Every finding on record at St Vincent Depaul Residence

Based on observations, record review, and interviews conducted during the Recertification Survey [DATE] -[DATE], the facility did not ensure that food was stored and prepared in accordance with professional standards for food service safety. Specifically, (1) there were boxes containing food stored past their use by/best by date. There was an open box containing mirepoix vegetable soup mix, an open box Capi vegetable blend, open box with coleslaw stored. There was also an open box containing expired raw frozen shrimp in the freezer. (2) a dietary staff with a beard and mustache was observed in the process of preparing food without a beard net. This was evident in the kitchen observation. The findings are: The facility policy titled Food and Supply Storage revised ,d+[DATE] documented all food used for food preparation shall be stored in such a manner as o prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Most, but not all, products contain an expiration date. The words sell by, best by enjoy by or use by should proceed the date The 'sell by date is the last date that food can be sold or consumed. Food past the use by, sell-by, best-by or enjoy by date should be discarded. Date and rotate items first in first out. Discard food past the use by or expiration date. The facility policy titled Food Handling Guidelines Hazard Analysis Critical Control Points (HACCP) revised ,d+[DATE] documented food is handled using Hazard Analysis Critical Control Points process in accordance with regulatory guidelines. Proper handling procedures and techniques are visually monitored on an ongoing basis. The Director of Food and Nutrition Services/Dining Services and The Executive Chef are responsible for the execution and monitoring Critical Control Points and records associated with safe food handling procedures. The individual responsible for maintaining the records should initial the form weekly verifying that proper procedures are been followed. The policy only mentions the use of single use disposable gloves in food preparation and no other uniform items are mentioned for food preparation persons to wear. The facility policy titled Uniform Dress code revised ,d+[DATE] documented personal cleanliness and a neat appearance are essential for the food service worker. Facial hair must be kept neatly trimmed, hair must be neat and glean, good grooming and personal hygiene is mandatory. Restrain all facial hair with a beard net/restraint. Because everything on this subject cannot possibly be addressed, Associates with questions about the appropriateness of a particular items should speak with the manger before wearing certain articles. The facility in-service on hairnet and beard guards dated [DATE] documented 12 employees and 1 manager attended the training. The facility in-service on food safety and quality assurance dated [DATE] was signed by 9 dietary staff. 1. An initial tour of the kitchen was conducted on [DATE] from 09:44 AM-10:10AM with the Director of Patient Food Services. The following were observed in the refrigerator: mirepoix veg soup mix ,d+[DATE] inch 4 x 5 pound use by [DATE] lot number167566, 4 bags of veg blend capri 5 way with lot number 169697 ,d+[DATE] pound box with a best if enjoyed by date of [DATE] and the open box dated [DATE], 1 ,d+[DATE] bags of coleslaw salad mix G/R cab/car 4 x 5 pound with a use by date of [DATE] lot number WO,d+[DATE] and the box was dated [DATE]. The following was observed in the kitchen freezer an open box containing frozen raw deveined white shrimp ,d+[DATE] count with a best if used by [DATE] with product number 22124 and purchase order #P101423. During an interview on [DATE] at 10:14 AM, the Food Service Worker was interviewed and stated they did not look at the food items on the shelf. The facility gets food deliveries on Tuesday and Friday and looked at [DATE] with use by date of [DATE]. They stated the food items mirepoix veg soup, vegetable blend capri 5 way and coleslaw salad mix should not be on the shelf. They look at items in the refrigerator and the cook informs them in they will use the item or not. It is important that food is used timely, so it does not expire and make people sick. We use the older stock first and then we use the newer food items. They stated they have not had training on food safety yet. During an interview on [DATE] at 10:28AM, the Food Service Supervisor stated that they look at the refrigerator and freezer 3 times a day. They also look at the refrigerator and freezer when they get food deliveries on Tuesday and Friday. They did not notice that anything in the refrigerator and freezer were expired. They stated they worked yesterday and did not notice any expired items and they looked at the freezer yesterday and they did not notice the expired food items. The food items should not be in the refrigerator and/or freezer due to food contamination, don't want to create foodborne illness and they had food safety training 1 month ago. On [DATE] at 10:34 AM, [NAME] #1was interviewed and stated, the shrimp is not cooked and the last time they prepared shrimp was 5 months ago on their shift. [NAME] #1 stated that the night cook prepares the vegetables for the meals. They look at date on food items daily and they are not aware of any food items that are expired. When the food comes in, it is used up. We don't want to use expired food because we don't want to get residents sick and it is a hazard. On [DATE] at 10:48 AM, the Food Service Manager was interviewed and stated, they look at the refrigerator/freezer when they open the kitchen daily. When they look at food items, they look for the expiration date, food appearance, received date and rotate food items when needed by the food best by date. If the food item is closed item, then the discard date would be based by the foods shelf life. Food stored in the refrigerator is dated for 3 days and anything opened dated 3 days for items start use date. If the food items are in a box we go by the receive date. The mirepoix veg soup mix is in the box and for prepackaged food items received and from the day the food item is open it is labeled for 3 days so it can be discarded on day 3. If the food item is unopened, we go by the receive date and if a food item is closer to date of discard we go by manufacturer date. The best by and use by dates are similar and they are based on manufacturer term. They looked at the freezer yesterday and yesterday shrimp was on the menu and some residents may have an allergy to shrimp and there are alternative foods available for residents with food allergies. They are not sure of the last time they looked at the raw shrimp. Expired food items could get residents sick, and this is why we keep fresh items in house instead of spoiled that can make residents sick. On [DATE] at 11:23AM, the Director of Patient Food Services was interviewed and stated, that they look at the refrigerator and freezer every morning and also at night. They stated they never noticed the shrimp before, and it is a catering item. We use the raw shrimp right away and the item is used quickly, and they contacted the vendor, and the food item needs to have more shelf life. For food safety of the residents we need to make sure food items are used timely. Last in-service that was done was on food inventory which has to be rotated using first in first out. 2. On [DATE] at 10:47 AM-10:58 AM [NAME] #2 was observed with a beard and mustache on their face approximately ,d+[DATE] inch to 1 inch in length in the kitchen not wearing beard net in kitchen. [NAME] #2 was observed with a closed box of chocolate brownie mix which was later opened and placed in a silver bowl and grabbing a spatula opposite the stove and going back to the prep area on the office side of the kitchen. On [DATE] at 11:30 AM, [NAME] #2 was interviewed and stated, they had a beard net on earlier but removed it and they were suppose to have one on their face. They don't want any hair to go in the food. On [DATE] at 11:02 AM, the Food Service Supervisor was interviewed and stated, staff with facial hair are required to wear a beard net. If staff have ,d+[DATE] inch to 1 inch of hair on their face they should wear a beard guard. They did not notice staff without a beard guard. Hair can fall into the food and it should be covered at all times and should be worn when entering the kitchen as this is part of the staff uniform. On [DATE] at 11:26AM, the Director of Patient Food Services was interviewed and stated, dietary staff uniforms includes hair nets, beard guards and non-slip shoes are part of the uniform. Dietary staff need to wear and use hair nets and beard nets When preparing and handling food so no hair will get in the food, staff should be using hair and beard covers. We always make sure staff have on their hair nets/beard nets and we are adamant about this. On [DATE] at 11:39 AM, the Infection Preventionist was interviewed and stated, they do kitchen rounds less often at least once every 2 weeks. They look for infection control such as use of hair nets, beard nets. There were no issues with hair nets/beard nets. Hair nets and beard nets need to be worn to avoid cross contamination of the food. 10 NYCRR 415.14(h)

Based on observation, interview, and record review conducted during the Recertification Survey from 01/02/2025 to 01/08/2025, the facility failed to maintain a clean, orderly, functional, and sanitary (homelike) environment for the residents. The deficient practice was identified for multiple resident rooms/units inspected: 1) room [ROOM NUMBER] had no hot water supply for about 3 weeks, 2) room [ROOM NUMBER] and shared shower room on Unit 3 were observed in disrepair/damaged/discolored/ dirt and dust accumulation, 3) 2nd floor dining room and rooms 201/202/210/211/212 were observed in disrepair/damaged/discolored. The findings are: The facility policy titled Hot Water Temperature with undated effective date documented the Department of Engineering is responsible for prompt follow-up on any problem, including investigation, repair or other action as appropriate. The facility policy titled Work Order Procedure with undated effective date documented this procedure will govern the insurance of engineering work orders for the safety, preventive maintenance, repair, facility modification and emergency work, indicating on what authority a work order needs to be approved, and prior to being scheduled into the department workload. 1) On 01/02/2025 during the initial pool process around 11:34 AM to 11:43 AM, and subsequent visit on 01/03/2025 around 10:38 AM to 10:43 AM, the surveyor conducted an environmental tour in the room [ROOM NUMBER] and observed there was no hot water coming out when the handle of the hot water faucet was turned on at the sink in the bathroom. On 01/02/2025 at 11:34 AM, Resident # 57 was interviewed and stated there was no hot water from the sink in the bathroom of room [ROOM NUMBER] for 3 weeks. Resident # 57 also stated the sink fell and broke about 3 weeks ago. Resident # 57 further stated the facility installed a new sink the next day and there was no hot water since then. Resident # 57 stated the Certified Nursing Assistant and themselves had to go to the bathing room across the hallway to get hot water when needed and it was very inconvenient. On 01/02/2025 at 11:43 AM, Resident # 95 was interviewed stated there had been no hot water in the bathroom sink of room [ROOM NUMBER] since the facility replaced the broken sink about 3 weeks ago. Resident # 95 also stated the Certified Nursing Assistant and themselves had to go to the bathing room across hallway to get hot water. Resident # 95 further stated they needed hot water supply in the room to wash hands and other purposes in the wintertime. The maintenance book was reviewed and had no documentation about hot water supply problem in the room [ROOM NUMBER]. The Maintenance Repair Requisition form documented the sink in room [ROOM NUMBER] became loose on 12/4/2024. The form also documented by Maintenance Department on 12/5/2024 that a sink was reinstalled, waterline was tied in, and sink was in working condition. On 01/07/2025 at 09:29 AM, Certified Nursing Assistant # 5 was interviewed and stated they were assigned to Resident # 57 and Resident # 95 in the room [ROOM NUMBER] in December 2024. Certified Nursing Assistant # 5 also stated they were aware there was no hot water supply in the room [ROOM NUMBER] during the morning report meeting from the nurse in December 2024 and did not recall the exact date or which nurse gave the report. Certified Nursing Assistant # 5 further stated they thought the hot water issue was known to the nurse already and did not follow up on the repair of hot water issue in room [ROOM NUMBER]. Certified Nursing Assistant # 5 stated they should report to the nurse in a few days if there was still no hot water supply in the room [ROOM NUMBER]. On 01/07/2025 at 09:52 AM, the Housekeeper was interviewed and stated they recalled there was no hot water in room [ROOM NUMBER] at least since the last week of December 2024. The Housekeeper also stated they did not report the problem to anyone as they saw someone was fixing the sink and was not sure who was fixing the sink. The Housekeeper further stated they thought the hot water problem was taken care by someone already. On 01/07/2025 at 03:40 PM, Certified Nursing Assistant # 6 was interviewed and stated they were newly hired and worked in the evening shift on the unit for a few weeks. Certified Nursing Assistant # 6 also stated they shadowed Certified Nursing Assistant # 7 and were assigned to residents in room [ROOM NUMBER]. Certified Nursing Assistant # 6 further stated they recalled the room [ROOM NUMBER] had no hot water supply at least starting the last week of December 2024. Certified Nursing Assistant # 6 stated they did not report the disrepair as they thought Certified Nursing Assistant # 7 was going to report the disrepair. On 01/07/2025 at 10:01 AM, Registered Nurse # 4 was interviewed and stated they made rounds on the floor at least 3 times a day to check if resident's room and bathroom were clean, resident care, and resident safety. Registered Nurse # 4 also stated they did not check water supply in the resident rooms and was not aware nor received any report that there was no hot water in the room [ROOM NUMBER]. Registered Nurse # 4 further stated they were not aware the Maintenance Department changed the sink in room [ROOM NUMBER]. Registered Nurse # 4 stated they would transfer both Resident # 57 and Resident # 95 to another room if they knew there was no hot water in the room [ROOM NUMBER]. Registered Nurse # 4 also stated there were empty rooms on the unit for a transfer if needed. On 01/07/2025 at 03:16 AM, the Maintenance Mechanic staff was interviewed and stated the unit staff called them for urgent repairs and documented non-urgent repair in the maintenance book. The Maintenance Mechanic staff stated they replaced the sink in room [ROOM NUMBER] on 12/5/2024. The Maintenance Mechanic staff also stated there was no problem for both hot and cold water supply in the room [ROOM NUMBER] before they left. The Maintenance Mechanic staff further stated they did not receive any report that there was no hot supply in the room [ROOM NUMBER] afterward. On 01/07/2025 at 10:14 AM, Director of Plant Operation and Maintenance was interviewed and stated the sink in the room [ROOM NUMBER] fell on [DATE] and they replaced a new one next morning on 12/5/2024. Director of Plant Operation and Maintenance also stated they did not receive any report until 1/3/2025 that there was not hot water coming out in the sink of room [ROOM NUMBER]. Director of Plant Operation and Maintenance stated they checked the issue and found out it was the speedy valve problem in the pipe running hot water to the room [ROOM NUMBER]. Director of Plant Operation and Maintenance also stated they would have the outside plumber to fix the problem if they were notified of the hot water problem in room [ROOM NUMBER]. On 01/07/2025 at 11:52 AM, the Administrator was interviewed and stated they were not aware there was no hot water supply in the room [ROOM NUMBER] until 1/3/2025. The Administrator also stated every room should have a hot water supply. 48711 2) During the Unit Tour on 1/3/2024 and 1/7/2025 of Unit 3 the following was observed: room [ROOM NUMBER] the wall behind the resident bed has multiple, deep, scratches with white substance exposed on the wall. The brown headboard has scrapings on it. Panel molding coming off the base of the floor. Located behind the entrance door is a large, white, spot, surrounded by pink colored paint. A review of the Unit 3 Maintenance log found no documented evidence that room [ROOM NUMBER] and the resident shared bathroom was in need of repairs. Resident shared shower room on Unit 3 was observed to have broken yellow tiles in the shower stall, shower head on the floor due to missing clamp holder, brownish to black substance observed in the corners of the shower stall and on the white wall tiles. [NAME] screen with dust on them, dead bees lying on the floor and brown colored stains observed on the white ceiling tiles. On 1/7/2025 at 12:25 PM interview with Maintenance Technician and stated the office management located on the 5th floor is responsible for doing a walkthrough of the resident rooms. The management staff consist of nursing, directors, and management. They will assign staff to go into the rooms to see what is going on. The maintenance logs are used for the overnight staff when on one is around. In the morning, the staff will call me, and I will come to see what needs repairing. My job is to make repairs, paint, fix lights, windows, fix the tiles and walls and any repairs that need to be done. Not aware of any of the listed items that need repair. On 01/07/25 at 01:54 PM the Director of Housekeeping and Maintenance was interviewed and stated, it is their responsibility to ensure that the common areas, hallways, and resident rooms are clean and in good repair. The rounds are done on a weekly basis by the Director of Housekeeping and Maintenance and nursing department. There are maintenance logs on every unit and those logs get check every morning by the maintenance workers. The Housekeeper on the unit is also supposed to check for any environmental issues and report as needed. On 01/07/2025 at 03:00 PM Registered Nurse #4, who is also the Nursing Supervisor for Unit 3, was interviewed and stated, that the nursing staff and supervisors make rounds of the unit daily to see if there are any issues and any need of repairs and write it in the maintenance logbook for maintenance to address. 42101 3). During observations made from 1/2/2025 at 3:34PM through 1/8/2025 at 12:28 PM, the following was observed on the 2nd Floor Unit: a. On 01/02/2024 at 3:34 PM, 01/02/25 03:44 PM, 01/03/25 12:05 PM, 01/06/25 11:16 AM, and 01/08/25 10:08 AM the 2nd Floor dining window screen lower bottom edge cracked. b. On 01/02/25 12:47 PM, 01/03/25 09:44 AM and 01/08/25 10:25 AM, room [ROOM NUMBER] Air conditioning/heater was noted with debris inside that included a sugar wrapper, purple crayon, dust coils left side and vents, and the room was noted with missing baseboard forming gaps along the room wall edges and behind headboard for B bed. c. On 01/02/25 12:42 PM, 01/02/25 03:23 PM, 01/03/25 09:47 AM, 01/08/25 10:28 AM, 01/02/25 12:42 PM, 01/02/25 03:23 PM, 01/03/25 09:47 AM, 01/08/25 10:28 AM - room [ROOM NUMBER] was observed with air conditioning/heater unit that was dusty. Baseboards in room coming off wall by the dresser between the A and B beds, peeling baseboards not affixed to the wall under Bed B headboard, by closet not affixed to wall and by door leading to the bathroom. Scratched dry wall observed in room to left of headboard. Baseboards not affixed to wall, peeled under headboard and by closet not affixed to wall and by door leading to bathroom not affixed to wall. d. On 01/02/2025 at 09:49 AM and 01/08/25 10:31 AM, room [ROOM NUMBER] footboard on bed veneer scratched on top, sides, outside and bottom edges and bathroom pipe faucet dripping water and left faucet could not be closed to stop water from dripping. e. On 01/03/2025 at 09:53 AM, room [ROOM NUMBER] was observed. Resident room baseboard behind headboard not affixed to wall and the dry wall behind headboard damaged, missing paint. Fall matt with curled edges on all 4 ends. f. On 01/02/25 03:41 PM and 01/03/25 09:57 AM and screen the same., room [ROOM NUMBER] - room window screen torn on left edge in 2 areas making up greater than 1/2 of the left side, missing rubber right side area, air conditioner/heater unit with 2 round items on top, g. On 01/07/25 at 03:43 PM - Fly noted flying in the dining room on the 2nd floor. On 01/08/25 10:43 AM black fly flying in 2nd floor hallway by nurses station leading to dining room. h. On 01/07/25 at 03:44 PM and On 01/08/25 at 10:12 AM the 2nd floor dining room pantry was observed and there was white colored granules on the corners and back of the left and right shelves and black colored stain on the outer edge of the middle right cabinet outer edge. On 01/08/25 10:58 AM, Certified Nursing Assistant #3 was interviewed and stated they had not noticed the window and due to it being cold they try not to expose residents too much to the cold air outside. The window is defective, and the end is broken and most of the time maintenance comes around the unit. The window looks like it has normal wear and tear. On 1/08/2025 at 11:10 AM and 2:46PM, the Maintenance tTechnician was interviewed and stated that they only correct issues when they have a work order. If staff don't notify them they do not know an issue had to be fixed. The Director of Plant Operations and Maintenance is in charge of checking for environment issues. The air conditioning/heater were looked at recently and the Facilities Director has the paperwork. The window screens have been there since 1992 and they did not notice issues with resident window screens that are damaged. The only way they are aware of anything that needs to be fixed is when reported to them or if they are notified by nursing staff. Someone came to look at window screens recently and the window screens do not close all the way. The bed in room [ROOM NUMBER] needs to be replaced and the water valve for hot water is bad and needs to be replaced. The air conditioning/heater was cleaned recently, and the Facilities Director has paperwork. Housekeeping can also clean the air conditioning/heater unit and if they need help with loosening the screws they can contact them. The resident's rooms need to be homelike since they live here. Any work done is done per a work order and if no work order they will not know what needs to be fixed. The last time they looked at the room baseboards was before November 2024. In relation to the spacing between the baseboards, the glue used was wrong and the last time the baseboards were worked on was 3 1/2 to 4 years ago and whoever installed them did it wrong. They are not sure when the window screens were last looked at and they have worked on the screens in the past they have changed the wire mesh to a plastic mesh in some areas. They look at the screens for holes and they look at the windows in resident rooms to see if they are damaged and the work on the windows. Resident can open the windows and damage the screens. They painted some room walls recently about 2 weekends ago. When the windows are damaged insects such as mosquitos and leaves can come into resident's rooms and the facility. There are only 2 maintenance persons for the building. Flies come in when we open the window and since the mesh does not close all the way they come in from outside. Staff should engage the latch to make sure the windows close completely. On 01/08/25 at 12:06 PM, the Director of Plant Operations and Maintenance was interviewed and stated the do rounds weekly. They do rounds on the 4th floor on Friday and round the other floors on Monday to Thursday. They look at residents rooms to include ceiling tiles, walls to make sure they are not damaged since residents beds can hit the wall behind causing scrapes and peeling paint. The air conditioning/heater units they check when they go check resident rooms and the last time they checked they documented it in their rounding binder. The air conditioning/heater units were cleaned last week and all air conditioning/heaters were cleaned throughout the facility and they are unsure of the date it was done. There was an audit list of the window screens done 1 month ago throughout the building and the vendor is coming to repair the ones on the list to be repaired and some window screens are damaged or missing and had to be taken down due to this damage. The air conditioning/heater are working, and we make sure it has the outer piece and are wiped down. We have a list of units that have concerns and are in the process of addressing that. The Director of Plant Operations and Maintenance stated work was done 2-3 months ago on the air conditioning/heater units and they will provide invoices for window work. 10 NYCRR 415.5(h)(2)

Based on interviews and record reviews made during a recertification survey (BYS411), the facility did not ensure that the Arbitration Agreement was explained to residents or their representatives in a form or manner that they understood. This was true in 3 of 21 residents sampled for Arbitration (Residents #22, 57 and 206). The findings are: The facility's policy and procedure entitled Admission Procedures, last reviewed 07/2019, states that the Admissions Director discusses the Admission Agreement with the resident and/or designated representative after admission to the facility. The facility includes a Binding Arbitration Agreement within its Admission Agreement which is written in legal language. The facility's admission packet was reviewed and revealed a brochure entitled, Your Rights as an ArchCare Resident which included the right to receive an explanation about care in a manner the resident can understand. On 01/07/2025 at 2:20 PM, the Admissions Director was interviewed and stated that when they explain the Arbitration Agreement, they let the resident know who they can talk to for legal advice and refers them to the corporate finance department for any questions. If the resident is unable to understand the legal language of the agreement, the Admissions Director stated that they read it out loud for them but do not paraphrase and stated, It's written for lawyers, but that's what we read. The Admissions Director stated that no one is obligated to sign as a condition of admission and that some residents do opt not to sign. The Surveyor obtained a list of recently admitted residents who had participated on their own or with their families in the admissions process. Resident #22 was admitted to the facility on [DATE] and as per their Minimum Data Set (a resident assessment tool), was mentally intact. On 01/08/2025 at 9:55 AM, Resident #22 was interviewed and stated that they did not know what papers were signed at the time they were admitted but that their family member, who was visiting, was aware. On 01/08/2025 at 9:57 AM, the resident's family member was interviewed and stated that they signed the Admission Agreement but that it was not explained to them. The family member stated, I would know about arbitration because I used to work in the public schools and I was part of the union. I has to do with dispute resolution, but I don't know exactly what it means. The family member stated that they were not told on admission that they had the right to refuse to sign or that if they signed the Arbitration Agreement, they were relinquishing the right to an attorney, and stated, They just told me to sign and I signed. The resident's Admission Agreement had been marked 'signed' but no signature was observed on the copy. Resident #206 was admitted to the facility on [DATE] with a Minimum Data Set documenting that the resident was mentally intact. On 01/08/2025 at 10:02 AM, Resident #206 was interviewed and stated, I remember signing that paper, but I don't know what it said, they didn't talk to me about it. I thought I had to sign or I would have to go back to the hospital, so I signed. The resident's Admission Agreement had been initialed by the resident. Resident #57 was admitted to the facility on [DATE] and was documented on their Minimum Data Set as moderately cognitively impaired. On 01/08/2025 at 10:04 AM, Resident #57 was interviewed and stated, I never sign anything, I won't do it. They wanted me to sign but I wouldn't. I am visually impaired and if I can't read it, I won't sign it. But they didn't even tell me what it was about. The facility submitted a statement that the resident refused to sign and their representative, who had not been present on admission, had also refused. On 01/08/2024 at 10:27 AM, the Administrator was interviewed and stated that the facility has never had any arbitrations. The Administrator stated that the Admission Agreement should be explained to the resident or their representative and that they should be given the opportunity to ask any questions. They should be referred to corporate finance only if there are questions that Admissions is unable to answer. The Administrator stated that the Agreement should be explained in its entirety including the Arbitration Agreement and that they would meet with Admissions to emphasize the need to explain it in simple language, not in legalese. 10 NYCRR 415.26

Based on record review and interviews during the recertification survey conducted from 01/02/2025 to 01/08/2025, the facility did not ensure that each resident was offered the Pneumococcal immunization. This was observed in 3 of 5 residents (Residents #6, #84, #96) sampled for Immunizations out of a total of 23 sampled residents. Specifically, there was no documented evidence that Residents #6, #84, and #96 were offered or educated on the Pneumococcal immunization. The facility policy titled Resident Immunizations effective 05/2014 documented that all residents will receive immunizations as recommended by the Immunization Practices Advisory Committee (ACIP) of the U.S. Department of Health and Human Resources. The resident's status regarding the Pneumococcal vaccine will be obtained and documented in the electronic medical record. If needed, the resident will be offered the Pneumococcal vaccine unless the resident declines or previously received it. Each resident will receive a fact sheet about the vaccine. If the resident received the vaccine in another facility or in the community, an attempt will be made to obtain that information and it will be documented in the electronic medical record. If the resident refuses the vaccine, the reason for the refusal will be documented in the medical record. Findings include: Resident #6 was admitted to the facility on [DATE] and had diagnoses including Non-Alzheimer's Dementia, and Hemiplegia and Hemiparesis following Cerebral Infarction. The Minimum Data Set Quarterly assessment dated [DATE] documented that Resident #6 had severe cognitive impairment. It also documented that Resident #6's Pneumococcal vaccination status was not up to date, with no reason documented for why the resident was not up to date on the Pneumococcal vaccination. Resident #84 was admitted to the facility on [DATE] and had diagnoses including Non-Alzheimer's Dementia and Type 2 Diabetes Mellitus. The Minimum Data Set Quarterly assessment dated [DATE] documented that Resident #84 had severe cognitive impairment. It also documented that Resident #84's Pneumococcal vaccination status was not up to date, with no reason documented for why the resident was not up to date on the Pneumococcal vaccination. Resident #96 was admitted to the facility on [DATE] and had diagnoses including Zygomatic Fracture, Hypertension, and Muscle Weakness. The Minimum Data Set Quarterly assessment dated [DATE] documented that Resident #96 was cognitively intact. It also documented that Resident #84's Pneumococcal vaccination status was not up to date, with no reason documented for why the resident was not up to date on the Pneumococcal vaccination. On 01/08/2025 at 11:03 AM, Resident #96 was interviewed and stated that they were educated on and received the Pneumococcal vaccine on 01/07/2025 but could not recall if they had been offered the vaccination prior to that. On 01/07/2025 at 11:06 AM, the Infection Preventionist was interviewed and stated that they had stepped into the Infection Preventionist role a few weeks ago after the facility's previous Infection Preventionist was unexpectedly no longer able to fill the position. They stated that the facility's policy was to offer the Pneumococcal vaccination to all residents on admission and annually after that if they declined on admission. The Infection Preventionist stated that after the surveyor requested resident Pneumococcal vaccination records on 01/06/2025, they realized that they did not have recent records reflecting that residents had been offered the vaccination so they immediately began to audit immunization records and offer the Pneumococcal vaccination to those who had not been offered it. The Infection Preventionist was unsure if the previous Infection Preventionist had been offering the vaccination to residents and was unable to produce documentation showing that it had been offered. On 01/08/25 at 10:58 AM, the Director of Nursing was interviewed and stated that the Infection Preventionist is responsible for ensuring residents receive immunizations. The Director of Nursing stated that they oversee the work done by the Infection Preventionist. They stated that the Infection Preventionist verified in the Citywide Immunization Record that it did not look like Residents #6, #84, and #96 had received the Pneumococcal vaccination, and they were unable to find documentation showing that it had been offered and declined. The Director of Nursing stated that the Pneumococcal vaccination should have been offered to these residents during admission and annually if they declined during admission, but based on the lack of documentation, it did not look like the residents had been offered the vaccination. They were unable to provide a reason for why this occurred. On 01/08/2025 at 11:14 AM, the Administrator was interviewed and stated that they believed that the lapse in the Pneumococcal vaccination being offered to residents was related to the unexpected change in staff members in the Infection Preventionist role. They stated that they believed that the previous Infection Preventionist may have been offering the vaccination to residents as per the facility's policy but they were unable to locate documentation reflecting that, because it was not in the electronic medical record. They stated that moving forward, the Infection Preventionist will ensure that residents' Pneumococcal immunization status is tracked and stored in the electronic medical record. 10NYCRR 415.19 (a) (1-3)

Based on interviews and record review conducted during the Recertification Survey from 01/02/2025 to 01/08/2025, the facility did not ensure residents, or their designated representatives were provided appropriate notification at the termination of Medicare Part A benefits. This was evident in 2 (Resident #36 and Resident #55) of 3 residents reviewed for Beneficiary Notification out of 23 total sampled residents. Specifically, the facility did not ensure that Notice of Medicare Non-Coverage were mailed to the residents' representatives on the same day telephone notification was made. The findings are: The facility policy titled Advanced Beneficiary Notice of Medicare Non Coverage Benefit Exhaust Letters with effective date 9/14 and last revision date of 12/23 documented the Advanced Beneficiary Notice required by the Centers of Medicare and Medicaid services are distributed to residents within the required time frames. The policy also documented the Benefit Exhaust Letters are sent to Residents/Representatives to inform them that Medicare A is no longer covering the skilled stay. The policy further documented to mail notice if necessary, following phone call under the section of Procedure. The Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 states that the form must be delivered at least two calendar days before Medicare covered services end and included the requirement that notification of changes in coverage for an institutionalized beneficiary/enrollee who is not competent be made to a representative. The instructions also stated that if the provider is personally unable to deliver a Notice of Medicare Non-Coverage to a person acting on behalf of an enrollee, then the provider should telephone the representative to advise them when the enrollee's services are no longer covered. The date of the conversation is the date of the receipt of the notice. Confirm the telephone contact by written notice mailed on that same date. The instructions also state that when direct phone contact cannot be made, the notice should be sent to the representative by certified mail, return receipt requested. 1) Resident #55 was discharged from Medicare skilled services on 07/17/2024 and remained in the facility. The Notice of Medicare Non-Coverage documented that Resident #55's designated representative was called on 07/15/2024 and a voice message was left. The Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage documented Resident #55's designated representative was called on 07/15/2024 and informed that Resident #55's coverage will end on 07/17/2024. There was no documented evidence that the notices were mailed to Resident #55's representative on the same day that telephone notification was made. 2) Resident #36 was discharged from Medicare skilled services on 11/4/2024 and remained in the facility. The Notice of Medicare Non-Coverage and the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage documented Resident #36's designated representative was called on 11/1/2024 and informed that Resident #36's coverage will end on 11/4/2024. There was no documented evidence that the notices were mailed to Resident #36's representative on the same day that telephone notification was made. On 01/08/2025 at 09:09 AM, Minimum Data Set Coordinator was interviewed and stated they had a utilization review meeting every week to discuss the resident discharge from Medicare Part A. Minimum Data Set Coordinator also stated that residents who will be discharged from Medicare Part A services are given at least 48-hour notice and that their right to appeal is explained. Minimum Data Set Coordinator stated that if a resident is cognitively intact, they ask them to sign the Notice of Medicare Non-Coverage and/or the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage. Minimum Data Set Coordinator also stated that if a resident is cognitively impaired to make decisions, they notify the resident's designated representative by phone call and did not mail them the notices unless the representatives requested the notices. Minimum Data Set Coordinator further stated they mailed the notices with certified mail receipt on same day if they were not able to reach the impaired resident's representative by phone call. Minimum Data Set Coordinator stated they spoke to the representatives of Resident # 55 and Resident # 36 and the representatives stated they did not want to receive the notices. Minimum Data Set had no proof of the refusal to receive the notices. On 01/08/2025 at 09:32 AM, the Administrator was interviewed and stated the Minimum Data Set Coordinator was responsible for providing Notice of Medicare Non-Coverage and/or the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage notices to residents and/or designated representatives to review and sign before discharging them from Medicare Part A. The Administrator also stated they should mail, email, or use other methods so the representative can receive the forms and keep a proof of it. 10 NYCRR 415.3(g)(2)(i)

Based on interviews and record review conducted during the Recertification/Complaint Survey (NY00343189) from 01/02/2025 to 01/08/2025, the facility did not ensure all alleged violations involving injuries of unknown source were reported immediately, but not later than 2 hours after the allegations were made, to the State Survey Agency. This was evident in 1 (Resident #96) reviewed for Accidents out of 23 total sampled residents. Specifically, the facility did not report that Resident # 96 was found with injuries of an unknown source to the New York State Department of Health within 2 hours. The findings are: The facility policy titled Clinical, Resident Abuse Reporting and Investigation Protocol, Policy and Procedure with effective date January 11, 2010 and last review date 08/01/2024 documented the source of the injury was not observed by any person or the source of the injury could not be explained by the resident, the facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, are reported immediately, but not later than 2 hours after the allegation is made. Resident #96 was admitted to the facility with diagnoses which included History of falling, Difficulty Walking, Hypotension, and Generalized Muscle Weakness. The Admission Minimum Data Set 3.0 assessment dated [DATE] documented Resident #96 has moderately impaired cognition and supervision with ambulating. The Nursing Progress note dated 5/23/2024 at 03:31AM documented Resident #96 was assessed to have swelling to left side of face by supraorbital region and scant blood on tip of nose. Resident #96 reported pain 8/10 to left arm with limited movement noted to extremity. The Nursing Progress note dated 5/23/2024 at 02:55 AM documented Resident #96 was found lying on the floor laterally to left side by doorway to room [ROOM NUMBER] with mild swelling to left side of their head with swelling and discoloration to the left supraorbital area, noted with scant bleed from nose, left forehead and supraorbital swelling, inability to move left arm and complaint of pain 6/10. Physician was notified and ordered for Resident #96 be transferred to the hospital for further evaluation. The Medical note dated 5/30/2024 documented Re-Admission Note for Resident #96 for status post fall, closed displaced fracture of proximal end of left humerus. The Accident /Incident Occurrence Report/Investigation form documented the occurrence happened at 11:30 PM on 05/22/2024. The Webform submission from Nursing Home Facility Incident Report emailed to the Administrator documented the incident was submitted to New York State Department of Health at 23:39 on 05/23/2024. During an interview on 1/6/2024 at 03:21 PM, Registered Nurse #5 stated was the nurse on the unit at the time of the incident. Registered Nurse #5 stated was informed by Certified Nurse Assistant #9, Resident #96 is lying on the floor. Upon arrival, observed Resident #96 lying on the floor in the hallway in front of their room. Registered Nurse #5 stated they called for the nurse manager to come to the unit. Resident #96 was assessed with head swelling and left arm with limited movement. The Medical Doctor was called and ordered for Resident #96 be transferred to the hospital. No one witnessed the incident or how Resident #96 came to be lying on the floor. Their roommate at the time was confused and unable to tell what had happened. The bathroom floor was observed to be wet, but when assessing Resident #96, their clothes and socks were dry. Prior to the fall, Resident #96 was on fall precautions such as low bed position and call bell. No known falls since their admission to the facility. No behaviors such as getting up in the middle of the night. Resident #96 was independent with their toileting prior to the incident. Resident #96 is known for sleeping through the night. During an interview on 1/6/2024 at 03:26 PM, Certified Nurse Assistant #9 stated they started their shift on 5/22/2024 around 11:10 PM and saw Resident #96 asleep in their bed. They then went down the hallway to prepare their linen cart for the night shift and when coming down the hall, noticed Resident #96 lying on the floor in the hallway by their room door. Certified Nurse Assistant #9 stated they called for the nurse who came to look at Resident #96 and was taken to the hospital. Certified Nurse Assistant #9 stated that Resident #96 was not able to tell what happened after giving more than one story of what had happened. No one saw how Resident #96 got on the floor. The roommate at the time was unable to tell what happened. Resident #96 did complain of left-hand pain. The bed is always in the low position. The call bell was in her reach, but it was not activated. During an interview on 01/07/25 at 02:36 PM, Minimum Data Set Coordinator stated they were called to file the complaint with the Department of Health. Since they don't have their laptop, the Minimum Data Set Coordinator, who typically completes report submission, is unable to recall what they submitted and when they sent the summary. Additionally, it was mentioned that any occurrence should be reported to the Department of Health within two hours of becoming aware of it. During an interview on 01/06/25 at 10:51 AM, Director of Nursing stated that it was reported that Resident #96 might have gone to use the bathroom and noticed water from the toilet on the floor and went to go to alert the staff and in the process fell and was found by their doorway entrance on the 2nd floor. The incident was unwitnessed. Director of Nursing was interviewed on 01/08/25 at 2:20 PM and stated the process for reporting incidents to the Department of Health is that the Director of Nursing Services will contact the Director of Nursing, who will collect and forward the allegation information to the Department of Health. If it is unwitnessed with injury, falls with major injury are not reportable. After the facility received a report from the hospital that Resident #96 sustained a fracture, the team decided to be safe and report the incident to the Department of Health. On 01/08/2025 at 02:19 PM, the facility Administrator was interviewed and stated, the Director of Nursing obtains the information and/or the supervisor and reports the information to the Department of Health. If it is an abuse case, it gets reported within 2 hours. Falls with injury are reported within 24 hours of the fall. As per the Administrator stated he needs more clarity on the reporting to the Department of Health. Resident #96 was not known to have an injury until the report came back from the hospital that Resident #96 had an injury, and it was then reported to the Department of Health. Stated needs more clarity on reporting of the incidents because not all incidents get reported. The Registered Nurse Supervisor on duty at the time of the incident is no longer employed at the facility and could not be reached for interview. 10 NYCRR 415.4(b)(2)

Based on observations, record reviews, and interviews during a Recertification Survey from 1/02/2025 to 1/08/2025, the facility did not ensure that assessments accurately reflected the residents' status. This was evident for 2 (Resident #36 and Resident #6) out of 23 total sampled residents. Specifically, 1) The Minimum Data Set 3.0 assessment did not document Resident #36's use of a Wanderguard and 2) The Minimum Data Set 3.0 assessment inaccurately documented Resident #6 as having clear speech, with ability to make self-understood. The findings are: The facility policy titled, Minimum Data Set Assessment Completion, last reviewed/revised 9/2023 documented, the interdisciplinary team will conduct comprehensive assessments as part of an ongoing process to identify each resident's preferences and goals of care, functional and health status, strengths, and needs, as well as offering guidance for further assessment once problems have been identified. 1) Resident #36 had diagnoses of Non-Alzheimer's Dementia, Schizophrenia, and Seizure Disorder. The Annual Minimum Data Set assessment dated [DATE] documented Resident #36 had severely impaired cognition and did not use a Wander/elopement alarm. On 1/02/2025 at 3:05 PM, 1/03/2025 at 9:39 AM, and 1/07/2025 at 10:59 AM, Resident #36 was observed with a Wanderguard to their right ankle. The Comprehensive Care Plan related to wandering and elopement initiated 9/20/2024 and last reviewed 12/21/2024, documented Resident #36 had a Wander Alert Bracelet to their right ankle. An Admission Nursing Note dated 9/21/2024 documented Wanderguard on Resident #36's right ankle per history of wandering behavior. The Physician Orders dated 9/21/2024 documented check Resident #36's Wanderguard placement/function every shift. 43350 2) Resident #6 was admitted to the facility on [DATE] with diagnoses including Aphasia and Dysphagia Following Cerebral Infarction. A Communication Care Plan was initiated for the resident on 09/02/2024 due to impaired ability to make self-understood secondary to slurred speech and was last reviewed 11/29/2024. However, the Minimum Data Set booklet dated 09/04/2024 documented the resident as having clear speech with ability to make self-understood. The Minimum Data Set booklet dated 11/29/2024 did the same. On 01/03/2025 at 10:58 AM, Resident #6 was observed seated in a wheelchair at the unit nursing station attempting to communicate with a staff member by rubbing their chin and shrugging their shoulders, then pointing to a passing aide. The staff member told the resident that they did not understand what the resident was trying to say, and the resident appeared frustrated, finally conveying through gestures only that they felt they had been shaved sloppily and would like an aide to go over their unshaven spots. On 01/07/2024 at 10:42 AM, Registered Nurse Supervisor #1 was interviewed and stated that Resident #6 had an unsuccessful trial of speech therapy following their admission but remained essentially nonverbal, able to grunt or scream but not to articulate words. The resident is cognitively intact and was subsequently provided with a communication board but refused to use it. They prefer to use gestures to convey their ideas, and most staff members have become adept at figuring out what their gestures mean. Those who aren't able call upon other staff until the resident's meaning becomes clear. On 01/07/2025 at 11:15 AM, the MDS Coordinator was interviewed and stated that Resident #6 and Resident #36's Minimum Data Set booklets were completed by the MDS Assessor, a Registered Nurse who was currently out on medical leave. The Coordinator stated that the nurse followed the progress notes, physician orders and care plans to fill out the booklets as well as meeting with the residents themselves. In the case of Residents #6 and #36, the Coordinator stated that they did not know how the nurse came to document their booklets so incorrectly as they are responsible for their accuracy but that the nurse is currently not available to discuss their line of thought. On 01/07/2025 at 1:54 PM, the Director of Nursing was interviewed and stated that the Nursing Department collaborates with the MDS Department in ensuring the accuracy of the information documented in the Minimum Data Set booklets. The MDS Coordinator directly oversees the MDS Assessor. 10 NYCRR 415.11(b)

Based on record review and interview conducted during the Recertification Survey from 1/2/2025 to 1/8/2025, the facility did not ensure that the Quality Assurance & Performance Improvement (QAPI) and Quality Assessment & Assurance (QAA) committee consisted at a minimum of the Medical Director, or their designee attended 4 quarterly meetings. Specificially, the Medical Director has not participated in Quality Assurance & Performance Improvement (QAPI) and Quality Assessment & Assurance (QAA) meetings for 2 out of the 4 meetings as required. The findings: The policy and procedure entitled Quality Assurance and Performance Improvement dated 08/15 documented Quality Assurance Performance Improvement shall have a committee consisting of, at a minimum, of Executive Director/Administrator, Director of Nursing, Medical Director, Quality Coordinator/Director, and Compliance Director. Each facility shall meet at least quarterly. Review of the Monthly Meeting Attendance Sheets entitled Quality Assurance and Assessment Committee revealed the Medical Director did not sign the attendance sheet for the following Quality Assurance & Performance Improvement meetings on 1/31/2024, 2/16/2024, 3/27/2024, 4/18/2024, June 20, 2024, 07/25/2024, 08/15/2024, 09/19/2024, 10/18/2024. Clinical Assistant attended the meeting in place of Medical Director on 5/16/2024 and 12/19/2024. There is no documented evidence that the Medical Director attended the Quality Assurance & Performance Improvement meeting via Microsoft teams or in person for 2 out the 4 quarterly meetings. On 01/08/25 at 11:14 AM interview with the Attending Physician stated has been working at the facility since 2020 and has not attended any Quality Assurance & Performance Improvement meetings. On 01/08/25 at 11:51 AM interview with the Medical Director stated they attend the Quality Assurance & Performance Improvement meetings monthly, however, does always attend in person. Gets invited via email and attends via Microsoft teams. If cannot attend the meeting, the Clinical Assistant will stand in their place. The Attending Physician does not attend the Quality Assurance & Performance Improvement meetings. On 01/08/25 at 12:23 PM interview with the Administrator stated that the Quality Assurance & Performance Improvement meetings are held monthly and that the Medical Director gets invited via email. The meetings are also held in person, by telephone and via Microsoft teams. The Clinical Assistant to the Medical Director will attend the meetings if the Medical Director cannot attend. The Attending Physician has not attended the meetings. On 01/10/2025 at 3:00 PM an interview with the Clinical Assistant who stated that their role as a Clinical Assistant is more of an Administrative Role. They input documents into the electronic Medical Record, does not give medications, provide care, or medical assistive care to the Medical Director. The Clinical Assistant stated they attend Quality Assurance & Performance Improvement meetings when the Medical Director cannot attend, which is not that many. The Clinical Assistant stated that they do not attend the Quality Assurance & Performance Improvement meetings as much and is not that familiar with the facility's policies, procedures, and practices. 10 NYCRR 415.15(a)

Based on observations, record review, and interviews conducted during the Recertification Survey from [DATE] to [DATE] the facility did not ensure that food was served in accordance with professional standards for food service safety to prevent foodborne illness and ensure that infection control practices were maintained. Specifically, a Certified Nursing Assistant #4 was observed assisting multiple residents with dining room in preparation for dining did not perform hand hygiene between residents. This was evident for 10 residents (of 23 total sampled residents for dining Resident # 7, #18, #19, #38, #39, #49, #52, #70, #72 and #87). (2) the facility did not ensure that disinfecting germicidal wipes, hand sanitizing solution was discarded by the manufacturer discharge date . This was evident for the infection control task. The findings are: The facility policy and procedure titled Uniform Dress Code revised ,d+[DATE] documented facial hair must be kept neatly trimmed, restrain all facial hair with heard net/restraint associates while working with food. The facility policy and procedure titled Hand Hygiene. Handwashing revised on [DATE], documented all personnel will perform hand hygiene appropriately in accordance with current standards of practice and Centers of Disease Control guidelines to prevent he transmission of organisms that cause infections. To reduce the risk of healthcare-associated infection by decreasing the risk of transmission of pathogenic microorganisms to resident and the persons within the health are setting. The facility considers hand hygiene for the prevention of healthcare associated infections. When to employ before and after resident contact, before/after meals of handling food items, after removing gloves. The facility policy and procedure titled Purchasing, Stocking Inventory Control (re-Order Points Procedure was last reviewed /revised [DATE] documented the supply chain manager request that inventory supplies are ordered as they are needed (when reorder point is reached. In addition, The Central Purchasing Office has major input into the inventory control system for establishing reorder points and reorder quantities based on delivery lead times, quantity discount, contract purchases, promotional sales and institutions cash flows. The Central Purchasing in conjunction with the facility Supply Chain Manager is responsible. The policy does not state what specific inventory control measures systems are utilized for the facility purchasing, stocking inventory control. 1. During an observation of dining on the 2nd floor on ,d+[DATE] from 1143 AM-1149 AM, Certified Nursing Assistant # 4 was observed assisting multiple residents in the 2nd floor dining room in preparation for dining. Certified Nursing Assistant # 4 with bare hands assisted Resident # 52 to clean their hands with a hand wipe, gave a hand wipe to Resident # 39, gave hand wipe to Resident # 87 and assisted Resident # 38 to clean their hands. Certified Nursing Assistant #4 with bare hands assisted Resident #49 to clean their hands then gave a hand wipe to Resident # 19 and then assisted Resident # 7 to clean their hands. Certified Nursing Assistant #4 did not perform hand hygiene between residents. Certified Nursing Assistant # 4 then applied a glove on their left hand and cleaned the hands for Resident # 70 and wipe their hands and they gave a hand wipe to Resident #18 with left glove still on their on hand. Certified Nursing Assistant #4 did not perform hand hygiene between residents. Certified Nursing Assistant # 4 with the same glove on their left hand only cleaned Resident # 72 hands, and then cleaned Resident # 49 hands and then assisted Resident #38 to clean their hands. Certified Nursing Assistant #4 did not perform hand hygiene between residents. Certified Nursing Assistant # 4 then proceeded to wash their hands in the handwashing sink in the 2nd floor pantry area. During an interview on [DATE] at 11:50 AM, Certified Nursing Assistant # 4 was interviewed and stated that before and after a meal they clean their hands. They forgot to change gloves and had a new pair and then stated they did not change gloves between residents. Certified Nursing Assistant # 4 stated they needed to wash their hands to prevent cross contamination and for infection control. Further stated they should have sanitized or washed their hands when they take off gloves and put on a new pair. During an interview on [DATE] at 12:30 PM, the Registered Nurse # 2 was interviewed and stated that when they monitor the dining room at lunch time, they observe staff performing hand hygiene. Staff are supposed to clean their hands before assisting residents, before they touch resident's trays, in-between residents, when they feed residents, assisting a resident in finishing a task and sanitize hands between residents for infection control. During an interview on [DATE] at 11:43 AM, the Infection Preventionist was interviewed and stated they do rounds during the day when they come in to work Monday to Friday. They stated that they observe hand hygiene during meals ,d+[DATE] times a week. There were no concerns related to hand hygiene that they identified. Hand hygiene is an infection control practice to prevent cross contamination of food. Further stated they did staff inservice on hand hygiene in the last 3 months. 2. On [DATE] at 11:25 AM, in the medication room on the 2nd floor the hand sanitizer was observed to be expired with an expiration date of ,d+[DATE]. During an observation on [DATE] at 03:58 PM the 3rd floor pantry was observed and in the lower left cabinet facing the nurses station side there was and opened container of disinfecting wipes lot #112923C with expiration date of [DATE]. During an observation on [DATE] at 12:18 PM to 12:23 PM, the central supply room in the basement was observed and the following was found: antimicrobial skin cleanser antiseptic hand sanitizer at doorway by desk with expiration date of ,d+[DATE]. There were 3 sealed boxes with disinfecting wipes on the shelf containing germicidal wipes with 150 count sheets and each box contained 24 containers with lot numbers 112523 and 113023C with expiration date of [DATE]. On [DATE] at 12:18 PM, the Central Supply Representative was interviewed and stated, that the units are provided supplies daily and as needed. They stated that they did not look at the date on the sanitizer and the wipes and as you can see the boxes were still sealed. The wipes that are expired are the old supply and we have new supply on the shelf. On [DATE] at 12:33 PM, the Infection Preventionist was interviewed and stated if expired hand sanitizer or disinfecting wipes supplies are used they won't be as effective. They stated that they have not looked at the sanitizing wipes, disinfecting wipes or hand sanitizer and that central supplies/housekeeping look at these supplies. On [DATE] at 12:06 PM and 1:01PM, the Director of Plant Operations and Maintenance was interviewed and stated, that the housekeeper changes sanitizer dispensers as needed once they are empty. If they need to be replaced such as if the sanitizer dispenser is not working then maintenance takes a look at the dispenser to see if they need to be replaced. The Central supply in the basement gives out germicidal wipes. Further stated that the central supply person is in charge of the supplies, and they look at it and they will check to see if the supplies are expired. 10 NYCRR 415.19(a)(1)(b)(4)

Based on observations, record review, and interviews conducted during the Recertification Survey from 01/02/2025 to 01/08/2025, the facility did not ensure that the last 3 years of facility survey results were posted in a place readily accessible to residents, family members, public, and legal representatives of the residents, where individuals wishing to examine survey results do not have to ask to see them. This was evident for 5 (#15, #49, #96, #29, #42) out of 11 residents attending the Resident Council meeting. Specifically, survey results were posted at the resident courtesy phone located on the left-hand side of the unit, not in plain view. The findings are: The facility policy titled Posting and Availability of Survey Results and Complaint Investigations effective 01/2025 documented the facility is committed to transparency and regulatory compliance by: Posting the results of the most recent survey in a location readily accessible to residents, family members, and legal representatives. Making survey reports, certifications, and complaint investigations from the past three years available upon request. Posting a notice in prominent areas to inform individuals of the availability of these documents. On 01/02/25 at 10:02 AM, The Department of Health Survey results are displayed on the wall adjacent to the security front desk in a blue binder that included the following surveys: 11/2/2023 survey results of Life Safety Code that was done on 9/5/2023. 10/3/2023 survey results of Recertification and Complaint Surveys performed on 08/07/023, 06/28/2023 results of Complaint Survey and 03/27/2023 to 3/29/2023 results of Complaint Survey. On 01/02/2025 and 01/03/202524 between 10:00 AM and 11:00 AM, a sign was posted in a cubby area located near the resident courtesy telephone on the left-hand side coming off the elevator in a non-visible area on Units 2, 3, and 4. Multiple observations were conducted on Units 2, 3, and 4 on 01/02/2025 and 01/03/2025 and there were no documented evidence that the last 3 years of Recertification Survey results were posted. Observed to be posted was survey results from 11/2/2023 of Life Safety Code, 10/3/2023 survey results of Recertification and Complaints, 06/28/2023 survey results of Complaint Survey and 3/27/2023 to 3/29/2023 Complaint Survey results. There was no evidence that the survey results from the year 2022 was posted. A review of the last 3 months of the Resident Council Meeting Minutes revealed there is no documented evidence that the location or the postings of the survey results were discussed at the Resident Council Meetings. On 1/3/2024 at 10:15 AM, a Resident Council Meeting was held with 11 residents. Resident #15, #49, #96, #29, and #42 stated during the meeting they do not know where they can find the survey results without asking. On 01/08/2025 at 11:50 AM interview with the Administrative Coordinator stated you are right, the last 3 years of the results of the survey should have been posted since 2022. On 01/08/25 at 12:20 PM interview with the Director of Nursing stated the survey results are usually posted on all the units. It is usually 3 years of postings. On 01/08/2025 at 02:19 PM the Administrator was interviewed and stated, the survey results are discussed in the minutes in resident council meetings and on admission as well. There is a sign of the posting of the survey results downstairs and near the courtesy phone. 415.3(1)(c)(1)(v)

Based on observation, record review, and interviews conducted during an Abbreviated Survey (NY00358734), the facility did not ensure the resident was immediately informed, consult with the resident's physician, and notify, consistent with their authority, the resident representative when there was need to alter treatment significantly. This was evident in 1 of 3 residents sampled (Resident #1). Specifically, on 08/07/2024, the Medical Doctor #1 ordered a urine test to rule out Urinary Tract Infection. On 08/11/2024, the positive urine test results were reported to the facility and the Medical Doctor was not informed. On 09/04/2024 at 1:55 PM, the Medical Doctor #2 reviewed the laboratory results and ordered antibiotic treatment for Urinary Tract Infection on 09/05/2024. Resident #1 's family was not notified about the positive urinary results on 08/11/2024 and on 09/05/2024, the family was not notified that antibiotic treatment was ordered,. The findings include: The facility Policy and Procedure entitled Notification of Changes Protocol, Policy, and Procedure, last reviewed/revised on 02/01/2022, documented it is the policy of the facility that changes in the resident's condition or treatment are immediately shared with the resident and/or the resident representative, and reported to the attending physician or delegate. The resident and /or resident representative will be educated about the treatment options and supported to make an informed choice about care preferences when there are multiple care options available. All pertinent information will be made available to the provider by the facility staff. Resident #1 was admitted to the facility on [DATE], with diagnoses that include Type 2 Diabetes Mellitus, Dementia, and Anxiety. The Minimum Data Set (a resident assessment tool) dated 10/21/2024, documented Resident #1 as severely cognitive impaired. A Medical Doctor's note dated 08/07/2024 at 5:12 PM, written by Medical Doctor #1 documented that a urinalysis (urine test) to rule out Urinary Tract Infection was ordered. A Physician Order dated 08/07/2024 at 5:14 PM, documented a Urine routine, Culture, and Sensitivity lab draw for Urinary Tract Infection. The laboratory results dated [DATE], documented that urine was collected on 08/08/2024, and the result showed Escherichia coli greater than 100.000 Colony-Forming Unit/Milliliter Escherichia coli. Specimen was collected on 08/08/2024, reported on 08/11/2024 and Medical Doctor #2 reviewed on 09/04/2024 at 1:55 PM. A review of the nursing progress notes from 08/08/2024 to 9/05/2024, reveals no documented evidence that nursing staff notified the Medical Doctor about urinary laboratory results dated [DATE]. There was no documented evidence that Resident #1's representative was notified about urinary laboratory test results dated 08/11/2024. A Medical Doctor's note dated 09/05/2024 at 3:53 PM, written by Medical Doctor #2 documented Resident #1 was seen due to a Urinary Tract Infection. Urinalysis on 08/08/2024 showed greater than 100.000 Colony-Forming Unit/Milliliter Escherichia coli, sensitive to Nitrofurantoin. The order was placed for Macrobid 100 mg, one tab twice daily for seven days. A Physician Order dated 09/05/2024 documented Nitrofurantoin Monohyd/M -Cyst (Macrobid) 100 miligrams give 100 milligrams twice daily for Urinary Tract Infection. There was no documented evidence that the Medical Doctor notified Resident #1's representative that the Resident #1 was diagnosed with a Urinary Tract Infection and antibiotic treatment had been ordered on 09/05/2024. During an interview on 11/20/2024 at 11:00 AM, the Complainant stated they were told in August a urine test will be ordered to check for Urinary Tract Infection. The Complainant stated the facility did not notify them about the result of the urine test. The Complainant stated they don't know if the urine test was ordered. During a telephone interview on 11/24/2024 at 1:50 PM, Registered Nurse #1, who worked on 08/11/2024 during the 7:00 AM-3:00 PM shift, stated the Unit Manager was responsible for following up with labs and calling the Medical Doctor and the family and taking the orders if any. Registered Nurse #1 stated they were not aware of Resident #1's laboratory results that came on 08/11/2024. During an interview on 11/20/2024 at 2:10 PM, Registered Nurse Unit Manager #3, stated when there are abnormal laboratory test results the medical doctor should be notified immediately by the Registered Nurse or Registered Nurse Manager. Unit Manager #3 stated that when the medical doctor ordered new treatment, the charge nurse or nurse manager was supposed to notify the resident's representative. Unit Manager #3 stated that the Medical Doctor would be the best option to notify the resident's representative, but most of the time, they endorse nurses to inform the family. During an interview on 11/21/2024 at 11:41 AM, Medical Doctor #2 stated Resident #1's representative should have been called about abnormal results and ordered antibiotic treatment. Medical Doctor #2 stated that Medical Doctor #1, who was covering for them in August, did not feel it necessary to address the laboratory test dated 08/11/2024 because the resident was asymptomatic. Medical Doctor #2 stated that they were supposed to inform Resident #1's representative when they reviewed the laboratory result and ordered antibiotic treatment for Urinary Tract Infection on 09/05/2024, but they don't remember if they called, and they did not document it in the resident medical record. During an interview on 11/21/2024 at 10:57 AM, The Director of Nursing stated Medical Doctor #1 was covering on 08/07/2024 and saw Resident #1 for an episode of unresponsiveness on 08/06/2024. The Director of Nursing stated the resident's adult child knew about the episode on 08/06/2024 and that laboratory tests were ordered. The Director of Nursing stated it was not documented that the resident's child was notified that a urine test was ordered. The Director of Nursing stated that charge nurses or medical doctors are supposed to call the family about abnormal laboratory test results and treatment or care plans and document it in the resident medical records. The Director of Nursing stated it was not done after the laboratory reported that the urine test was abnormal on 08/11/2024. The Director of Nursing stated on 09/05/2024, the primary Medical Doctor #2 reviewed the laboratory results of a urine test and started antibiotic treatment because the family insisted, but Medical Doctor #2 did not document the progress note that the family insisted on. The Director of Nursing stated Resident #1' s Representative should have been notified about abnormal urine results on 08/11/2024 and that treatment of antibiotics that was ordered on 09/05/2024. 10 NYCRR 415.3(e) (2) (ii) (b)

Based on record review and interviews conducted during an abbreviated survey (NY00358734), the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan. This was evident in 1 out of 3 residents sampled (Resident #1). Specifically, on 08/07/2024, the Medical Doctor #1 ordered a urine test to rule out Urinary Tract Infection. On 08/11/2024, a positive urine test results were reported to the facility for Escherichia coli (greater than 100.000 Colony-Forming Unit/Milliliter Escherichia coli). On 09/04/2024 at 1:55 PM, Medical Doctor #2 reviewed the urine test results, and ordered antibiotic treatment for Urinary Tract Infection which started on 09/05/2024, this resulted in 26 days delayed in treatment for Urinary Tract Infection. The findings are: The facility's Policy and Procedure entitled Urinary Tract Infection, effective date 03/27/2007, documented the purpose of the policy is to establish clear guidelines and procedures for the prevention, identification, and management of Urinary Tract infections among residents. This document also revealed the physician would order appropriate treatment for verified or suspected Urinary Tract Infections and/or urosepsis based on a pertinent assessment. Resident #1 was admitted to the facility on [DATE] with diagnoses that include Type 2 Diabetes Mellitus, Dementia, and Anxiety. The Minimum Data Set (a resident assessment tool) dated 10/21/2024, documented Resident #1 as severely cognitive impaired. A Medical Doctor's note dated 08/07/2024 at 5:12 PM, written by Medical Doctor #1 documented that a urinalysis (urine test) to rule out Urinary Tract Infection was ordered. A Physician Order dated 08/07/2024 at 5:14 PM documented a Urine routine, Culture, and Sensitivity lab draw for Urinary Tract Infection. A laboratory results dated [DATE], documented that urine was collected on 08/08/2024, and the result showed Escherichia coli greater than 100.000 Colony-Forming Unit/Milliliter Escherichia coli. The urine specimen was collected on 08/08/2024, reported to the facility on [DATE] and Medical Doctor #2 reviewed the results on 09/04/2024 at 1:55 PM. A review of the nursing progress notes from 08/08/2024 to 9/04/2024 reveals no documented evidence that nursing staff followed up with urine test results. There was no documented evidence that the Medical Doctor evaluated Resident #1 after the laboratory sent urine test results on 08/11/2024. A Physician Order dated 09/05/2024, documented Macrobid (antibiotic) 100 milligram give twice daily for Urinary Tract Infection. A Medical Doctor's note dated 09/05/2024 at 3:53 PM, written by Medical Doctor #2 documented Resident #1 was seen due to a Urinary Tract Infection. Urinalysis on 08/08/2024 showed greater than 100.000 Colony-Forming Unit/Milliliter Escherichia coli, sensitive to Nitrofurantoin. The order was placed for Macrobid 100 milligram, one tab twice daily for seven days. A Care Plan for Antibiotic Treatment dated 09/06/2024, related to Urinary Tract Infection as evidenced by Escherichia coli, resolved on 11/05/2024. Interventions included monitoring vital signs and administering antibiotic therapy as ordered. During an interview on 11/20/2024 at 11:00 AM, the Complainant stated they were told in August a urine test to check for Urinary Tract Infection will be done. The Complainant stated the facility did not notify them about the result of the urine test. The Complainant stated they don't know if the urine test was ordered. During a telephone interview on 11/24/2024 at 1:50 PM, Registered Nurse #1, who worked on 08/11/2024, stated the Unit Manager was responsible for following up with labs and calling the Medical Doctor and family and taking the orders if any. Registered Nurse #1 stated they were not aware of Resident #1's urine test results that came on 08/11/2024. During an interview on 11/21/2024 at 10:16 AM, Registered Nurse Unit Manager #1 stated when laboratory results were ready, the laboratory would send results to the computerized resident Electronic Medical Record, and the charge nurse was supposed to check and follow up with the result and notify the Medical Doctor immediately. The Registered Nurse Manager #1 also stated sometimes, the laboratory would call if the result were positive or critical. The Registered Nurse Manager #1 stated they were not aware of the urinalysis result on 08/11/2024. During a telephone interview on 12/10/2024 at 11:46 PM, Registered Nurse Unit Manager #2, who worked on the 08/11/2024, stated the laboratory would normally call them if there were abnormal labs. Registered Nurse Unit Manager #2 stated they did not receive a call from the laboratory and did not look at the computer. Registered Nurse Unit Manager #2 stated that both Registered Charge Nurses and Registered Nurse Unit Managers are responsible for checking the computer to see if there are results and to following up. Registered Nurse Unit Manager #2 stated they were supposed to check the labs on the computer, call the Medical Doctor, and notify the family about the laboratory results and what the Medical Doctor ordered. Registered Nurse Unit Manager #2 stated they and all nurses were in-serviced to follow-up with the labs. During an interview on 11/21/2024 at 11:41 AM, Medical Doctor #2 stated on 08/07/2024, Medical Doctor #1 was covering and evaluated Resident #1 for an episode of unresponsiveness on 08/06/2024. Medical Doctor #2 stated that Medical Doctor #1 ordered intravenous fluids, blood work, and a urinary analysis to rule out urinary tract infections. Medical Doctor #2 stated they were on vacation from 08/07/2024 to 08/23/2024 and saw laboratory results on 09/05/2024 were not addressed. Medical Doctor #2 stated they reviewed the laboratory results, and it qualified for antibiotic treatment. Medical Doctor #2 stated that the facility procedure is if the Medical Doctor orders the labs when the result comes, the nurses on the floor should notify the doctor of the result, and the doctor will give the appropriate order. Medical Doctor #2 stated it was not done until 09/05/2024. Medical Doctor #2 stated that they rely on the nurses to call with the results of the laboratory results for a fast response. Medical Doctor #2 stated that every Medical Doctor could check laboratory results on the computer, but the results are not always immediately posted. During an interview on 11/21/2024 at 10:57 AM, the Director of Nursing stated that when the laboratory results are ready, the medical doctors can see them online right away. The Director of Nursing stated that the charge nurse or manager on duty can also receive the result, call the doctor, and anticipate orders, if any. The Director of Nursing stated they didn't know why the charge nurse did not call the doctor about the result of positive Urine Tract Infection urine laboratory results on 08/11/2023. The Director of Nursing stated Medical Doctor #1 was covering on 08/07/2204 and saw Resident #1 for an episode of unresponsiveness on 08/06/2024. The Director of Nursing stated the laboratory results should be reviewed by Medical Doctor #1 as soon as possible. On 09/05/2024, primary Medical Doctor #2 reviewed laboratory results and started antibiotic treatment because the family insisted, but Medical Doctor #2 did not document the progress note that the family insisted on. 10 NYCRR 415.12

Based on observation, record review, and interviews conducted during the recertification survey from 8/1/2023 to 8/7/2023, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This was evident during observation of the kitchen. Specifically, cold sandwiches were not maintained at the proper temperature of 41 degrees Fahrenheit (F) or below. The findings are: The facility policy titled Food Handling Guidelines dated 2/2023 documented food is handled in accordance with regulatory guidelines. Proper handling procedures and techniques are visually monitored on an ongoing basis. During an observation of the kitchen on 8/2/2023 at 11:38 AM, the Food Service Director (FSD) was observed calibrating a thermometer in the kitchen to test food items on the tray line. The FSD removed two ham/cheese sandwiches and one tuna salad sandwich from the cold prep refrigerator. Temperature checks of the cold food items revealed that 1) ham/cheese sandwich measured 54.8 degrees F, 2) tuna salad sandwich measured 41.9 degrees F, and 3) second ham/cheese sandwich measured 57.3 degrees F. On 8/7/2023 at 9:31 AM, the FSD was interviewed and stated the temperature of the ham and cheese and tuna sandwiches were above the acceptable range because the sandwiches were just made and put away in the refrigerator. Salads, meats, and cheeses are kept on ice while sandwiches are being made. Cold sandwiches should be held at 40 degrees F or below. The FSD also consulted with a technician to see if there is a temperature problem with the kitchen refrigerator. 415.14(h)

Based on observation, record review, and interviews conducted during the Recertification survey from 08/01/2023 to 08/07/2023, the facility did not ensure that person-centered comprehensive care plans (CCP) were developed to address the residents' medical, physical, mental, and psychosocial needs. This was evident for 3 (Resident # 40, # 98, and # 91) out of 5 residents reviewed for Unnecessary Medications out of 27 total sampled residents. Specifically, 1) a CCP related to anticoagulant (AC) therapy was not developed for Resident #40, 2) a CCP related to AC therapy was not developed for Resident #98, and 3) a CCP related to AC therapy was not developed for Resident #91. The findings are: The facility policy titled CCP dated 6/23/2020 documented the CCP will be initiated by the interdisciplinary team (IDT) members on admission, quarterly, readmission, significant change, or any change in resident's plan of care. 1) Resident #40 had diagnoses of chronic atrial fibrillation and congestive heart failure. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #40 was moderately cognitively impaired and received AC medication daily. The Physician Order dated 9/16/2022 documented Resident #40 received Rivaroxaban (Xarelto) 20mg daily. The Medication Administration Record (MAR) for July 2023 documented Resident #40 received Xarelto 20mg daily according to Physician Order. There was no documented evidence a CCP related to AC medication use was developed for Resident #40. 2) Resident #98 had diagnoses of cerebral infarction and diabetes mellitus. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #98 was cognitively impaired and received AC medication daily. The Physician Order dated 6/29/2023 documented Resident #98 received Heparin Sodium 5000/ML injection 5000 unit (1 mL) subcutaneously twice daily. The Medication Administration Record (MAR) for July 2023 documented Resident #98 received Heparin injections twice daily according to Physician Order. There was no documented evidence a CCP related to AC therapy was developed for Resident #98. On 08/03/2023 at 02:45 PM, Registered Nurse (RN) #3, also the nurse manager of day shift, was interviewed and stated they were responsible for creating, reviewing, and updating resident CCPs. Resident diagnoses, medications, and change of condition were used for CCP creation and update. CCPs were created and updated after each MDS assessment and as needed. A resident receiving AC therapy should have a CCP related to AC therapy in place. RN #3 reviewed the medical record of Resident #40 and #98 and stated they did not have a CCP related to AC therapy in place. RN #3 stated they must have overlooked Resident #40 and #98 and inadvertently did not create their CCPs. On 08/04/2023 at 10:42 AM, the Director of Nursing (DON) was interviewed and stated the nurse managers were responsible for creating, reviewing, and updating the CCPs after the initial and quarterly CCP meeting and as needed. Residents #40 and #98 had CCPs related to AC therapy in place but the CCPs were resolved and discharged from their medical record in error. A CCP related to AC therapy should be in place for any resident receiving AC medication. The DON was not able to explain the reason Residents #40 and #98 did not have CCPs related to AC therapy in place. 45351 3) Resident #91 had diagnoses of peripheral vascular disease and hypertension. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #91 received AC medication daily. The Physician's Order initiated 5/31/2023 documented Resident #91 receive Xarelto 2.5 mg daily. The Medication Administration Record (MAR) for July 2023 documented Resident #91 received Xarelto daily according to Physician Order. There was no documented evidence a CCP related to AC therapy was developed for Resident #91. On 8/7/2023 at 11:51 AM, the Assistant Director of Nursing (ADON) was interviewed, and stated Resident #91 is receiving AC medication and does not have a CCP related to AC therapy in place. The ADON stated Resident #91 should have a CCP developed for AC therapy. 415.11(c)(1)

Based on observations, record review, and interviews conducted during the Recertification survey from 08/01/2023 to 08/07/2023, the facility did not ensure infection control practices and procedures were maintained. This was evident for 3 (Resident #100, #103, and #42) of 27 total sampled residents. Specifically, Registered Nurse (RN) #1 was observed using the same Blood Pressure (BP) cuff with Resident #100, #103, and #42 without cleaning and disinfecting the BP cuff in between each resident. The findings are: The facility's policy titled Disinfection of Reusable Medical Equipment dated 3/2020 documented the BP cuff will be sanitized after each use. Staff members will wash hands, wipe down the equipment with micro kill wipes, and let air dry. On 08/04/2023 at 09:16 AM, RN #1 was observed in Resident #100's room with the BP machine. RN #1 did not sanitize the BP cuff prior to placing the BP cuff on Resident #100's right arm. RN#1 finished taking Resident #100's BP and rolled the BP machine into the hallway next to the medication cart. RN #1 did not sanitize the BP cuff or machine and rolled the BP machine into Resident #42's room, applied the BP cuff to the resident's arm, finished taking the residents BP, and rolled the BP machine out of Resident #42's room without sanitizing the BP cuff or machine. RN #1 rolled the BP machine into Resident #103's room and placed the BP cuff on Resident #103's right arm without sanitizing the BP cuff or machine. On 08/04/2023 at 10:23 AM, an interview was conducted with RN#1 who stated they were taught to clean the BP machine and cuff after each resident use to promote infection control. RN #1 stated they did not sanitize the BP cuff in between resident use with Resident #100, #42, and #103. On 08/04/2023 at 04:16 PM, an interview was conducted with the Assistant Director of Nursing (ADON) who stated RN#1 was given general training and competencies regarding proper sanitizing practices for BP cuffs. On 08/07/2023 at 02:39 PM, the Director of Nursing Services (DNS) was interviewed and stated the nurses are aware, and in-services were given that BP cuffs and machines be sanitized before use. The nurses know they need to wipe and clean the cuffs with bactericidal wipes. 415.19 (b)(4)

Based on observations, record reviews, and interviews during a Recertification survey, the facility did not ensure that assessments accurately reflected the residents' status. This was evident for 2 (Resident #39 and #64) 38 total sampled residents. Specifically, The Minimum Data Set 3.0 (MDS) assessment did not document Resident #39 and Resident #64's use of Wander Alert Device (WAD). The findings are: 1) Resident #39 had diagnoses of schizophrenia and End Stage Renal Disease (ESRD). The MDS assessment dated [DATE] documented Resident #39 had moderately impaired cognition and did not use a WAD. On 08/01/2023 at 12:42 PM, Resident # 39 was observed in the hallway with a WAD on their left ankle. The Comprehensive Care Plan (CCP) related to wandering and elopement initiated 10/5/2020 and last revised 4/1/2021, documented Resident #39 had a WAD to the left ankle. The Elopement assessment dated [DATE] documented Resident #39 was at high risk for elopement and had a WAD in place. The physician order's dated 06/06/2023 documented check Resident #39's WAD every shift. 2) Resident # 64 had diagnoses of dementia and depression. The MDS assessment dated [DATE] documented Resident #64 was cognitively impaired and did not have a WAD in place. On 08/02/2023 at 10:39 AM, Resident #64 was observed with a WAD to their left ankle. The Comprehensive Care Plan related to wandering and elopement initiated 10/5/2020 and last revised 4/1/2021 documented Resident #64 had a WAD to their left ankle. The physician order's dated 03/02/2021 documented Resident #64 have their WAD checked every shift. On 08/07/23 at 12:01 PM, the MDS Coordinator was interviewed, and they could not explain the reason the WAD was not captured on the MDS assessments for Resident #39 and Resident #64. The MDS Assessor who completed the MDS no longer works at the facility. The MDS Assessor is responsible for assessing the residents and completing the MDS. 415.11 (b)

Based on record review and interviews conducted during a Recertification survey from 8/1/2023 to 8/7/2023, the facility did not ensure that the resident and/or their representative were provided with a written summary of the baseline care plan (BCP). This was evident for 1 (Resident # 219) 27 total sampled residents. Specifically, there is no documented evidence Resident #219, and their representative were provided with a copy of the resident's BCP within 48 hours of the admission to the facility. The findings are: The facility policy titled BCP dated 12/03/2018 documented the resident and the representative, if applicable, is provided with a written summary of the BCP from the Minimum Data Set (MDS) or Social Worker (SW). Resident # 219 was admitted [DATE] with diagnoses of unspecified cord compression and muscle weakness. The MDS assessment dated [DATE] documented Resident # 219 was cognitively intact, and Resident # 219 and their representative participated in the assessment. On 08/01/2023 at 10:55 AM, Resident #219's representative was interviewed and stated they did not recall the facility providing them with a written copy of Resident #219's BCP. The BCP created on 7/13/2023 and completed on 7/15/2023 did not document a signature of Resident #219 or their representative acknowledging receipt of the BCP. There was no documented evidence Resident #219, or their representative was provided with a copy of the BCP within 48 hours of admission to the facility. On 08/03/2023 at 02:48 PM, Registered Nurse (RN) #3, also the nurse manager for day shift, was interviewed and stated the nurse manager on duty during the resident's admission created the BCP assessment. The other disciplines complete their respective sections in the BCP within 48 hours of the resident admission to the facility. RN #3 stated the SW was responsible for providing a copy of the BCP to the resident and/or their representative. RN #3 did not know if the SW documented this in the medical record. On 08/03/2023 at 03:37 PM, the SW was interviewed and stated the interdisciplinary team (IDT) meets with the resident and/or their designated representative on the 1st or 2nd day of admission to complete the BCP assessment. The SW is responsible for providing a copy of the BCP to the resident and/or designated representative and documenting this in the medical record as a proof it was provided. The SW reviewed Resident # 219's medical record and stated they were unable to find documented evidence a copy of the BCP was provided to Resident # 219 and/or their designated representative. The SW stated they were unable to provide a reason it was not documented in Resident # 219's medical record that the resident and their representative received a copy of the BCP. On 08/04/2023 at 09:52 AM, the Director of Social Services (DSS) was interviewed and stated the SW is responsible for providing a copy of the BCP to residents and their representatives. The DSS stated the SW Department did not document it in the medical record as evidence that the BCP was provided to the resident and/or their designated representative. The DSS stated they believed a copy of BCP was provided to Resident # 219 and/or their representative because the representative visited Resident # 219 every day in the facility. On 08/04/2023 at 10:34 AM, the Administrator was interviewed and stated the SW was responsible for providing the BCP to newly admitted residents and/or their representative. The MDS Coordinator previously facilitated the process but not for the past several months. The former MDS Coordinator left the facility about 4 months ago and the new MDS Coordinator was not familiar with the BCP process yet. The SW must document in the resident's medical record when the BCP is provided to the resident and/or their representative. 415.11 (c)

Based on observation, staff interviews, and record review conducted during an abbreviated survey (Case # NY00311094), the facility failed to notify a resident representative that the resident was being given an increased dose of a medication. This was evident in 1 out of 4 residents sampled (Resident #1). Specifically, on 09/08/2022, Resident #1's Health Care Proxy (HCP) was notified, by Licensed Practical Nurse (LPN) #1, that the Psychiatrist recommended that Paxil (Paroxetine HCL, for Depression) be increased from 10 Milligram (mg) to 20mg, and the HCP stated that they did not want the Paxil to be changed. The facility ordered and administered Paxil 20mg daily by mouth from 09/09/2022 to 09/26/2022 without notifying the HCP. The HCP became aware that Resident #1 was receiving Paxil 20mg during a Care Plan Meeting on 09/27/2022. The findings are: The facility Policy and Procedure titled Clinical, NOTIFICATION OF CHANGES Protocol, Policy, and Procedure (All Nursing Homes) which was last reviewed on 02/01/2022, states that changes in resident's condition or treatment are immediately shared with the resident or resident representative and reported to the attending physician/delegate. The resident or resident representative will be educated about treatment options and supported to make an informed choice about care preferences when there are multiple care options available. Notification is provided to the physician to facilitate continuity of care and obtain input from the physician about changes, additions to or discontinuation of treatments. Notification is provided to residents and /or the resident representative(s) to promote the resident's right to make choices about care and treatment and to keep them informed of the resident's current health status. The facility Policy and Procedure titled Health Care Proxy last revised on 04/2022, states Health Care Proxy Law, Article 29-C of the New York Public Health Law, enables competent adults to protect their health care wishes by appointing someone they trust - a health care agent - to decide about treatment on their behalf when they are unable to decide for themselves. Resident #1 was admitted to the facility with diagnoses including Essential Hypertension, Congestive Heart Failure (CHF), and Unspecified Atrial Fibrillation. Review of the Minimum Data Set (MDS, a resident assessment tool) dated 06/18/2022, documented that Resident #1 was severely impaired. A Psychiatry Consult dated 09/07/2022, documented that Resident #1 has disruptive behavior, has been screaming, confused, and not physically aggressive. The Resident was started on Paxil due to anxiety and irritability. The Resident had been calmer but continues with screaming, cursing, and making allegations. The plan was to consider increasing Paxil to 20mg at night to target irritability and anxiety. A Medical Note dated 09/08/2022 at 3:32pm, documented that Resident #1 was seen by the Psychiatrist on 09/07/2022 and that they agreed with the plan to consider increasing Paxil to 20 mg at night to target the Resident's anxiety and irritability. A Nursing Note, by LPN #1, dated 09/08/2022 at 5:03pm, documented that Resident #1's HCP was notified that Resident #1's Paxil was increased to 20 mg. It is documented that the HCP said to not change the order and that they would get back to the facility. A Pharmacy Order, by MD, dated 09/09/2022 documented Paxil 20 mg, give 20mg (1 tablet) by mouth daily at 9:00pm. A MAR dated from 09/09/2022 to 09/26/2022, documented that Resident #1 received Paxil 20mg. Paxil was not administered on 09/14/2022 and 09/16/2022 because Resident #1 refused the medications. A Nursing Note, by LPN #2, dated 09/27/2022 at 1:24pm, documented that Resident #1 was observed to be on Paxil 20mg by mouth that was recommended by the Psychiatrist. The Paxil was not approved by the HCP. The Assistant Director of Nursing (ADON) spoke with the HCP regarding the issue and Paxil was decreased back to 10mg. A Pharmacy Order dated 09/27/2022, documented that Paxil 20mg was discontinued effective 09/27/2022. During an interview on 03/24/2023 at 11:16 am, Resident #1's HCP stated that the facility increased Resident #1's Paxil from 10 mg to 20 mg without family's consent. The HCP stated that they received a call from a nurse stating that Resident #1 was seen by psychiatry on 09/07/2022 and that the Psychiatrist recommended to increase the Paxil dose. The HCP stated that they informed the nurse to hold off on increasing Paxil to 20 mg. The HCP stated that they became aware that Resident #1 was receiving the increased Paxil during the care plan meeting (09/27/2022). During an interview on 03/24/2023 at 2:24pm, the MD stated that Resident #1 has behavior issues and was seen by the Psychiatrist for evaluation. The MD stated that they reviewed the psychiatry consult report and the Psychiatrist recommended to increase Paxil to 20 mg and they agreed and ordered the increase. The MD stated that they did not discuss the medication dosage change with the family member and that they were not aware that the HCP did not want to increase the Paxil dosage. The MD stated that they cannot recall the nurse informing them that the family declined the dosage increase. The MD stated that they discontinued Paxil 20 mg as soon as they became aware that the family member did not agree with the dose increase. During an interview on 04/03/2023 at 4:58 pm, the DON (Director of Nursing) stated that they read the note that Resident #1's Paxil dose was increased without permission from Resident #1's next of kin and knew that it was an issue. The DON explained that when the psychiatry consult has a recommendation, the nursing staff reviews the recommendation with the MD. The DON further stated that the nurse will obtain an order from the MD but will notify the family before the order is processed. The DON stated that if a family member declines, the nurse notifies the MD about the family's decision. The DON stated that they are not sure of what happened in Resident #1's case. During an interview on 04/04/2023 at 1:43 pm, the Administrator stated that the facility's policy is to notify the resident or their representative of any changes in treatment or medication before proceeding. 10 NYCRR: 415.3 (f)(2)(ii) (c)

Based on observation, record review, and staff interviews conducted during an abbreviated survey on [DATE] through [DATE], the facility failed to ensure personnel provided basic life support, including Cardiopulmonary Resuscitation (CPR), to a resident. The resident was a DNR such emergency care prior to the arrival of emergency medical personnel. The facility failed to perform Cardiopulmonary Resuscitation (CPR) in a timely manner to a resident they thought was full code. This was evident for 1 out of 10 residents sampled for DNR. Specifically, Resident #1 was found unresponsive and not breathing at 5:35am. From 5:35am to 6:00am, facility staff only administered two chest compressions to Resident #1. The facility staff did not call 225 to announced Code 99 to alert other staff at the facility of the code. The facility assumed that Resident #1 was Full Code and did not check his medical record until after EMS arrived at 6:00am and started CPR. This resulted in Immediate Jeopardy and Substandard Quality of Care with the likelihood for serious, injury, serious harm, serious impairment, or death to all Full Code residents. The findings are: The facility's Policy and Procedure on Cardiopulmonary Resuscitation with effective date [DATE], states that if the resident has expressed his/her wishes and does not wish to be resuscitated, then there will be a Do Not Resuscitate (DNR) order in their chart. Do not institute CPR on any resident with a DNR order in their chart. The color PURPLE designates a DNR order. All residents who have a DNR order have a PURPLE dot on their ID band and on the name plate outside of their door. Termination of CPR: Once CPR is initiated by a CFR (Certified First Responder), EMT or Advanced Emergency Medical Technicians (AEMT) it must be continued until one of the following occurs: effective spontaneous circulation has been restored, resuscitative efforts have been transferred to another appropriately trained individual who continues CPR and other basic life support measures, a physician assumes the responsibility for emergency care, a valid non-hospital DNR form is present, or the CFR, EMT or AEMT is exhausted and physically unable to continue resuscitation. Responsibilities: any staff member certified in CPR may initiate CPR. Any staff member at any level, in any department, may call a Code 99. Any staff member certified in CPR may function as a first responder. Responsibility of staff present: determine unresponsiveness. Resident has no pulse, not breathing, gasping, no blood pressure; dial security (extension 4225) to announce, Define Code 99. First CPR certified Responder should check for signs of circulation, open airway, instruct staff member to call 911, begin CPR, if necessary and continue until EMS arrives or Medical Doctor (M.D.) orders to stop the code. Resident #1 was initially admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A 5-Day Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #1 had a Brief Interview for Mental Status (BIMS), (used to determined attention, orientation and) score of ,d+[DATE], indicating moderately impaired cognition. A printout of the Life Vest strips report dated [DATE] revealed that Resident #1 was in Asystole (heart stopped beating, [CONDITION(S)]) on [DATE] at 5:30:19 AM. The length of time Resident #1's heart stopped beating was documented as 119 seconds. At 5:37:06AM, 119 seconds, the strips showed that the resident flatlined. A Nursing Progress Note, by Registered Nurse Supervisor (RNS #1), dated [DATE] documented that RNS #1 received a call from the unit charge nurse, RN #1, at 5:40AM stating that Resident #1 was unresponsive. RNS arrived on the unit and observed Resident #1 in bed with Life Vest in place. Resident #1 had no palpable pulse, respiration, and blood pressure. CPR was initiated and 911 called. Right saline lock inserted without any difficulty. EMS (emergency medical services) arrived, AED (automated -external -defibrillator) applied and resuscitative measures were stopped after discovery of the resident's DNR order. Resident #1 was pronounced dead at 6:10AM by EMS personnel. During an interview on [DATE] at 5:00PM, the Director of Nursing (DON) stated when Resident #1 was found unresponsive, and staff was unable ascertain resident's code status due to the missing ID band and purple dot under the resident's name plate. The DON stated the nurse should have checked the Electronic Medical Record for the order and the resident's physical chart for the MOLST. During an interview on [DATE] and [DATE], with RN #1, who found Resident #1 unresponsive, stated that he/she was not aware that Resident #1 had a DNR order as the resident was not wearing a name band and there was no purple dot next to the resident's name outside the door. RN #1 stated that he/she worked the night shift (11pm-7am) and received Resident #1 in the wheelchair on oxygen at 2L. Resident #1 was wearing a Life Vest. RN #1 stated at 5:35AM Resident #1 was observed with his/her head bent, Life Vest beeping and unresponsive in the wheelchair. RN #1 stated that upon discovering Resident #1 unresponsive, he/she asked a Certified Nursing Assistant (CNA) #1 to assist him/her to transfer the resident to their bed. RN #1 stated that he/she assessed Resident #1 and checked the Blood Pressure (BP), carotid and radial pulses, and the resident had no pulse and no BP. RN #1 stated that RNS #1 was called at 5:40AM and arrived quickly and assessed Resident #1. There was no BP or pulse. RN #1 reported that the RNS #1 looked at Resident #1's name on the door and there was no purple dot. RN #1 stated that the RNS #1 notified him/her that Resident #1 was full code and asked him/her to check Resident #1's blood glucose. RN #1 stated that RNS #1 also instructed him/her to get the emergency box to start intravenous fluid and to bring the crash cart. RN #1 stated that he/she brought the emergency box to RNS #1 and RNS #1 instructed them to call 911. RN #1 stated that EMS staff arrived fast and took over the resuscitation and placed an Automated External Defibrillator (AED) pad on Resident #1's chest. The AED kept saying analyzing, analyzing. RN #1 stated that EMS instructed them (staff) to step outside of the room. RN #1 stated that the AED did not shock Resident #1. RN #1 stated that he/she went to the computer to prepare for Resident #1 to be transferred to the hospital and when he/she retrieved the resident's medical record, he/she realized that Resident #1 had a DNR order. RN #1 stated that he/she went back to Resident #1's room and informed EMS that Resident #1 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #1 stated that he/she did not attempt to do chest compressions on Resident #1 because he/she was not sure of the resident's code status. RN #1 stated that he/she just kept assessing Resident #1 from head-to-toe until RNS #1 arrived on the unit and took over. RN #1 stated it did not occur to him/her to check the doctor's order for the resident's code status. RN #1 also stated that he/she was scared after finding Resident #1 unresponsive in the wheelchair. During an interview on [DATE] at 1:00PM, CNA #1 assigned to Resident #1 stated that while he/she was caring for another resident, he/she heard an alarm beeping and went into Resident #1's room to check. CNA #1 stated that he/she observed Resident #1 sitting in the wheelchair slumped over. CNA #1 stated that RN #1 came into the resident's room and they both transferred Resident #1 from the wheelchair to the bed. CNA #1 stated that RN #1 checked Resident #1's BP and instructed him/her to call the RNS #1. CNA #1 stated that he/she could not recall what time the supervisor was called or what time Resident #1 was put back in bed. CNA #1 stated that RNS #1 came quickly and started performing CPR. During subsequent interview on [DATE] at 1:46PM, the RNS #1 stated that he/she was in the nursing office when he/she received a phone call from CNA #1 at 5:40AM stating that a resident in room [ROOM NUMBER]A was not responding. RNS #1 stated that he/she was aware of the time (5:40AM) because he/she looked at the clock in the office. RNS #1 stated that he/she arrived in Resident #1's room at 5:45AM and observed Resident #1 lying in bed lifeless and not breathing. RNS #1 stated he/she called Resident #1 by name and the resident did not answer. RNS #1 stated that Resident #1 was wearing the Life Vest and no sounds were coming from the Life Vest. RNS #1 stated that RN #1 and CNA #1 were in Resident #1's room, and it appeared that they had just put Resident #1 in the bed. RNS #1 stated, first thing, I checked the resident carotid pulse and there was no pulse. The second thing, I looked at the Life Vest monitor, and it did not have a green light it was blank. I took another battery (in the room) and replaced it. After replacing the battery, the light was not green; it was red. The machine was speaking in Spanish giving instructions. I had no idea what the machine was saying. The machine then went blank. RNS #1 stated that as soon as the machine went blank, he/she instructed the RN #1 to bring the fingerstick machine. RNS #1 stated that RN #1 also went for the Emergency Box. RNS #1 stated that RN #1 took Resident #1's fingerstick and he/she (RNS) applied the BP cuff to Resident #1's left arm. The BP machine had no reading. Then, he/she switch to resident's right arm, and the BP machine had no reading. RNS #1 stated that he/she went outside the room and checked the room door for the purple sticker (DNR), and there was no purple sticker on the room door. RNS #1 stated that he/she checked the resident's wrists, and there was no ID Band. RNS #1 stated that he/she told RN #1 it's a full code call 911. RNS #1 stated that he/she started CPR and after 2 compressions to the chest, I stopped. RNS #1 stated that he/she does not know how long it took between the time Resident #1 was identified without vital signs and the time CPR was initiated and stopped. RNS #1 stated that he/she stopped the compressions because the BP machine read zero. RNS #1 stated that he/she instructed RN #1 to get the IV equipment and he/she inserted a needle. RNS #1 stated that after the needle was inserted, EMS arrived and took over. RNS #1 stated that when EMS applied the AED, it announced analyzing. RNS stated that after the AED announced analyzing, the EMS team instructed them (staff) to step outside of the room. RNS #1 stated that he/she told EMS, We need to make sure resident is full code. RNS #1 stated that he/she instructed RN #1 to check for Resident #1's code status and he/she followed behind RN #1 who looked at the resident's chart and said resident is DNR. RNS #1 stated that he/she informed EMS that Resident #1 was DNR. RNS #1 stated that when EMS arrived, I was not doing CPR. RNS #1 stated that Resident #1's chart was checked for code status when EMS arrived at 6:00AM. RNS #1 stated that a code was not called, and Medical Doctor was not notified when Resident #1 was observed unresponsive. Immediate Jeopardy (IJ) was identified and declared. The facility administrator and Director of Nursing were notified on [DATE] at 5:48PM. The facility submitted a removal plan that was reviewed and accepted by NYS DOH on [DATE] at 9:00PM. On [DATE] at 4:17PM, the survey team declared the IJ was removed based on the following corrective actions taken by the facility: Observations were conducted from [DATE] to [DATE] on the 2nd floor, 3rd floor & 4th floor. All 39 residents with DNR status were wearing ID Band with purple dot and purple dot at residents' names on the outside of the door. On [DATE], the facility audited all residents code status to ensure proper doctor's orders were in place. Names of residents and orders provided to surveyors. During observations, no residents were observed in distress and no Cardiopulmonary Resuscitation (CPR) was performed. From [DATE] through [DATE], in-service on Cardiopulmonary Resuscitation was provided to ,d+[DATE] nurses, ,d+[DATE] CNAs. One Physical Therapist (PT) received in-service. In-service was ongoing. On [DATE] through [DATE], surveyors interviewed 31 staff including nursing staff, Social Worker, Rehab staff, Administrator, Director of Nursing Service (DNS), and facility Educator. On [DATE], the facility revised the Policy and Procedure on Cardiopulmonary Resuscitation to include steps that staff should take when a resident is observed unresponsive. Staff should check the medical record for resident code status. If the resident is not a DNR, staff should call 225 for a Code 99. The first CPR certified responder should initiate CPR and continue until EMS arrived or until the Medical Doctor terminates the CPR. On [DATE], the facility developed a Code 99 Drill form with steps on what to do when a resident is identified as unresponsive. Surveyors received and reviewed the form. The facility has 120 direct hire/active employees. The facility has 1 RNS, 3 CNAs and 1 housekeeping staff on leave. Staff will be in-serviced upon return and before start of shift. The facility has 32 agency staff. The facility provided in-services to ,d+[DATE] staff (91%). Fourteen (14) staff (9.3%) will be trained when they return to work. On [DATE] at 9:00PM, the facility trained a total of 135 employees. ,d+[DATE] Administrator; RNs=,d+[DATE], LPNs =,d+[DATE] ( 2 LPNs out on leave and will be trained prior to start of shift); ,d+[DATE] CNAs (12 CNAs to be trained when they returned to work); Administrative staff = ,d+[DATE]; Social Worker= ,d+[DATE]; Rehab=,d+[DATE]; Dietary= ,d+[DATE] (2- dietary staff are on leave and will be trained before resuming duty); Recreation staff =,d+[DATE]; Housekeeping =,d+[DATE]; transporter =,d+[DATE]; Beautician=,d+[DATE]; Maintenance =,d+[DATE]; purchasing staff=,d+[DATE]; Security= ,d+[DATE]; Medical staff=,d+[DATE] and Scribe=,d+[DATE]. The surveyors interviewed 10 RNS/RNs, 1 LPN, 20 CNAs, 1 Social Worker, 7 Dietary - staff and 3 Rehab staff. In-service Attendance sheets with dates and signatures received and reviewed by surveyors. In-service Post-Tests received and verified by surveyors. On [DATE] the facility conducted a Mock Code Drills on the ,d+[DATE]AM shift (9 staff). On [DATE] on the 7AM-3:00PM (13 staff); ,d+[DATE]PM (14 staff); ,d+[DATE]AM (9); all shifts on [DATE], ,d+[DATE] (12 staff); ,d+[DATE]PM (9 staff) and ,d+[DATE]AM (8 staff). On [DATE], the facility developed a Code 99 Sheet - to ensure that proper standard of practice is being followed. Code 99 sheets Received and reviewed by surveyors. Post Code Documentation form dated [DATE], received and reviewed by surveyors. 415.12

Based on observations, record reviews, and interviews conducted during an abbreviated survey (NY 711) on [DATE] through [DATE], the facility failed to ensure a resident's right to refuse, and or discontinued treatment. This was evident for 1 out of 10 residents' sample (Resident #1). Specifically, Resident #1 had a doctor's order for Do Not Resuscitate (DNR, allow natural death, do not perform cardiopulmonary resuscitation, CPR, in the event the heart stopped) and facility staff and EMS performed CPR when resident #1 was found unresponsive on [DATE]. The findings are: The facility's Policy and Procedure titled: Cardiopulmonary Resuscitation, reviewed [DATE] documented if the resident has expressed his/her wishes and does not wish to be resuscitated, then there will be a (Do Not Resuscitate (DNR) order in chart. Do not institute CPR on any resident with a DNR order in chart. The color PURPLE designates a DNR order. All residents who have a DNR order have a PURPLE dot on their ID band and on the name plate outside of their door. The facility Policy and Procedure on Cardiopulmonary Resuscitation did not instruct staff on what to do if a resident was not wearing any identifier. There were no instructions for staff to check the doctor's order to confirm a resident code status. Resident #1 was initially admitted to facility [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS, a resident assessment tool) dated [DATE] documented that Resident #1 had a Brief Interview for Mental Status (BIMS, used to determined attention, orientation and) score of ,d+[DATE] associated with moderately impaired cognition. A facility document entitled End-of-Life treatment Preferences and Goals of Care dated [DATE], signed by Resident #1 and family, declining life-sustaining therapy/intervention -cardiopulmonary resuscitation (CPR). The End-of-Life form was signed by Resident #1's family member, the SW (social worker), and Resident #1's Attending Physician. A Document entitled DNR Order for Individuals with Capacity dated [DATE] was signed by Resident #1, Resident #1's physician and witnessed by social worker. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #1 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #1's Advance Directive Care Plan (ADCP) dated [DATE] documented that Resident #1 had a current Advanced Directives orders in place. The Social Worker reviewed the Advance Directives with Resident #1 and family and DNR was elected. A Social Worder's (SW) note dated [DATE] documented that Resident #1 was admitted on [DATE]. Resident #1's niece/ family member was contacted via conference call. Resident #1 and family continued in agreement with DNR order. The MDS dated [DATE], S- section, documented, Advanced Directives, Do-not-Resuscitate and Do-not-Intubate resident. A printout of the Life Vest strips report dated [DATE] revealed that Resident #1 was in Asystole (heart stopped beating, [CONDITION(S)]) on [DATE] at 5:30:19 AM. The length of time Resident #1's heart stopped beating was documented as 119 seconds. At 5:37:06AM, 119 seconds, the strips showed that the resident flatlined. A Nursing Progress Note, by Registered Nurse Supervisor (RNS #1), dated [DATE] documented that RNS #1 received a call from the unit charge nurse, RN #1, at 5:40AM stating that Resident #1 was unresponsive. RNS arrived on the unit and observed Resident #1 in bed with Life Vest in place. Resident #1 had no palpable pulse, respiration, and blood pressure. CPR was initiated and 911 called. Right saline lock inserted without any difficulty. EMS (emergency medical services) arrived, AED (automated -external -defibrillator) applied and resuscitative measures were stopped after discovery of the resident's DNR order. Resident #1 was pronounced dead at 6:10AM by EMS personnel. Resident #1's Certificate of Death dated [DATE], revealed that Resident #1 was pronounced at 6:10AM. During an interview on [DATE] at 5:00PM, the Director of Nursing (DON) stated when Resident #1 was found unresponsive, and staff was unable ascertain resident's code status due to the missing ID band and purple dot under the resident's name plate. The DON stated the nurse should have checked the Electronic Medical Record for the order and the resident's physical chart for the MOLST. During an interview on [DATE] and [DATE], with RN #1, who found Resident #1 unresponsive, stated that he/she was not aware that Resident #1 had a DNR order as the resident was not wearing a name band and there was no purple dot next to the resident's name outside the door. RN #1 stated that he/she worked the night shift (11pm-7am) and received Resident #1 in the wheelchair on oxygen at 2L. Resident #1 was wearing a Life Vest. RN #1 stated at 5:35AM Resident #1 was observed with his/her head bent, Life Vest beeping and unresponsive in the wheelchair. RN #1 stated that upon discovering Resident #1 unresponsive, he/she asked a Certified Nursing Assistant (CNA) #1 to assist him/her to transfer the resident to their bed. RN #1 stated that he/she assessed Resident #1 and checked the Blood Pressure (BP), carotid and radial pulses, and the resident had no pulse and no BP. RN #1 stated that RNS #1 was called at 5:40AM and arrived quickly and assessed Resident #1. There was no BP or pulse. RN #1 reported that the RNS #1 looked at Resident #1's name on the door and there was no purple dot. RN #1 stated that the RNS #1 notified him/her that Resident #1 was full code and asked him/her to check Resident #1's blood glucose. RN #1 stated that RNS #1 also instructed him/her to get the emergency box to start intravenous fluid and to bring the crash cart. RN #1 stated that he/she brought the emergency box to RNS #1 and RNS #1 instructed them to call 911. RN #1 stated that EMS staff arrived fast and took over the resuscitation and placed an Automated External Defibrillator (AED) pad on Resident #1's chest. The AED kept saying analyzing, analyzing. RN #1 stated that EMS instructed them (staff) to step outside of the room. RN #1 stated that the AED did not shock Resident #1. RN #1 stated that he/she went to the computer to prepare for Resident #1 to be transferred to the hospital and when he/she retrieved the resident's medical record, he/she realized that Resident #1 had a DNR order. RN #1 stated that he/she went back to Resident #1's room and informed EMS that Resident #1 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #1 stated that he/she did not attempt to do chest compressions on Resident #1 because he/she was not sure of the resident's code status. RN #1 stated that he/she just kept assessing Resident #1 from head-to-toe until RNS #1 arrived on the unit and took over. RN #1 stated it did not occur to him/her to check the doctor's order for the resident's code status. RN #1 also stated that he/she was scared after finding Resident #1 unresponsive in the wheelchair. During subsequent interview on [DATE] at 1:46PM, the RNS #1 stated that he/she was in the nursing office when he/she received a phone call from CNA #1 at 5:40AM stating that a resident in room [ROOM NUMBER]A was not responding. RNS #1 stated that he/she was aware of the time (5:40AM) because he/she looked at the clock in the office. RNS #1 stated that he/she arrived in Resident #1's room at 5:45AM and observed Resident #1 lying in bed lifeless and not breathing. RNS #1 stated he/she called Resident #1 by name and the resident did not answer. RNS #1 stated that Resident #1 was wearing the Life Vest and no sounds were coming from the Life Vest. RNS #1 stated that RN #1 and CNA #1 were in Resident #1's room, and it appeared that they had just put Resident #1 in the bed. RNS #1 stated, first thing, I checked the resident carotid pulse and there was no pulse. The second thing, I looked at the Life Vest monitor, and it did not have a green light it was blank. I took another battery (in the room) and replaced it. After replacing the battery, the light was not green; it was red. The machine was speaking in Spanish giving instructions. I had no idea what the machine was saying. The machine then went blank. RNS #1 stated that as soon as the machine went blank, he/she instructed the RN #1 to bring the fingerstick machine. RNS #1 stated that RN #1 also went for the Emergency Box. RNS #1 stated that RN #1 took Resident #1's fingerstick and he/she (RNS) applied the BP cuff to Resident #1's left arm. The BP machine had no reading. Then, he/she switch to resident's right arm, and the BP machine had no reading. RNS #1 stated that he/she went outside the room and checked the room door for the purple sticker (DNR), and there was no purple sticker on the room door. RNS #1 stated that he/she checked the resident's wrists, and there was no ID Band. RNS #1 stated that he/she told RN #1 it's a full code call 911. RNS #1 stated that he/she started CPR and after 2 compressions to the chest, I stopped. RNS #1 stated that he/she does not know how long it took between the time Resident #1 was identified without vital signs and the time CPR was initiated and stopped. RNS #1 stated that he/she stopped the compressions because the BP machine read zero. RNS #1 stated that he/she instructed RN #1 to get the IV equipment and he/she inserted a needle. RNS #1 stated that after the needle was inserted, EMS arrived and took over. RNS #1 stated that when EMS applied the AED, it announced analyzing. RNS stated that after the AED announced analyzing, the EMS team instructed them (staff) to step outside of the room. RNS #1 stated that he/she told EMS, We need to make sure resident is full code. RNS #1 stated that he/she instructed RN #1 to check for Resident #1's code status and he/she followed behind RN #1 who looked at the resident's chart and said resident is DNR. RNS #1 stated that he/she informed EMS that Resident #1 was DNR. RNS #1 stated that when EMS arrived, I was not doing CPR. RNS #1 stated that Resident #1's chart was checked for code status when EMS arrived at 6:00AM. RNS #1 stated that a code was not called, and Medical Doctor was not notified when Resident #1 was observed unresponsive. During an interview on [DATE] at 1:29 PM, The Director of Social Service (DSS) was interviewed and stated that the SW is responsible for sending emails to all departments informing them of the change in the resident's DNR status. The DSS stated that the admission department is the first line to generate DNR bracelet with purple dot for the resident and the admitting nurse places the bracelet on the resident's wrist. The admitting department is also responsible for putting the purple dot to residents' name plate. During an interview on [DATE] at 9:15 AM, the Physician stated that Resident #1 had the Life Vest monitor because of irregular heartbeat. The Physician stated that the nurse called him/her in January to inform that Resident #1 had expired at 6:10AM. 415.3(e)(1)(ii)