (one staff member for the resident and their roommate) while awake. During an interview on 3/9/2022 at 12:18 PM, the Director of Nursing (DON) stated they did not know how or when 1:2 supervision was established and implemented in the facility and did not have a policy for the 1:2 supervision. The DON stated they were not sure if staff understood the meaning of 1:1 and 1:2 supervision, and that the CNAs had not received any formal training about the expectation of the 1:1 supervision in the last year. The DON also stated it was hard to train when you are not sure about the definition. During an interview on 3/9/2022 at 2:42 PM, the Administrator stated they reviewed Resident #1's record and said the resident needed 1:2 supervision, which meant one staff member with two residents who required the same level of supervision. The Administrator said there was no policy for 1:2 supervision. The Administrator stated they did not know if CNAs had received any training for the 1:2 supervision. The Administrator said for 1:2 supervision, staff should have eyes on the resident, be within arms-reach of the resident, and should not be across the room. Staff should be able to visualize the resident and should be engaged with the resident. 10 NYCRR 415.26

Based on record review and interviews during an abbreviated survey (Case #s NY 145 and NY 379), the facility did not ensure that all alleged allegations involving neglect were reported immediately, but not later than 24 hours after the allegation was made, if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the Administrator and to the State Survey Agency, for 2 (Resident #s 4 and 5) of 4 residents reviewed for abuse, neglect, and mistreatment. Specifically, the facility did not ensure the Administrator and the NYSDOH were immediately notified after an incident on 3/4/2022 when Resident #4 was observed in bed, with a package of personal cleansing wipes and pieces of the personal wipes packaging in their mouth. The incident was reported to the NYSDOH on 3/9/2022. Additionally, the facility did not ensure the Administrator and the NYSDOH were immediately notified after an incident on 3/1/2022 when Resident #5 was observed pouring a bottle of medication from an unattended medication cart into their lap. The incident was reported to NYSDOH on 3/9/2022. This was evidenced by: The Policy and Procedure (P&P) titled Incident Reporting Policy last reviewed 1/9/2022, documented that it was the facility's policy to comply with applicable federal and state laws, rules, and regulations that require certain alleged incidents to be reported to the Administrator and when required, to the New York State Department of Health (NYSDOH). The P&P documented that an incident was any happening that was not consistent with the routine operation of the facility, or the routine care of a resident. Incidents included neglect and was defined as but not limited to the failure to follow the care plan and the failure to adequately supervise the whereabouts and activities of residents. Any staff member who, through visual or auditory observation, became aware of an alleged incident, was to immediately report the incident to a licensed nurse assigned to the unit, or to their immediate supervisor. The P&P documented the definition of immediately to mean as soon as possible, but not to exceed twenty-four (24) hours after the discovery of the incident. Nursing/facility administration would determine if the incident was reportable to the NYSDOH. Resident #4: Resident #4 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-an assessment tool) dated 11/19/2021, documented the resident rarely made themselves understood and rarely understood others. The Comprehensive Care Plan (CCP) for Safety Care last revised 5/6/2020, documented the resident needed safety monitoring due to decreased safety awareness, and excessive mouthing of many non-food items. The resident was to have 1:2 supervision (one staff member for the resident and their roommate) while awake. An Incident Report dated 3/4/2022 at 9:27 AM, documented the Speech Language Pathologist (SLP) #2 entered Resident #4's room and observed the resident in bed with a package of personal cleansing wipes. The resident was observed to have pieces of the packaging in their mouth. SLP #2 removed the material from the resident's mouth and removed the wipes. -The report included incident details that were documented and signed by SLP #2 and documented Registered Nurse Manager (RNM) #2 had knowledge of the event. -There was no other documentation on the report and was not signed by RNM #2. -There was no documentation on the report that the Administrator and/or NYSDOH were notified. The Nursing Progress Notes did not include documentation about the incident dated 3/4/2022. The NYSDOH Intake Information report for Case# NY 145, documented that on 3/9/2022 at 6:24 PM, the facility reported an incident involving Resident #4 that occurred on 3/4/2022 at 9:30 AM. During an interview on 3/7/2022 at 1:35 PM, SLP #2 stated that on 3/4/2022 at around 9:30 AM, SLP #2 entered the resident's room and noticed Resident #4 in bed with a package of personal cleansing wipes. There was no other staff in the resident's room. SLP #2 said 3 large pieces of the packaging were in the resident's mouth. SLP #2 was able to remove the pieces with a toothbrush. SLP #2 said the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . SLP #2 said there was usually an aide assigned to Resident #4, but SLP #2 could not figure out who the assigned aide was, and that Registered Nurse Manager (RNM) #2 could not identify who the assigned aide was. SLP #2 said Resident #4 was care planned to have 1:2 supervision. SLP #2 said that at 10:30 AM, they brought the resident out of their room, was getting ready to leave the unit and wanted to ensure the resident had supervision. SLP #2 said they were told by CNA #10 that Resident #4 was on 15-minute checks. SLP #2 reviewed the Kardex with CNA #10 and it documented 1:2 supervision. CNA #10 said they were not assigned to the resident. During an interview on 3/7/2022 at 4:55 PM, CNA #11 was sitting in Resident #4's room. CNA #11 stated they were floated to the unit to do the 1:2 supervision for Resident #'s 4 and the resident's roommate (Resident #5) on 3/7/2022. CNA #11 stated both residents did not need to be on 1:2 supervision because they really did not do anything. CNA #11 was unaware of the incidents with Resident #'s 4 and Resident #5. During an interview on 3/8/2022 at 1:40 PM, CNA #13 stated they were not aware of the incident with Resident #s 4 and 5, until just now when the surveyor asked about it. CNA #13 said the incident was not reported to staff on the unit. CNA #13 stated that there was a lack of communication from the chain of command. During an interview on 3/8/2022 at 4:13 PM, RNM #2 stated they were responsible for the South/New South units. RNM #2 said they were not familiar with Resident #4's care plan but knew that the resident was not always aware of safety limitations and needed oversight because of that. RNM #2 said if Resident #4 was being supervised at the time of the incident when the resident put something in their mouth, someone would have intervened just like SLP #2 did. RNM #2 said they did not tell any staff about the incident with Resident #4 and said they were comfortable with walking away because the aides would have taken care of Resident #4's immediate need. RNM #2 said they did not notify the physician, DON or Administrator about the incident. RNM #2 stated that Resident #4 would do it again because it was their personality. During an interview on 3/9/2022 at 12:18 PM, the Director of Nursing (DON) stated Resident #4 and their roommate Resident #5, who was their sibling, were supposed to be supervised while awake. The DON said Resident #4 would put things in their eyes, ears, and mouth. The DON said they never saw the resident ingesting anything but and said there was a history of them doing that in the CCP. The DON said they were not aware of the incident with Resident #4 until 3/7/2022, when the surveyor was onsite. During an interview on 3/7/2022 at 10:37 AM, the Administrator stated they were not aware of an incident with Resident #4. The Administrator said Resident #4 was the type of resident who would grab things and put them in their mouth. Resident #4 was supposed to have 1:2 supervision (one staff supervised 2 residents) with their sibling, who shared the room. The Administrator said an incident report should have been filed and an investigation started to see if it rose to the level of being reportable to the NYSDOH. During a subsequent interview on 3/7/2022 at 12:15 PM, the Administrator stated they found an incident report for Resident #4 dated 3/4/2022, in RNM #2's office. The Administrator stated would have an RN assess the resident and would start an investigation. Resident #5: Resident #5 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-an assessment tool) dated 1/21/2022, documented the resident rarely made themselves understood and rarely understood others. The resident resided on the New South Unit. The Comprehensive Care Plan (CCP) for Elopement Risk/Wanderer last revised 2/10/2020, documented the resident was at risk related to impaired safety awareness and independent with wheelchair mobility with decreased safety skills/cognition/impulsivity. The resident was to have 1:2 supervision (one staff member for the resident and their roommate) while awake. An Incident Report dated 3/1/2022 at 3:55 PM, documented SLP #2 discovered Resident #5 pouring a medication bottle onto their lap. The resident was removed from the medication cart and was moved to a safe place with supervision. -The report included incident details that were documented and signed by SLP #2 and documented Registered Nurse Manager (RNM) #2 had knowledge of the event. -The report included an RN assessment, Safeguards to the resident, and follow up by the Nurse Manager that was signed by RNM #2 on 3/2/2022. -There was no documentation on the report that the Administrator and/or NYSDOH were notified. The Nursing Progress Notes did not include documentation of the incident. The NYSDOH Intake Information report for Case# NY 379, documented that on 3/9/2022 at 6:11 PM, the facility reported an incident involving Resident #5 that occurred on 3/1/2022 at 4:00 PM. During an interview on 3/4/2022 at 1:35 PM, SLP #2 stated they went out into the hall, and observed Resident #5 pouring liquid medication from a medication cart in their lap. SLP #2 said they removed the medication and noticed the resident also had two unopened bottles in their lap. SLP #2 stated they yelled for the nurse. During an interview on 3/7/2022 at 4:55 PM, CNA #11 was sitting in Resident #4's room. CNA #11 stated they were floated to the unit to do the 1:2 supervision for Resident #'s 4 and the resident's roommate (Resident #5) on 3/7/2022. CNA #11 stated both residents did not need to be on 1:2 supervision because they really did not do anything. CNA #11 was unaware of the incidents with Resident #'s 4 and Resident #5. During an interview on 3/8/2022 at 1:40 PM, CNA #13 stated they were not aware of the incident with Resident #s 4 and 5, until just now when the surveyor asked about it. CNA #13 said the incident was not reported to staff on the unit. CNA #13 stated that there was a lack of communication from the chain of command. During an interview on 3/8/2022 at 4:13 PM, RNM #2 stated they did not inform the DON or Administrator about the incident with Resident #5 that occurred on 3/1/2022. During an interview on 3/9/2022 at 12:18 PM, the DON stated they were not aware of the incident with Resident #5 until 3/7/2022, when the surveyor was onsite. The DON said RNM #2 did not inform them or the Administrator about the incident. During an interview on 3/9/2022 at 2:42 PM, the Administrator stated they may have heard about the incident with the medication indirectly but was not informed by RNM #2. 10 NYCRR 415.4(b)(2)

Based on record review and interviews during an abbreviated survey (Case #s NY 145 and #NY 379), the facility did not ensure that they thoroughly investigated an alleged violation of neglect for 1 (Resident #5) of 4 residents reviewed for abuse, neglect, and mistreatment. Specifically, the facility did not have evidence of a thorough investigation after Resident #5, who was care planned for 1:2 supervision, was found unattended by staff and was observed in the hallway pouring medication onto their lap on 3/1/2022. This was evidenced by: Refer to F609 Refer to F689 The Policy and Procedure (P&P) titled Incident Reporting Policy last reviewed 1/9/2022, documented that neglect was defined as but not limited to, the failure to follow the care plan and the failure to adequately supervise the whereabouts and activities of residents. Any staff member who, through visual or auditory observation, became aware of an alleged incident, was to immediately report the incident to a licensed nurse assigned to the unit, or to their immediate supervisor. The licensed nurse would take and/or direct any and all appropriate actions to safeguard the resident(s) while the alleged incident was investigated to prevent further abuse, neglect, and mistreatment. The licensed nurse or supervisor would promptly initiate a thorough investigation regarding the alleged incident to determine whether it was reportable in accordance with this policy. Resident #5: Resident #5 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-an assessment tool) dated 1/21/2022, documented the resident rarely made themselves understood and rarely understood others. The resident resided on the New South Unit. The Comprehensive Care Plan (CCP) for Elopement Risk/Wanderer last revised 2/10/2020, documented the resident was at risk related to impaired safety awareness and independent with wheelchair mobility with decreased safety skills/cognition/impulsivity. The resident was to have 1:2 supervision (one staff member for the resident and their roommate) while awake. An Incident Report dated 3/1/2022 at 3:55 PM, documented SLP #2 discovered Resident #5 pouring a medication bottle onto their lap. The resident was removed from the medication cart and was moved to a safe place with supervision. -The report included incident details that were documented and signed by SLP #2 and documented Registered Nurse Manager (RNM) #2 had knowledge of the event. -The safeguards to the resident documented increased supervision. -The safeguards implemented to protect other residents who could similarly be affected documented that medication should be kept in a safe location, out of reach from residents. -The root cause and contributing factors to the event documented that Resident #5 gained access to a bottle of medication while the floor nurse had their attention elsewhere. -The actions to prevent reoccurrence documented that medications should be kept in a safe location, out of reach from residents. -The report was signed by RNM #2 on 3/2/2022. The report did not include documentation that the resident was not provided with 1:2 supervision at the time of the incident. The Nursing Progress Notes did not include documentation of the incident. During an interview on 3/8/2022 at 4:13 PM, RNM #2 stated they did not inform the DON or Administrator about the incident on 3/1/2022 with Resident #5. During an interview on 3/9/2022 at 12:18 PM, the DON stated they were not aware of the incident with Resident #5 until 3/7/2022, when the surveyor was onsite. The DON said RNM #2 did not inform them or the Administrator about the incident. The DON stated that they would expect the nurse who initially learned of the incident to initiate the basic investigation and then inform the DON so they could review and expand the investigation if necessary. The DON said that RNM #2 had received training about incidents and reporting when they were hired. The DON said that there was no investigation outside of what was documented on the incident report. During an interview on 3/9/2022 at 2:42 PM, the Administrator stated they may have heard about the incident with the medication indirectly but was not informed by RNM #2. The Administrator stated that there was no investigation of the incident and no investigation as of the time of the interview. The Administrator said they would start an investigation. 10 NYCRR 415.4(b)(3)

Based on medical record review and staff interviews during a complaint investigation (complaint #NY 531) it was determined that for one (Resident # 1) of 2 residents reviewed, the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psycho social well-being, in accordance with established policies and procedures and standards of practice. Specifically, Resident # 1 developed respiratory distress with oxygen saturation levels in the 70's and 80's (normal level greater than 90%), he was not sent out to the emergency room for approximately 4 hours. The facility was notified by the local emergency department (ED) approximately 35 minutes after the resident left the building that the resident had expired. This was actual harm for the resident that is not immediate jeopardy. This is evidenced by the following: THIS IS A REPEAT DEFICIENCY FROM THE SURVEY OF [DATE]. Resident# 1 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] assessed the resident to have long and short term memory impairment. In a facility provided document titled "Final Report" signed by the facility Director of Nursing (DON), the author documented that the facility registered nurse supervisor (RNS) was called to see Resident # 1 on [DATE] at 1:00am. The supervisor found the resident to be pale, slightly cyanotic with an oxygen saturation level of 77%. The report documented that oxygen was applied and the oxygen saturation level rose to 97%. The resident's vital signs were blood pressure, ,[DATE], heart rate of 135(,[DATE] beats per minute), respirations at 26 (normal ,[DATE] per minute) and oxygen saturation that ranged from ,[DATE]%. The RNS continued to monitor the resident. 911 was called at 4:35 am and the resident was transported to the ED. The ED staff called the facility at 5:25 am on [DATE] to report that the resident had passed away. Nurses notes revealed the following: The RNS wrote on [DATE] at 4:48 am, that he was called to the residents room at 1:00 am on [DATE]. The resident was observed to be slightly cyanotic, around the mouth and tips of his fingers. Oxygen saturation level was 77%. Oxygen was applied and the resident's oxygen saturation level fluctuated between 77 and 97 %. Attempts to keep the resident's saturation levels above 90% were unsuccessful. Calls were placed to the oncall physician at 3:00 am and 3:30 am and there was no response. At 4:00 am another physician was called and again no response. Finally the "manager on call" was contacted and the RNS was given permission to send the resident to the emergency room (ER). A 911 call was made at 4:35 am, responders arrived at approximately 4:40 am and resident left the facility via ambulance at approximately 4:48 am. In a second nurse's note, dated and timed for [DATE] at 6:30 am, the author (illegible) documented that he/she was called to the resident's room at 2:30 am and vital signs were BP:,[DATE], heart rate:135, Oxygen Saturation 82% with oxygen at 5 liters/min and respirations were 46. The author wrote that the resident was cyanotic at nailbeds in all 4 extremities and mottling was noted to lower the extremities. Resident was experiencing shortness of breath unrelieved by oxygen. Remained in resident's room until ambulance arrived. In the hospital ED report, the physician (MD) dictated in the initial assessment that the resident arrived in the ED in acute respiratory distress with heart rate in 160's, blood pressure unable to obtain, and respiratory rate in 40's to 50's and oxygen saturation 75 to 85% on 10 liters oxygen by a non-rebreather. The resident was described as having mottled appearance in all four extremities and a bluish tone to the skin. The MD dictated that his impression was that the resident ' s acute [MEDICAL CONDITION] and respiratory distress was caused by an asthma attack vs pneumonia, or possible a [MEDICAL CONDITION] embolism. In a later reassessment note, the MD dictated that after discussion with both parents the resident was neither resuscitated nor intubated. The Resident ' s heart rate dropped from the 160's to 90's and subsequently pulse was lost. There were no heart sounds and no respirations. Time of death was 5:37am. In a document titled, Emergency Medical Treatment, Conditions Requiring Rapid Assessment of Respiratory and Cardiac Status, with Resident # 1's name, (an individualized facility protocol) staff are instructed what to do for specific situations. The document instructs the following: respiratory rate over 60 or under 12. A heart rate over 160 (for a child over 5 years old), cyanosis, respiratory distress (follow policy by applying oxygen if oximetry is under 90% or a child who is cyanotic or in severe distress, life threatening [MEDICAL CONDITION] or a fever over 105 not brought down with Tylenol, [MEDICATION NAME] or tub soaks. In the above circumstances, if the resident does not respond to treatment within 5 minutes or upon nursing judgment, the nursing staff must immediately contact the physician, or covering physician. Beep the physician and add "99" to indicate the emergency nature of the situation. At night call the physician at home before beeping. If the nursing staff cannot contact the physician within 5 minutes of the call, then 911 should be called. During an interview on [DATE] at approximately 10:30am, a Registered Nurse Unit Manager (RNUM) stated that she was called by the RNS on [DATE] at approximately 4:00am. The RNS was not able to get hold of a doctor to send a resident out to the ER. The RNUM stated that she instructed the RNS to send the resident out and not to wait for a doctor to call back. The RNUM stated that as it turned out, the RNS was calling the wrong doctor. The RNUM added that RNs can always send residents out to the ED if they think they need to go and the nurse does not want to take the time to contact the MD first. During an interview on [DATE] at approximately 3:00pm the RNS stated that he was called to the unit around 1:00am and the resident was in bed and his O2 Sat was 77%. He was cyanotic around the mouth and nail beds. We placed oxygen on him and he did not like mask so we switched to a nasal cannula. The residents O2 sats were in the ,[DATE]'s and we were not able to maintain it in over 90%. I knew he should go out to the ER. I was in and out of his room. The resident's cyanosis never improved. I went to get the oxygen saturation machine myself to check his saturation. There were parts of the machine missing and I had to get all the parts together. There were other things going on in the house. I called the doctor around 3:00am and then again around 3:30am. When I did not receive a call back, I called another doctor around 4:00am. Sometime after 4:00am I called the manager on call and she told me to send the resident out anyway. I think we can send a resident out if we think they need to go, but I guess I was asking permission because I did not want to have repercussions later. I sent him out right after I spoke to the manager. In hindsight I should have sent him out sooner. I think I lost my confidence. I will never hesitate again. During an interview on [DATE] at approximately 2:30pm, a Licensed Practical Nurse (LPN#1) stated that she was asked by a Certified Nursing Assistant (CNA) to look at Resident # 1 at approximately 1:00am on [DATE]. The LPN #1 stated that the resident was short of breath and not acting right. The resident appeared cyanotic around the mouth and at the nail beds. LPN#1 stated that she thought the resident probably needed to go out to the emergency room and she called for the RNS, who came and assessed the resident. LPN #1 stayed with the resident most of the night until he was sent out at approximately 5:00am. LPN#1 added that it seemed to her that the RNS was taking an unusually long time to contact an MD to get an order to have the resident transferred out to the ER but she thought the RNS must know what he was doing. LPN#1stated there were one or two other registered nurses working on the ventilator unit that night but she never considered calling one of them to ask that they come and assess Resident # 1 or to assist the RNS. LPN#1 explained that she thought the RN ' s on the vent unit covered only the vent unit and the RNS was the registered nurse covering her unit and Resident # 1. LPN #1added that she thought Resident#1 should have gone out to the ER when she first called the RNS around 1:00am but she thought she had done her job by contacting the RNS to come and make the decision about what to do for Resident # 1. During an interview on [DATE] at approximately 2:00pm, a Licensed Practical Nurse (LPN#2) stated that she was working the night shift on [DATE] and entered Resident # 1's room to assist the rest of the staff. LPN#2 recalled that the resident appeared very restless and it was a challenge to keep the resident in bed. LPN#2 thought the resident appeared to be in respiratory distress and added the RNS had already been called and had seen Resident#1. LPN#2 stated that she noticed the RNS was walking back and forth near the office and she heard the RNS say to himself that, "he (referring to Resident # 1) doesn't fit the parameters to be sent out." LPN#2 added that she saw the RNS make a couple of phone calls but was not sure who he had called. LPN#2 explained that there were parameters for each resident and they explained when the resident should be sent out to the ER. LPN#2 stated that she thought the resident should have been sent out sooner. During an interview on [DATE] at approximately 2:30pm, a Certified Nursing Assistant (CNA#1) stated that she was one of several people in Resident #1's room on [DATE] trying to care for the resident. CNA#1 stated that the resident was having trouble breathing and it did not appear that the nurses were getting help for the resident. CNA#1 stated that she thought the resident should have been sent out to the emergency room sooner and that it seemed that the nurses were not sure what to do for the resident. CNA#1 stated that she asked the two nurses in the room why they did not call one of the nurses from the vent unit and see if they would come and look at Resident # 1 and they would probably know what to do for the resident. CNA#1 stated, "They didn't ask one of the vent unit nurses to come and help. I guess they didn't want to listen to me because I'm an aide. I thought the vent nurses would know what to do." 10NYCRR 415.12

Based on medical record review and staff interviews during a complaint investigation (complaint #NY 579) it was determined that for one (Resident # 1) of two residents reviewed, the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psycho social well-being, in accordance with established policies and procedures and standards of practice. Specifically, on [DATE], CNA #1 disconnected Resident #1 from the oxygen saturation and heart rate (O2 sat & HR) monitoring system, to provide care to the resident (this was the accepted practice at the facility). CNA #1 did not reactivate the monitoring system when care was completed. The resident experienced a decrease in heart rate and O2 sat to critically low levels. The resident required resuscitation and a subsequent evaluation at the hospital. Nine days earlier CNA #1 had left another resident disconnected and received re-education. Additionally, the resident was identified as the most unstable on the unit and would require assessment by a professional nurse when off the monitors. This resulted in actual harm that is not immediate jeopardy. This is evidenced by the following: Resident #1: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent minimum (MDS) data set [DATE] assessed the resident to have long and short memory impairment and severely impaired decision-making ability. On Resident #1's care plan for ventilator/[MEDICAL CONDITION] dependence, under the approach column the following is documented: monitor pulse oximetry (O2 saturation) continuously while in room and as needed while out of room, per respiratory therapy/registered nurse clinical judgment. In the Facility Investigation of this incident, the facility's Director of Program Operations (DPO) wrote that Resident # 1 had experienced multiple episodes of desaturations since her admission, that required the interventions of increased oxygen, suctioning and at times assisted ventilation with bagging. The resident has responded positively to each of these interventions and oxygen saturations have returned to appropriate levels. The resident's pulse oximetry and heart rate are continuously monitored via (Masimo) Monitoring system. There is a probe on the resident's foot with a cord that leads to the monitor. There is a connection juncture between the probe on the resident's foot and the cord that leads to the monitor. All staff had been trained to disconnect the probe at the connection juncture when transferring and providing personal care for the resident. In the conclusion section of the Facility Investigation, the author wrote that although Resident #1 had a pulse oximetry probe on her foot, the probe was disconnected between the probe and the monitor. Resident # 1 was disconnected from the monitoring system for 23 minutes and for 18 of those minutes, the resident was left unattended. Because she was not connected to the monitoring system, nursing and respiratory therapy were not alerted to Resident# 1's decline in oxygen saturation and heart rate on [DATE], at approximately 10:05 am. In a statement dated [DATE], a medical records coordinator (MRC) documented that on [DATE] at approximately 10:20 am she entered Resident #1's room and noted that the resident's color was yellowish and the resident was very still. The MRC called for help and when the registered nurse arrived she told the MRC that she needed help. The MRC then ran to the nurses station and stated the RN needed a respiratory therapist stat (immediately). Several staff then ran to the resident's room to assist the RN. In a written and signed statement dated [DATE], a registered nurse RN#1 wrote that on [DATE] around 10:05 am she was summoned to Resident #1's room by a CNA. RN#1 went immediately to the room and wrote that upon entering the room, she observed that Resident # 1 was pale, had no skin color, was dusky, unresponsive and looked like she was "gone" (deceased ). RN#1 wrote that chest compressions were initiated and the resident was bagged (Ambu bag assisted breathing to increase oxygen saturation) and she observed that the oxygen saturation probe was on the resident but it was not connected to the monitor. In a written and signed statement dated [DATE], at 3:dpm a respiratory therapist (RT #1) wrote that on the morning of [DATE] she was alerted that there was an emergency in Resident # 1's room. She responded and upon entering the room noted that Resident #1 was cyanotic. RT#1 began bagging the resident and instructed another nurse to check for a heart rate. In a written statement dated [DATE], CNA # 1 wrote that she had Resident # 1 on her assignment on [DATE] and around 10:00 am she went into the resident's room and cleaned the resident up. When she was finished, she placed the resident on her side but the resident looked like she was gasping (guppy breathing), so she placed the resident on her back and then raised the side rails of the crib. CNA#1 wrote that when cleaning/changing the resident you have to take the pulse oximeter probe off of the residents. As she was raising the side rail of the crib CNA #1 was about to sneeze and she then turned and left the room and went to help with another resident. She was later told that Resident # 1 had a code blue (required CPR). During an interview on [DATE] at approximately 9:00 am, the registered nurse unit manager (RNUM), the respiratory therapy manager (RTM) and the facility's administrator (FA) offered the following information: On [DATE] at approximately 10:15 am, CNA #1 left Resident # 1 unattended in her room, on a ventilator and did not reactivate the O2 sat & HR monitor that she had deactivated while providing personal care to the resident. A short time later the facility's medical records clerk entered Resident # 1's room and noted that the resident did not look right and called out for help. Nursing staff arrived, noted that the resident appeared cyanotic and was not hooked up to the O2 sat & HR monitor, which would have alerted them to the resident's low oxygen level and low heart rate. It was necessary to initiate CPR and when the resident was eventually reattached to the O2 sat & HR monitor, her heart rate was in the low 50's. Eventually the resident's heart rate and oxygen saturation level returned to normal levels and the resident was sent out to the hospital for evaluation. The RTM stated that it was the practice of staff members when working with a resident on a ventilator, to disconnect the O2 sat & HR probe attached to the resident from the monitor cable while providing care. This allowed staff as much time as needed to complete personal care without the O2 sat & HR monitor alarm sounding. The alarm would be reactivated when the probe and monitor cable were reconnected when the staff member had finished with care. The alternative to this practice would be to completely remove the O2 sat & HR probe pad from the resident: with this method, the monitor alarm would sound after the probe had been off of the resident for two minutes. This method would required the staff member to silence the alarm every two minutes until the probe was reattached to the resident. The alternative method was not used by staff during care because of the need to silence the alarm every two minutes. During an interview on [DATE] at approximately 11:00 am, the registered nurse unit manager (RNUM) stated that on [DATE], CNA #1 was providing care to resident #2. CNA #1 left the resident alone in his room and did not reconnect the resident's O2 sat & HR monitor. Resident #2 was found unmonitored by another staff member. In response to this, CNA#1 was given a "job coaching." The RNUM explained that a "job coaching" was a conversation where a staff member would be re-educated about the proper way to perform a certain function. The RNUM stated that during the job coaching on [DATE], CNA #1 was reminded that if she left a ventilator dependent resident unattended, for even a minute, that the resident's O2 sat & HR monitor alarms must be activated. The RNUM stated that was the extent of the reeducation. The CNA's explanation for not reactivating Resident #2's alarm on [DATE] was that she forgot. During an interview on [DATE] at approximately 9:15 am the facility Respiratory Therapy Manager (RTM) stated that she knew the medical needs and in particular the respiratory status of Resident # 1 very well. She stated that Resident #1 had a history of [REDACTED]. The RTM stated that Resident # 1 was far more sensitive and desatted far more frequently and quickly than any other resident on the unit. After the events of [DATE] when Resident # 1 was found off of the monitor, the interdisciplinary team (IDT) had reviewed the care plan and when the resident returned from the hospital, staff would be instructed that they were no longer to separate the O2 sat & HR probe from the monitor cable while providing care to Resident # 1. Instead, they were to remove the probe from the resident completely and silence the alarm every two minutes when it sounded until the residents care was complete. They felt this was a safer way to care for Resident #1. 10NYCRR 415.12

Based on record review and staff interview during an abbreviated survey (Complaint #NY 370), the facility did not assure care was provided to maintain the highest practicable physical condition for 1 ( Resident #1) of 3 residents reviewed. Specifically, the facility did not assure that staff were knowledgable of all care needs, that assistive devices were placed and that physician ordered treatment was not completed. This resulted in no actual harm but has the potential for more than minimal harm. This is evidenced by the following: The Resident was admitted to the facility on [DATE] diagnosed with [REDACTED].The Minimum Data Set dated 1/24/13 assessed the resident had severe cognitive impairment and was totally dependant for all care. physician's order [REDACTED]. Nursing Fact Sheet last updated on 1/31/13 documented that the resident required two person assistance for all care, transfers and turning and positioning in bed. An occupational therapy (OT)/ physical therapy (PT) Nursing Intervention Sheet last revised on 1/14/13 documented a tumble form roll was to be placed on the left side. Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Incident Report dated 3/3/13 documented that at 12:10 am the resident was found by a Certified Nurses Aide (CNA) in his bed with blood all over his face. The Registered Nurse (RN) assessment documented that the resident was observed with a 1.4 centimeter (cm) by 0.4 cm abrasion to his forehead and the bridge of the resident ' s nose was very swollen with blood noted and pain to touch. The Incident Report documented that the reisdent was transfered to the hospital for evaluation. emergency room discharge summary documented that the resident was evaluated for Nasal and Forehead Trauma and discharged . During an interview on 3/6/13 at 9:15 am, Licensed Practical Nurse ( LPN) #1 stated that she was familiar with Resident #1 and occassionally was assigned to him on days when he is still in bed on her 7:00 am - 3:00 pm shift. LPN #1 stated that she was responsible for insuring that residents have all of their safety devices at all times. LPN #1 stated that she was unaware that the resident was care planned for a tumble roll, was unaware that there was a PT/OT sheet in addition to the care card and does not recall seeing a tumble roll in his bed. During an interview on 3/6/13 at 9:50 am, CNA #3 stated that she was a regular care giver to the resident. CNA #3 stated that the resident leans to the left side sometimes and a couple of months ago, a tumble roll was added to his PT/OT sheet to assist with positioning in bed. CNA #3 stated that approxmiately 3 times per week, she had noticed that the tumble rolls were not placed while the resident was in bed. CNA #3 stated that she noticed that the tumble rolls were missing usually when " float " staff were assigned to the resident and were placed when he had regular staff. During an interview on 3/6/13 at 11:00 am, CNA #1 stated that she was a new CNA and had been hired by the facility approximately two months prior to the incident and was a part time employee. The CNA stated that on 3/2/13 she was working a 3:00 pm - 11:00 pm shift with another CNA who assisted her placing Resident #1 in bed. CNA #1 stated that she and CNA #2 had no difficulties in placing the resident in bed and last saw the resident at about 10:30 pm. CNA #1 stated that she remained on duty for the 3/3/13 - 3/4/13, 11:00 pm to 7:00 am shift and at approximately 12:10 am, she responded to an oxygen saturation alarm in the resident ' s room and observed the resident in his bed with his face " planted " into the side rail of his bed. CNA #1 stated she noticed that the resident had blood on his face and immediately called for the nurses to assist the resident. CNA #1 stated that she reviews resident care cards and PT/OT sheets (the instructional sheets in the resident ' s room that CNAs use to identify all care and safety needs including, assistive devices, and positioning instructions) on a weekly basis and had not reviewed the resident ' s care card or PT/OT sheets on the evening of the incident. CNA #1 stated that she was unaware of the need for an assistive device in the resident ' s bed, she and CNA #2 had not placed anything in his bed, did not not know what a tumble roll was, did not recall seeing a tumble roll in his room, nor did she find him with a [MEDICAL CONDITION] machine on when she responded to the alarm. During an interview on 3/6/13 at 1:00 pm, LPN #2 stated that she was working on 3/3/13 when CNA #1 called for assistance. LPN stated that she responded to the resident ' s room, noted the blood from the resident ' s face and his swollen nose. LPN #2 stated that when she arrived in the resident ' s room, the tumble roll was not on his bed and does not recall if there was one in his room. LPN #2 stated that she was aware that the resident required a tumble roll on his bed and believed that it was added about a month ago. LPN #2 stated that all safety and assistive devices were on the care card and if there is a PT/OT sheet, both should have the same information. During an interview on 3/6/13 at 8:45 pm, RN #1 stated that he was assigned to Resident #1 on 3/2/13 and was responsible for passing medications and providing treatments. RN#1 stated that on 3/2/13 at approximately 8:00 pm, he provided Resident #1 a treatment and the resident was wide awake in his bed. RN #1 stated that he usually applies the resident ' s [MEDICAL CONDITION] mask when the resident is prepared for bed, but usually before he leaves at 11:00 pm. RN #1 stated that he was unable to place the resident ' s bi-pap because he was busy with other resident ' s care needs but when the 11:00 pm - 7:00 am nurse came on, he reported that the resident needed his bi-pap placed. During an interview on 3/7/13 at 9:30 am, LPN #3 stated that she was assigned to the resident on 3/3/13 for the 11:00 pm to 7:00 am shift on 3/4/13. LPN #3 stated that she received report from RN #1 who informed her that the resident ' s [MEDICAL CONDITION] needed to be placed because he didn ' t have time to do it. LPN #3 stated that she agreed to apply it, but didn ' t do so immediately. LPN #3 identified her initials on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. LPN #3 stated " I definitely didn ' t place the bi-pap, I should have, but I didn ' t and I have no excuse, I should not have signed that I applied it. " LPN #3 stated that at about 12:10 am, CNA#1 called for the nurses and she responded to the resident ' s room and observed blood on his forehead and swelling to his nose. LPN #3 stated that the resident had an " egg " on his head and when she lightly touched the resident ' s nose, he winced in pain and was sent to the emeregency room. LPN #3 stated that there were no bolsters (tumble roll) on his bed and she does not recall seeing one in his room. LPN #3 stated that she worked with Resident #1 routinely and provided medications and treatments to him at least twice per shift. LPN #3 stated that she knew that the resident would slide to the left side, sometimes would see a tumble roll on the left side of his bed and usually they "would have at least a pillow on the left side. " LPN #3 stated that she never thought to look at the PT/OT sheet so was unaware that the tumble roll was a part of the resident's plan of care. During an interview on 3/8/13 at 11:00 am, the Registered Nurse Supervisor (RNS) stated that she was working on 3/3/13 and was on the unit when CNA #1 called for assistance. RNS stated she assessed the resident and arranged his transfer to the hospital. The RNS stated that she observed that the resident did not have his [MEDICAL CONDITION] on, which is usually placed on him between 8pm and 9pm. RNS stated that she did not address the issue with the nurse's because her focus was getting the resident out. The RNS stated that she had a serious concern about the injuries to the resident and that CNA #1 didn't know what happened, that the resident was flat on his back when she entered the room, which meant that CNA #1 must have moved him by herself and that there was no bloster (tumble roll) on the resident's bed or in the resident's room. The RNS stated despite her concerns about the origin of the resident ' s injuries, she had no choice due to minimum staffing levels but to send CNA #1 to the hospital with the resident although, she should have sent the CNA home pending an investigation into the potential neglect of the resident. During an interview on 3/8/13 at 4:45 pm the Administrator stated that her investigation revealed several care plan violations and she was concerned that staff did not have the resident's tumble roll and bi-pap on, however, stated that all of the care needs had been documented, however, staff did not do what they were suppose to do. The Administrator stated " this is very frustrating " . 10 NYCRR 415.12

Based on observation, medical record review and staff interviews during a partial extended abbreviated survey complaint investigation (NY 373), the facility failed to ensure that one (Resident # 1) of three residents reviewed was free of significant medication errors. Specifically, the facility failed to ensure that an 8 year old resident received the physician ordered dosage of medication twice a day. Instead, the resident received double the physician ordered dosage of the medication twice a day from 1/29/2012 until 2/15/2012. The significant medication error was made by ten licensed nursing staff for a total of 31 incorrect dose administrations. This resulted in no actual harm with the potential for serious harm that is Immediate Jeopardy to residents' health and safety and Substandard Quality of Care. This is evidenced by the following: Resident # 1: This 8 year old resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident to have severe cognitive impairment. The Policy and Procedure (P&P) for Medication Administration dated 8/10/10, documented that it was the responsibility of Registered Nurses (RN) and Licensed Practical Nurses (LPN) to administer medications as ordered by the physician. Nurses were to compare the drug and dosage schedule on the Medication Administration Record (MAR) with the drug label prior to administering a medication to a resident. A physician's orders [REDACTED]. The MAR for 1/2012 documented that the resident was to receive [MEDICATION NAME] 50 mg by mouth twice a day beginning 1/3/12. The MAR was signed by nurses twice a day from 1/3/12 through 1/31/12 that the resident received 50 mg of [MEDICATION NAME] twice a day. The MAR for 2/2012 documented that the resident was to receive [MEDICATION NAME] 50 mg by mouth twice a day. The MAR was signed by nurses twice a day from 2/1/12 through 2/15/12 that the resident received 50 mg of CoQ 10 twice a day. An undated facility investigation documented that on 2/15/12 at 3:45 pm, an LPN discovered that the physician order [REDACTED]. The facility's investigation documented that the resident received twice the dose (100 mg) than the physician had ordered (50 mg) from 1/29/2012 until 2/15/2012 for a total of 31 doses. The error had been made by 10 nurses. The investigation documented that the nurses were neglectful in following the Five Rights of Medication Administration, prior to giving a medication, a nurse was to ensure the following data were correct: the right resident, the right medication, the right route for administering the medication, right dose of medication and the right time. The facility's plan was to inservice all licensed nurses and would include the 5 Rights of Medication Administration and the legal and safety aspects of accurate medication administration. During an observation on 2/22/12 at 9:00 am, the surveyor observed that the [MEDICATION NAME] 50mg medication was a white gelatin capsule. The 100mg dose of the same medication was a larger, green gelatin capsule. During an interview on 2/22/12 at 8:45 am, the Director of Nursing (DON) stated that after an agency contracted nurse reported that the pharmacy had delivered the medication in the incorrect dose, the facility immediately began an investigation. The investigation showed that 10 nurses were involved and that the resident had received the wrong dose 31 times. The investigation revealed that the nurses were not checking the medication label to ensure that the dose of the medication matched what the physician had ordered. The DON stated that the facility had not yet begun educational inservices regarding medication administration and that not all the involved nurses had been reeducated and/or disciplined. During an interview on 2/22/12 at 9:32 am, the Registered Nurse Manager (RNM) stated that all nurses were supposed to check the Five Rights of Medication Administration prior to administering a medication to a resident and that this was to occur for every medication, for every resident, every time. The nurses were supposed to check the label on the medication packet to ensure that the dose of the medication matched what the physician had ordered. She also stated that checking the Five Rights of Medication Administration was a basic fundamental of nursing, and that the nurses who made the error had not practiced the 5 Rights by not ensuring the proper dose of the medication was being given. She stated that she had gathered statements from the involved nurses and had not yet reeducated the nurses to correct the error to prevent it in the future. She also said that, at this point, staff were not taking ownership of their error or taking it seriously and that was evidenced by the nurses' comments on the statement forms that they were rushed or did not have time. The RNM stated that this was a significant error and that the resident was not harmed but could have been if the error had involved some other medications. During an interview on 2/22/12 at 10:21 am, LPN#1 stated that she did not know how she had made the same mistake of giving the resident twice the dose of [MEDICATION NAME] on sixteen occasions. She stated that she must have had busy days and just not noticed that the medication had been provided from the pharmacy in the wrong dosage. She stated that she did not always check the dosage on the medication label because she knew the shape, size and color of the medications that her residents were on. LPN#1 stated that she continued to do this because the medications in the medication cart are almost always correct when they come from the pharmacy. When asked why she did not read the dosage on the medication label, the LPN stated that there were a lot of medications to pass for a lot of residents and if she took the time to read every single medication that thoroughly she would never get medications out on time for all the residents. The LPN also stated that after this error had been identified, she was told to complete a Medication Administration Incident Report, and that she was not reeducated or disciplined for the error. During an interview on 2/22/12 at 12:21 pm, LPN#2 stated that when administering the [MEDICATION NAME] medication to the resident she must not have checked the dosage printed on the medication label. She stated that it was her practice to check the medication and the dosage very closely the first time she administered a medication to a resident, but after the first time, unless there was a physician's orders [REDACTED]. She stated that on 2/21/12 she received a Medication Administration Incident Report concerning her error and was told to complete the form. There had been no reeducation or discipline regarding her medication error. During an interview on 2/22/12 at 3:07 pm, LPN#3 stated that she did not normally work on this resident's unit so she was not that familiar with the residents and their medications. She stated that she always looked at the MAR and the name and drug on the medication label but that if the medication was in the cart she would have thought the medication and dosage would have been correct. She did not check the dosage on the label because she assumed it would be correct. She stated that she probably became complacent because she gave the same medications to the same residents day after day and that she did not look at the medications all that closely. She had not been reeducated or disciplined for her medication error with this resident. During an interview on 2/22/12 at 10:56 am, the Medical Director stated that the nurses not checking the dose of a medication being given to a resident was concerning to him because the nurses were not being thorough. He stated that this resident receiving the wrong dose so many times and by so many nurses was a significant error, and that when he wrote a medication order he expected the medication to be given as ordered. The physician also stated that nurses not checking the dosage on a medication label every time for every medication was unacceptable and that it was not safe to simply go by the size, color and/or shape of the medication. During an interview on 2/22/12 at 1:14 pm, the Administrator stated that the investigation revealed that 10 nurses gave this resident the wrong dose of a medication over a two week period because they were not checking the accuracy of the medication that had been delivered from the pharmacy. She also stated that the nurses involved had not been reeducated or disciplined at that time and that the facility was reviewing the whole case to determine steps needed to be taken. It was unacceptable for nurses to be complacent about medications and it was unacceptable for them to not follow basic fundamentals of nursing such as the Five Rights of Medication Administration. 10 NYCRR 415.12(m)(2)

Based upon interviews and medical record review during an partial extended abbreviated survey (Case #NY 687) it was determined that for three residents (Resident #s 1, 2 and 3) of four residents reviewed, the facility failed to ensure a thorough investigation was completed involving a resident who decannulated (removal of [MEDICAL CONDITION]) and was found without signs of life, failed to identify that staff who were monitoring the resident were performing other duties, and failed to notify the State Department of Health (DOH) of this incident. The facility also failed to investigate a [MEDICAL CONDITION] decannulation when the [MEDICAL CONDITION] ties were found unsecured, and failed to investigate how an oxygen tank that was in use on a resident ran empty. This resulted in actual harm for Resident #1 that was Immediate Jeopardy to the resident's health and safety and Substandard Quality of Care. This had the potential to effect all residents that used the common area on the unit. For Residents # 2 and 3 there was no actual harm but had the potential for more than minimal harm that is not immediate jeopardy. The Immediate Jeopardy was removed prior to exit. This is evidenced by the following: Resident #1: The resident was admitted to the facility on [DATE]. The child was born a twenty-four week preemie, and was admitted with [DIAGNOSES REDACTED]. The resident had developmental delays and was not interviewable. The facility policy/procedure titled Incident Reporting dated 10/17/11, documented the purpose of the policy was to provide protocols for identifying, reporting and documenting an incident to the DOH and if necessary to local law enforcement; and to provide protocols for completing facility incident reports. The term incident is defined as any happening which is not consistent with the routine operation of the facility or the routine care of a particular resident. Th policy/procedure documented under the section, a list of occurrences to determine whether an incident is reportable, that "Malfunction or misuse of equipment: one of the following elements is needed for a report to the DOH: malfunction or intentional misuse of equipment; adverse effects or potentially adverse effects related to use of equipment. The facility form titled "Incident Report" dated 12/9/11 at approximately 12:20 pm documented that the resident was found in a supine position, unresponsive, apneic( without respiration), mucous membranes pink. The resident was transferred to a wedge (table) and bagged (manual breathing with resuscitation Ambu bag) immediately by Respiratory Therapy (RT). [MEDICAL CONDITION] was determined to be out and was replaced. Code Blue was paged. The resident's pulse was checked and was noted to be absent. Cardio [MEDICAL CONDITION] Resuscitation was initiated, and 911 was called. The physician arrived on the unit, emergency medical services arrived and the resident was transferred to the hospital. Under the section titled "Follow-up by Unit Manager" it was documented that the resident was weaned on 10/31/11 and remained on the ventilator unit due to medical fragility. The resident had an extensive medical history and was not on a pulse oximeter at the time of the incident per standards. The resident was in the common area under supervision. An investigation was completed by the Director of Nursing (DON). It was documented that the incident was not a reportable incident. A facility typed report with the resident's name and date of the incident (12/9/11) documented under a section titled "conclusion" that the resident's death was not expected. The investigation did determine that there was an appropriate level of supervision at all times. Additionally typed on the bottom of the page it is documented that the plan included the guidelines for covering the common area are being revised and all staff will be educated. During an interview on 2/1/12 at 11:50 pm Respiratory Therapy (RT) #1 stated that the resident was found in the common area, and when the nurse picked her up it was obvious there were no signs of life. RT #1 demonstrated where the resident was found in the play yard. During an Interview on 2/1/12 at 12:10 pm LPN #1 stated that the resident had just started walking that day, the resident came up to her and held her arms up, and LPN #1 asked if the resident was tired and the resident shook her head yes. The LPN picked the resident up held her for a few minutes then seated her in the play yard. LPN #1 knew that she placed the resident near the front facing right corner of the play yard. The LPN stated she did not verbally inform any staff that the resident was placed in the play yard. During an interview on 2/1/12 at 12:30 pm certified nursing assistant (CNA) #2 stated she was relieving the assigned CNA for the common area at the time of the incident. CNA #2 stated she was feeding another resident at the table, opposite where Resident #1 was located. CNA #2 was not aware that Resident #1 was in the play yard. During an interview on 2/1/12 at 1:30 pm the DON stated this incident was not called in to the DOH and that she spoke with a representative from DOH who stated it was not reportable. The DON later stated that she did not actually speak with a representative from DOH, but received a phone message and may not have given all the details in her message to the DOH representative. Resident #3: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident had moderately impaired cognition. The policy/procedure (P&P) titled Incident Reporting dated 10/17/11, documented the purpose of the policy was to provide protocols for identifying, reporting and documenting an incident to the state department of health (DOH) and if necessary to local law enforcement; and to provide protocols for completing facility incident reports. The term incident is defined as any happening which is not consistent with the routine operation of the facility or the routine care of a particular resident. The Comprehensive Care Plan (CCP) for continuous ventilator support and daily respiratory therapy dated 10/19/10 documented that the resident's oxygen saturation was to be continuously monitored while in his room and as needed when out of his room. Physician orders [REDACTED]. The Respiratory Care Flow Sheet dated 12/25/11 documented that the resident's oxygen flow rate was 2 Liters Per Minute (LPM). The oxygen tank had been checked in the morning and there was 3,000 pounds per square inch (PSI) in the tank (the tank was full). It was also documented on this record that the resident received medications that required an increased oxygen flow rate at 6:00 am, 12:45 pm, another administration that the time was not documented, and at 6:00 pm. A note documented that at 6:45 pm, the Respiratory Therapist (RT) was called to the dayroom and the resident's color was blue. An Ambu bag (a bag connected to 100% oxygen, attached to the [MEDICAL CONDITION] and manually squeezed by a staff member to deliver oxygen in the event of mechanical ventilation failure), was applied and the resident quickly recovered. It was documented that the reason the resident had turned blue was that the oxygen tank was empty. An Incident Report (I&A) dated 12/20/11 at 6:45 pm, documented that the resident was in the dayroom when a Certified Nursing Assistant (CNA) yelled out that the resident was blue. An assessment found that the resident was cyanotic (a blue or purple coloration of the skin due to a lack of sufficient oxygen). The nurse called for an RT, and took the resident to the oxygen delivered from a wall mounted delivery system. Ten breaths were delivered to the resident through the Ambu bag and the resident's color returned to normal. The Unit Manager Follow Up section of the I&A documented that the resident was 2 years old and was dependent on a mechanical ventilator for breathing. The resident had been in the common area on a portable oxygen tank and that the tank had run empty. The I&A was signed by the Registered Nurse Manager (RNM), the DON, the Medical Director and the Executive Director. During an interview on 2/7/12 at 1:09 pm, the Respiratory Therapy Manager (RTM) stated that on 12/20/11, the resident had turned blue because the oxygen tank the resident was hooked up to had run empty. The resident had been on a portable oxygen tank instead of the wall mounted system. The RTM stated that she did not know who brought the resident out of his room or at what time he was put in the dayroom and that she did not know why he had remained on a portable oxygen tank. She stated that she did not interview staff to determine how this incident happened. During an interview on 2/8/12 at 12:57 pm, the DON stated that the RTs were responsible for checking and monitoring the oxygen tanks. She reviewed the I&A and stated that the information on the form was too vague to come to a conclusion as to how the oxygen tank ran empty. Resident #2: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE], assessed the resident to have severely impaired cognition. The P&P for Incident Reporting dated 10/17/11, documented the purpose of the policy is to provide protocols for identifying, reporting and documenting an incident to the state department of health (DOH) and if necessary to local law enforcement; and to provide protocols for completing facility incident reports. The term incident is defined as any happening which is not consistent with the routine operation of the facility or the routine care of a particular resident. The P&P for [MEDICAL CONDITION] Care dated 9/2010 and revised on 8/9/10, documented that the purpose of the P&P was to ensure airway patency, maintain skin integrity and prevent infection. It was also documented that the Velcro [MEDICAL CONDITION] ties were to be adjusted for proper fit and staff was to make sure that both Velcro tabs were secure to the neckband. The Respiratory Care Flow Sheet dated 12/5/11 documented that the resident had an [MEDICATION NAME] and that [MEDICAL CONDITION] care was completed at 1:05 am. An I&A dated 12/5/11 at 10:05 pm, documented that when the resident was picked up the [MEDICAL CONDITION] ties were not secure and the [MEDICAL CONDITION] came out of the resident's airway (decannulation). The [MEDICAL CONDITION] was reinserted by a Licensed Practical Nurse (LPN). The medical record was reviewed and the last [MEDICAL CONDITION] care had been documented by the RT on 12/5/12 at 1:05 am. The policy was for [MEDICAL CONDITION] care to be done three times a day. The RTM was preparing an education for the staff about documentation of [MEDICAL CONDITION] care. No staff statements were attached to the I&A. The I&A was signed by the RNM, DON, Medical Director and the Executive Director. During an interview on 2/8/12 at 10:15 am, the RTM stated that the facility's policy was for [MEDICAL CONDITION] care to be performed three times a day. After this incident she was able to determine that the RTs had done [MEDICAL CONDITION] care but did not document it. The RTM was asked what was meant in the I&A that the [MEDICAL CONDITION] ties were not secure and she stated that it meant that they were either not tied or they were loose. She stated that based on what was written on the I&A she did not know if they were loose or untied. She also stated that she did not obtain statements from staff regarding the incident other than to determine that [MEDICAL CONDITION] care had been completed and just not signed for. During an interview on 2/8/12 at 10:15 am, the DON stated that she did not know if the [MEDICAL CONDITION] ties were loose or untied and did not obtain staff statements to determine the circumstances of the ties not being secure. The Immediate Jeopardy was removed on 2/8/12 which was prior to the New York State Department of Health (DOH) exit from the facility on 2/9/12. The facility performed the following corrective actions to have the immediacy removed: The facility contracted with an independent consultant to assist in the correction of the identified issues. When residents were in the common area, there was to be direct oversight of the staff provided by management personnel. The role of the CNA was modified and clarified so that the individual assigned to the common area had no additional responsibilities beyond interaction and supervision of the children in the common area. The CNA role was defined to give clear directives that they were not to participate in feedings, activities of daily living or transporting residents outside of the common area. CNAs were to give verbal report to transfer care from one to another staff member while standing with the resident prior to departure. The common area was reconfigured to allow for greater observation of the area by the staff. One hundred percent of the Nurse Managers and supervisory personnel were inserviced on the need to monitor appropriate staff activities while they were in the common area. One hundred percent of the staff who had worked since the Immediate Jeopardy had also been trained on the policy and procedures, plan for supervision and the expected communication of care for each resident at each change of shift. There was also a plan in place to educate the remaining staff prior to returning to work. Licensed nursing personnel had been inserviced on the use of the 24 Hour Report book. As part of every shift change the Registered Nurse in charge was to receive a report from all CNAs assigned to that shift and that information was to be communicated to the incoming shift at shift change. Incident reports were to be reviewed each day by the Administrator and/or the DON to determine whether the incident was reportable to the DOH and what actions were necessary to ensure the safety and well-being of the residents. An on-call Administrator would field calls in the absence of the Administrator and the DON. All of the individuals received a copy of the DOH Incident Reporting Manual and were aware of their responsibilities to initiate an investigation immediately in the event of an incident. Policies and Procedures were reviewed and expectations clarified. All resident deaths that were the result of abuse, neglect or mistreatment according to the guideline were to be reported. The facility had also arranged for reviews by a Quality Assurance expert skilled in investigations, of all incidents involving resident death or serious harm to determine if the facility investigations were complete and whether appropriate actions were taken. 10 NYCRR 415.12(b)(1)(ii)

Based upon interviews and medical record review during a partial extended abbreviated survey (Case #NY 687) it was determined that for two (Resident #s 1 and 3) of four residents reviewed, the facility failed to ensure that the resident environment remains free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. Specifically, Resident #1 who has a history of decannulating, was placed in a common area in a play yard without staff, who were responsible for monitoring the play yard, knowing that the resident was in the play yard. The resident was found at least thirty minutes later, without signs of life and decannulated (removal of tracheostomy tube). Also, the facility failed to have procedures in place to monitor oxygen tank levels when in use by a resident. Subsequently, a resident was found blue in color and required immediate intervention to prevent serious harm or death. This resulted in actual harm for Resident #1 that was Immediate Jeopardy to resident's health and safety and Substandard Quality of Care. This had the potential to affect all residents that used the common area of the unit. This resulted in no actual harm with the potential for serious harm for Residents # 3. The Immediate Jeopardy was removed prior to exit on 2/8/12. This is evidenced by the following: Resident #1: The resident was admitted to the facility on [DATE]. The resident was born a twenty-four week preemie, and was admitted with [DIAGNOSES REDACTED]. The resident has developmental delays and was not interviewable. A Resident Incident Report dated 9/17/11 at 1:30 pm, documented that the resident was witnessed to be decannulated (the breathing tube had come out) and had no pulse. The tracheostomy tube was re-inserted and cardio-pulmonary resuscitation was performed for two minutes and the resident returned to spontaneously breathing. The Follow-up by Unit Manager section documented that the resident was doing short periods off the ventilator (a mechanical breathing machine) in a weaning process, and was more mobile and interactive since admission. The Registered Nurse (RN) and the Certified Nursing Assistant (CNA) were both in the common area when the tracheostomy was pulled out. There were reverse tracheotomy ties for added stability, and staff acted appropriately during the incident. It was also documented that no care plan changes or corrective actions were made. The resident would continue to be monitored. A facility typed form titled "In-service" dated 12/5/11 documented by the Registered Nurse Manager (RNM) documented that effective that date, the resident would no longer be covered by Respitory Therapy (RT). All of the medications and treatments were to be done by nursing. Any time the resident was left alone in her room, she needed to be hooked up to the proper oximeter monitor. Additionally, the baby monitor was to be used so staff could hear the alarms from the pulse oximeter because the pulse oximeter was not loud enough to be heard without the baby monitor. The baby monitor speaker was located at the nurse's station and the Registered Nurse (RN) assigned to resident should carry a monitor. It was also documented that there had already been one instance when RT had to check on the resident because no one responded to this alarm. It was documented that, "This is very serious and everyone needs to be focused on this for her safety." There was no direction documented for monitoring the resident's oxygenation when the resident was in the common area. The Comprehensive Care Plan (CCP) for Ventilator Support and Daily Respiratory Therapy last updated 12/3/11, documented that when the tracheostomy tube needed to be changed due to a mucous plug. There was no documentation that the resident was weaned from the ventilator or additional measures to monitor the resident's respiratory status. An additional CCP titled "increased risk for bronchospasm" documented that the resident was weaned from the ventilator on 10/31/11. There were no CCP developed for when the resident was in the common area in the play yard. The Nursing Fact Sheet (caregivers use to know what care to provide to the resident) last dated 10/27/11, documented that the resident was on trials of Passey Muir valve (used when weaning off a ventilator) and that the resident used a wheel chair for transportation. The facility form titled "Incident Report" dated 12/9/11 at approximately 12:20 pm documented that the resident was found in a supine position, unresponsive, apneic ( without respirations), mucous membranes pink. Resident was transferred to a wedge (table) and bagged (manual breathing with resuscitation Ambu bag) immediately by Respiratory Therapy (RT). Tracheostomy tube was determined to be out and was replaced. Code Blue paged. The resident's pulse was checked and was noted to be absent. Cardio Pulmonary Resuscitation was initiated, and 911 was called. The physician arrived on the unit, emergency medical services arrived, and the resident was transferred to the hospital. Under the section titled "Follow-up by Unit Manager" it was documented that the resident was weaned on 10/31/11 and remained on the ventilator unit due to medical fragility. The resident had an extensive medical history and was not on a pulse oximeter at the time of the incident per standards. The resident was in the common area under supervision. Investigation completed by the Director of Nursing (DON). During an interview on 2/2/12 at 10:45 am, the Physical Therapist (PT) stated that the resident no longer used the wheel chair, but was using a walker. The PT also stated that the resident was independent with sitting and needed no support. During an interview on 2/2/12 at 11:50 am the Respiratory Therapist #1 (RT#1) stated that the resident was no longer receiving respiratory therapy services and that all care was being provided by nursing. During an interview on 2/1/12 at 12:10 pm, LPN #1 stated that the resident had just started walking that day, the resident came up to her and held her arms up, and LPN #1 asked if the resident was tired and the resident shook her head yes. The LPN picked the resident up held her for a few minutes then seated her in the play yard. LPN #1 stated that she placed the resident near the front facing right corner of the play yard. LPN did not verbally inform any staff that the resident was placed in the play yard. During an interview on 2/1/12 at 12:30 pm, Certified Nursing Assistant (CNA) #2 stated that she was relieving the CNA assigned to the common area at the time of the incident. CNA #2 stated she was feeding another resident at the table opposite of the area where Resident #1 was located. CNA #2 was not aware that Resident #1 was in the play yard. The Director of Nursing (DON) was interviewed on 2/1/12 at 1:30 pm and stated there was no protocol available for the monitoring of the common area available. Resident #3: The facility did not ensure that a system was in place to monitor oxygen tank volumes. On 12/20/11, this resident's oxygen tank ran empty and the the resident was found cyanotic and required immediate intervention. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident to have moderately impaired cognition. The CCP for continuous ventilator support and daily respiratory therapy dated 10/19/10 documented that the resident's oxygen saturation was to be continuously monitored while in his room and as needed when out of his room. Physician orders [REDACTED]. The Respiratory Care Flow Sheet dated 12/25/11 documented that the resident's oxygen flow rate was 2 Liters Per Minute (LPM). The oxygen tank had been checked in the morning and there was 3,000 pounds per square inch (PSI) in the tank (the tank was full). It was also documented on this record that the resident received medications that required an increased oxygen flow rate at 6:00 am, 12:45 pm, another administration that the time was not documented, and at 6:00 pm. A note documented that at 6:45 pm, the Respiratory Therapist (RT) was called to the dayroom and the resident's color was blue. An Ambu bag (a bag connected to 100% oxygen, attached to the tracheostomy and manually squeezed by a staff member to deliver oxygen in the event of mechanical ventilation failure), was applied and the resident quickly recovered. It was documented that the reason the resident had turned blue was that the oxygen tank was empty. An Incident Report (I&A) dated 12/20/11 at 6:45 pm, documented that the resident was in the dayroom when a Certified Nursing Assistant (CNA) yelled out that the resident was blue. An assessment found that the resident was cyanotic (a blue or purple coloration of the skin due to a lack of sufficient oxygen). The nurse called for an RT and took connected the resident to the oxygen delivered from a wall mounted delivery system. Ten breaths were delivered to the resident through the Ambu bag and the resident's color returned to normal. The Unit Manager Follow Up section of the I&A documented that the resident was 2 years old and was dependent on a mechanical ventilator for breathing. The resident had been in the common area on a portable oxygen tank and that the tank had run empty. The I&A was signed by the Registered Nurse Manager (RNM), the Director of Nursing (DON), the Medical Director and the Executive Director. During an interview on 2/7/12 at 1:02 pm, the RNM stated that on 12/20/11, the resident had turned blue because the oxygen tank the resident was hooked up to had run empty. She stated that she assumed the RTs were to monitor the volumes remaining in oxygen tanks and that nursing had not been responsible for checking the oxygen tanks. During an interview on 2/7/12 at 1:09 pm, the Respiratory Therapy Manager (RTM) stated that on 12/20/11, the resident had turned blue because the oxygen tank the resident was hooked up to had run empty. The resident had been on a portable oxygen tank instead of the wall mounted system. The RTs were responsible for checking the volume remaining in an oxygen tank once a shift and that was documented on the Respiratory Care Flow Sheets but the time the check was done was not documented. She stated that the oxygen tank in use for this resident on 12/20/11 had sufficient volume in it to last an entire shift if it was running at 2 LPM, but because the resident also required medications to be delivered through the tracheostomy, those medications required an increased oxygen flow rate to deliver the medications. She stated that there was no system or policy in place at the time to consistently check and document the monitoring of oxygen tank levels when they were in use other than the RTs checking them once a shift. During an interview on 2/8/12 at 12:57 pm, the DON stated that the RTs were responsible for checking and monitoring the oxygen tanks and that the nursing department had not been specifically instructed to monitor the tanks. The Immediate Jeopardy was removed on 2/8/12 which was prior to the New York State Department of Health (DOH) exit from the facility on 2/9/12. The facility performed the following corrective actions to have the immediacy removed: The facility contracted with an independent consultant to assist in the correction of the identified issues. When residents were in the common area, there was to be direct oversight of the staff provided by management personnel. The role of the CNA was modified and clarified so that the individual assigned to the common area had no additional responsibilities beyond interaction and supervision of the children in the common area. The CNA role was defined to give clear directives that they were not to participate in feedings, activities of daily living or transporting residents outside of the common area. CNAs were to give verbal report to transfer care from one to another staff member while standing with the resident prior to departure. The common area was reconfigured to allow for greater observation of the area by the staff. One hundred percent of the Nurse Managers and supervisory personnel were inserviced on the need to monitor appropriate staff activities while they were in the common area. One hundred percent of the staff who had worked since the Immediate Jeopardy had also been trained on the policy and procedures, plan for supervision and the expected communication of care for each resident at each change of shift. There was also a plan in place to educate the remaining staff prior to returning to work. Licensed nursing personnel had been inserviced on the use of the 24 Hour Report book. As part of every shift change the Registered Nurse in charge was to receive a report from all CNAs assigned to that shift and that information was to be communicated to the incoming shift at shift change. Incident reports were to be reviewed each day by the Administrator and/or the DON to determine whether the incident was reportable to the DOH and what actions were necessary to ensure the safety and well-being of the residents. An on-call Administrator would field calls in the absence of the Administrator and the DON. All of the individuals received a copy of the DOH Incident Reporting Manual and were aware of their responsibilities to initiate an investigation immediately in the event of an incident. Policies and Procedures were reviewed and expectations clarified. All resident deaths that were the result of abuse, neglect or mistreatment according to the guideline were to be reported. The facility had also arranged for reviews by a Quality Assurance expert skilled in investigations, of all incidents involving resident death or serious harm to determine if the facility investigations were complete and whether appropriate actions were taken. 10 NYCRR 4115.12(h)(1)

Based on observation, record review and staff interviews during a post survey revisit and a complaint investigation (NY 898), it was determined that for one (Resident # 1) of three residents reviewed, the facility failed to ensure that the resident environment remains free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. Specifically, the facility did not ensure that staff caring for Resident #1 had accurate resident care information, and proper training for the equipment used for Resident #1. This resulted in actual harm for Resident #1 that is not Immediate Jeopardy. This is a repeat deficiency from the partial extended abbreviated survey on 2/8/2012. This is evidenced by the following: Resident #1 The resident was readmitted to the facility on [DATE] diagnosed with [REDACTED]. The Minimum Data Set dated 2/23/12 assessed the resident had severe cognitive deficits. The residents closet door, where care instructions are kept for use by Certified Nurses Aides (CNA) needing to provide care, did not have available the Nursing Fact Sheet. The Weight Worksheet (undated) documented that Resident #1 needed to be weighed, and documented that the type of scale to be used was a crib scale. The worksheet documented that weights are to be done during the week and under the supervision of the unit manager or designee. The Comprehensive Care Plan (CCP) for Alteration in self care, last documented as reviewed on 11/25/11, documented that Resident #1 would have Activities of Daily Living (ADLs) attended to by staff including bathing, dressing, hygene, grooming, transfers and elimination daily. The documented approaches included, to provide 2-person lift transfers and 1 person repositioning. Total assistance of one for all ADLs. The Nursing Fact Sheet last modified 1/24/12 documented that Resident #1 required a 2-person transfer. The toileting and positioning fields do not have documented a notation of the number of staff needed to provide care. The Physical Therapy Nursing Interventions (undated) documented that Resident #1 was a 2-person scoop transfer and required 2-person repositioning. The Incident Report (IR) dated 3/24/12 at 1:35 pm documented that Resident #1 was assisted to a weight bed by two caregivers when one caregiver stepped away momentarily and the other care giver noticed the resident was wet and attempted to pull the siderails up but the resident jerked sideways and rolled off of the weight bed falling approximately three and a half to four feet onto the hard floor causing injury to the resident's mouth. The form documented that the Registered Nurse assessed the resident with two upper left teeth missing, right tooth chipped at an angle and bleeding from the upper lip. The IR documented that the care plan was not followed and there was evidence of neglect. The IR documented that the Director of Nursing (DON) completed the investigation and the report was signed by the DON on 3/27/12 and the Executive Director on 3/30/12. The Emergency Transfer Form dated 3/24/12 at 2:00 pm documented that Resident #1 was being transferred to the hospital after a fall from a crib, approximately 3 and a half feet, with bleeding from the mouth and two missing teeth. In a statement prepared for the facility investigation, CNA #1 documented that she and CNA #2 transferred Resident #1 to the crib to be weighed when she realized Resident #1 was wet. CNA #1 documented that she left CNA #2 with the resident while she went to retrieve needed supplies. CNA #1 documented that she began to change Resident #1 and CNA #2 stated that she would be back to transfer the resident. CNA #1 documented that she tried to put the rails up when the resident started to move around and fell on the floor. In a statement prepared for the facility investigation, CNA #2 documented that she assisted CNA #1 transfer Resident #1 onto the weight bed. CNA #2 documented that she noticed the resident was wet so CNA #1 attempted to change the resident and she went to tend to her assigned residents. During an interview on 4/9/12 at 9:00 am, the DON stated that she completed an investigation into Resident #1's fall and although she had not written up the summary, she stated that two agency CNAs were working on the day of the fall and CNA #1 was the assigned caregiver for Resident #1. The DON stated that CNA #1 was aware that care instructions were on the inside of the closet door and the CNA #1 was aware that Resident #1 required the assistance of two caregivers. The DON stated that CNA #1 and CNA #2 transferred the resident to a weight crib when the CNAs realized the resident needed to be changed. The DON stated that CNA #2 walked away to care for her assigned residents and that CNA #1 was attempting to put up the crib rails when the resident fell from the crib. The DON stated that CNA #1 was negligent because she took her eyes and hands off of the resident. The result was the resident fell out of the crib. During an interview on 4/9/12 at 9:30 am, CNA #3 stated that she regularly cares for Resident #1 and she always provides care to the resident with another CNA because the resident can move quickly. CNA #3 stated that she has had to weigh Resident #1 in the past and does so on a weigh bed located in Resident #1's room. CNA #3 stated she had not used the crib to weigh the resident in approximately 6 months. During an interview on 4/9/12 at 1:00 pm, CNA #2 stated that she and CNA #1 were the only CNAs assigned to the unit on 3/23/12 and that she had not been assigned to that unit in approximately a month. CNA #2 stated that during the morning, the LPN had given both CNAs a sheet to record the weights of several of the residents. CNA #2 stated that she went to another unit and retrieved the weight crib. CNA #2 stated that she learned how to use the crib from working with another CNA some time ago. CNA #2 stated that she informed CNA #1 that Resident #1 needed to be weighed and she and CNA #1 transferred Resident #1 into the crib. CNA #2 stated that they noticed that the resident was wet and that and she told CNA #1 that the resident should be transferred back into bed to be changed. CNA #2 stated that CNA #1 gave her attitude and stated "you're not staff" implying that she was not a facility employee and therefore should not be telling her what to do. CNA #2 stated that she told CNA #1 to think about what she wanted to do and that she would be right back to assist her. CNA #2 stated that she was aware that Resident #1 was a 2-person assist for transfers but was not sure if the resident required a 2-person assist for everything. CNA #2 stated that she was in a rush and had her own assigned residents to care for and that contributed to her walking away from CNA #1 with Resident #1 in the weight crib. During an interview on 4/9/12 at 2:00 pm, CNA #1 stated that she had cared for Resident #1 one time in the past on a school day when most of her care had already been completed by the night shift. CNA #1 stated that she was aware that Resident #1 required two staff to assist for transfers, the resident's care cards did not specifically state anything about assistance with other care but she and CNA #2 had provided all care, prior to the incident, to the resident together. CNA #1 stated that CNA #2 brought the weight crib to her and she and CNA #2 transferred the resident into the weight crib. CNA #1 stated that she had never had to weigh anyone before and was not trained on how to use the weight crib. CNA #1 stated that she noticed that the resident needed to be changed and she left the resident with CNA #2 to get supplies. CNA #1 stated that she began to change the resident and CNA #2 stated that she would be right back and she didn't understand why CNA #2 was leaving. CNA #1 stated she then tried to raise the siderails to the crib while she was waiting for CNA #2 to return however, as she was trying to figure out how to raise the siderails, Resident #1 fell to the floor. CNA #1 stated that she thought it was odd that two agency staff would be on a unit together without a facility staff member that was more familiar with the residents. During an interview on 4/9/12 at 4:45 pm, the Administrator stated that she reviewed and signed off on the incident report on 3/30/12. The Administrator stated that the DON had conducted an investigation and had reported to her that CNA #1 was negligent because CNA #1 looked away from Resident #1's while she was on the weight crib and the DON described it as an "open and shut case". The Administrator stated as of the date and time of this interview, she had not reviewed any statements from staff and did not have concerns about the thoroughness of the investigation based on her conversations with the DON. The Administrator stated that she was not happy that the two staff responsible for care were agency staff and not facility staff or that a crib was being used to weight the resident when there is a wheelchair scale available which would have been a better situation for Resident #1 given her size. During a follow-up interview on 4/16/12 at 9:15 am, the Administrator stated that since the interview on 4/9/12 with the surveyor, she reviewed the incident in more detail and was not able to determine if CNA #2 violated Resident #1's care plan because she identified descrepancies between Resident #1's comprehensive care plan and the care instructions documented on the Nursing Fact Sheet, Occupational Therapy Nursing Intervention Sheet and Physical Therapy Intervention Sheets used by CNAs to provide care, and was not sure how many caregivers were needed after the resident had been physically transferred from one point to the other. The Administrator stated that she did not know if CNAs were trained on the use of the weigh crib, but thought CNAs should know how to use it based on common knowledge and instructions on the side rail bars. During an interview on 4/16/12 at 10:30 am, the Registered Nurse Manager (RNM) stated that all members of the interdisciplinary team are responsible for updating the comprehensive care plans and the instructional cards used by CNAs. The RNM stated that in the absence of specific care instructions, she knows the residents on the unit and would use her judgement to determine the safest way to care for residents. The RNM stated that she would expect that if something on the care instructions were not clear or not present, she would expect the CNAs to ask a nurse or use their judgement for the safest situation for the resident. During an interview on 4/16/12 at 11:30 am, the DON stated that there is a descrepancy in the way nursing, physical therapy and occupational therapy communicate the resident's care instructions to CNAs. The DON reviewed Resident #1's nursing fact sheet, physicial therapy and occupational therapy instruction sheets and stated that the care instructions are not clearly documented for the CNAs. The DON stated "we realize this is a problem and we are trying to fix it." During an interview on 4/16/12 at 11:45 am, the Administrator stated that she identified that care instructions are not clear, "we are working on it, but apparently, I just can't fix it fast enough." 10 NYCRR 4115.12(h)(1)

Based on medical record review and staff interview during an extended abbreviated survey (Case # NY 687) it was determined the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The Administration failed to ensure that resident's care was provided in a safe, secure and supervised environment for residents at risk for decannulation. Specifically, for Resident #1 the facility's administration failed to ensure that effective systems to maintain residents safety were developed and implemented, failed to ensure residents were supervised to prevent accidents and failed to thoroughly investigate and report an incident of decannulation to the State Department of Health (DOH). This resulted in actual harm that was Immediate Jeopardy to the resident's health and safety and Substandard Quality of Care for Resident #1. The Immediate Jeopardy was removed prior to exit on 2/8/12. This is evidenced by the following: F 225 was found to be at a pattern which constituted immediate jeopardy for resident health and safety. The facility failed to ensure that a thorough investigation was completed involving a resident who decannulated (removal of [MEDICAL CONDITION]) and was found without signs of life, failed to identify that staff who were supposed to monitor the resident were performing other duties, and failed to notify the State Department of Health of this incident. During an interview on 2/6/12 at 5:18 pm, the Administrator stated that the incident involving Resident #1 was not reported to the New York State Department of Health (DOH) because they could find no evidence of abuse, neglect or equipment failure. She stated that the DON had left a telephone message with the DOH and that the return telephone message had said that it did not sound as though the incident required reporting to the DOH. The Administrator stated that after reading the DOH Incident Reporting Manual, and based on the telephone message they had received, a determination was made that the incident did not require reporting. F 323 was found to be at a pattern which constituted immediate jeopardy for resident health and safety. The facility failed to ensure that the resident environment remains free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. Specifically, the resident who has a history of decannulating, was placed in a play yard without staff who were responsible for monitoring the play yard knowing that the resident was in the play yard. The resident was found at least thirty minutes later, decannulated and was found without signs of life. The Director of Nursing (DON) was interviewed on 2/1/12 at 1:30 pm and stated there was no protocol available for the monitoring of the common area available. F 490 was found to be at a pattern which constituted immediate jeopardy for resident health and safety. During an interview on 2/6/12 at 5:18 pm, the Administrator stated that prior to the incident involving Resident #1 on 12/9/11, there was no policy or procedure in place to describe the responsibilities of staff monitoring the residents in the dayroom. She stated that she was not aware that staff monitoring residents in the dayroom were known to get involved in conversations with other staff, and be involved with resident care such as feeding residents and changing soiled clothing and other activities of daily living. The Administrator stated that staff monitoring residents in the dayroom should have been giving one another a report of the residents in the dayroom when they were being relieved for breaks or at the end of the shift. She was not aware that there was no report being given. The Administrator stated that when Resident #1 was in her crib she was on mechanical alarms, so if something went wrong staff would have known. When the resident was in the dayroom, she did not have the mechanical alarms and that was why staff were supposed to closely monitor the child and the other residents in the dayroom. On 12/9/11, the Certified Nursing Assistant (CNA) assigned to the dayroom had been relieved for a break by another CNA. The CNA who took over was also feeding another resident at the table and it was possible for Resident #1 to be out of her line of sight. 10 NYCRR 415.26

Based on record review and staff interview the facility was not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, for one ( #1) of three residents reviewed the Administration failed to ensure that resident's care was provided in a safe, secure and supervised environment for residents. For Resident #1 the facility's administration failed to ensure that effective systems to maintain residents safety were developed and implemented, failed to ensure residents were supervised to prevent accidents and failed to thoroughly investigate to determine the root cause of an incident. The facility did not ensure accurate information was communicated to the certified nurses aides caring for the resident. Resident #1 fell from a weigh bed, sustained facial injuries and required hospitalization . This is a repeat deficiency from the partial extended abbreviated survey on 2/8/2012. This was not actual harm but has the potential for more than minimal harm. This is evidenced by the following: Refer to Resident Behavior and facility Practices F 225 scope /severity G Refer to Quality of Care Accidents F323 scope/severity G During an interview on 4/9/12 at 4:45 pm, the Administrator stated that she reviewed and signed off on the incident report on 3/30/12. The Administrator stated that the DON had conducted an investigation and had reported to her that CNA #1 was negligent because CNA #1 looked away from Resident #1's while she was on the weight crib and the DON described it as an "open and shut case". The Administrator stated as of the date and time of this interview, she had not reviewed any statements from staff and did not have concerns about the thoroughness of the investigation based on her conversations with the DON. The Administrator stated that she was not happy that the two staff responsible for care were agency staff and not facility staff or that a crib was being used to weight the resident when there is a wheelchair scale available which would have been a better situation for Resident #1 given her size. During a follow-up interview on 4/16/12 at 9:15 am, the Administrator stated that since the interview on 4/9/12 with the surveyor, she reviewed the incident in more detail and was not able to determine if CNA #2 violated Resident #1's care plan because she identified descrepancies between Resident #1's comprehensive care plan and the care instructions documented on the Nursing Fact Sheet, Occupational Therapy Nursing Intervention Sheet and Physical Therapy Intervention Sheets used by CNAs to provide care, and was not sure how many caregivers were needed after the resident had been physically transferred from one point to the other. The Administrator stated that she did not know if CNAs were trained on the use of the weigh crib, but thought CNAs should know how to use it based on common knowledge and instructions on the side rail bars. 10NYCRR 415.26