Every finding on record at Swan Lake Nursing and Rehabilitation

Based on observations, record review, and staff interviews during the Recertification survey initiated on 09/25/2025 and completed on 10/01/2025, the facility failed to ensure that the resident's environment remained free of accident hazards. This was identified for one (1) (Resident #39) of six (6) residents reviewed for Accidents. Specifically, Resident #39, who had a diagnosis of Schizophrenia and had moderately impaired cognition with behaviors including requesting excessively hot water to wash their clothing in their bathroom sink. On multiple observations on 09/29/2025, Resident #39's bathroom sink water temperature was found to be 136.2 degrees Fahrenheit, 123 degrees Fahrenheit, and 127 degrees Fahrenheit. This resulted in a likelihood for serious injury and harm to Resident #39, that is Immediate Jeopardy. The finding is: 42 CFR 483.470 (d)(3) PART 483-REQUIREMENTS FOR STATES AND LONG-TERM CARE FACILITIES 483.470 Condition of Participation: Physical environment. (d) Standard: Client bathrooms. The facility must ensure: (3) In areas of the facility where clients who have not been trained to regulate water temperature are exposed to hot water, ensure that the temperature of the water does not exceed 110 Fahrenheit. The facility policy entitled Accident and Supervision, revised on 08/20/2025, documented resident's environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. All staff, including Professional, Administrative, and Maintenance staff, are to be involved in observing and identifying potential hazards in the environment, while taking into consideration the unique characteristics and abilities of each resident. The facility policy entitled Legionella in potable Water sampling and management plan, revised on 12/13/2024, the facility's hot water (150 degrees) main is branched into two. There are no storage tanks occupied. One of the branches supplies the hot water to the kitchen and laundry room at 150 degrees Fahrenheit. The second hot water main branch is fed into a tempering valve at 150 degrees Fahrenheit, which automatically adds cold water to a set discharge temperature of 110 degrees Fahrenheit. The 110-degree Fahrenheit hot water is then supplied to all the resident areas, such as taps, showers, and sinks. Resident #39 was admitted with diagnoses of schizophrenia, schizoaffective disorder, and post-traumatic stress disorder. The Quarterly Minimum Data Set (a resident assessment tool) dated 07/27/2025 documented a Brief Interview of Mental Status of nine (9), which indicated the resident had moderately impaired cognition. The Quarterly Minimum Data Set documented that Resident #39 required substantial (helper does more than half the effort) assistance for toileting, supervision or touching assistance for personal hygiene, and substantial assistance with toilet transfers. Resident #39 was always continent with bowel and bladder. The behavior care plan initiated on 04/26/2024, documented Resident #39 displayed the following behaviors: puts inappropriate items in the toilet, which has resulted in flooding in the room, screams, talks very loudly, and refuses care. The interventions included, but were not limited to, psychiatric evaluation and follow-up as needed, and psychological evaluation and follow-up as needed.The Psychiatric Nurse Practitioner progress note dated 08/29/2025 documented the resident had paranoia with auditory hallucinations (hears voices when not present). The resident had a significant history of schizophrenia with past treatments. The resident has erratic and unpredictable triggers that vary based on the resident's perception. The facility staff reported the resident exhibited persistent behaviors of using other peers' toilets to wash their clothes and attempting to flush items in the toilet. The resident was agitated with poor impulse control and denied the behavior of using peers' toilets to wash clothes. During an interview on 09/29/2025 at 9:45 AM, the Director of Social Work stated that Resident #39 had a behavior of washing their clothes in their bathroom sink and flushing the clothes in the toilet bowl. The Director of Social Work stated the resident's behavior continued despite redirections. During an observation and interview on 09/29/2025 at 10:20 AM, Resident #39 was sitting on the edge of their bed. A wet pair of pants and a wet shirt were placed on the nightstand. The water was dripping from the wet clothes. Resident #39 stated they washed their own clothes in the bathroom and pointed to the bathroom in their room.During an observation on 09/29/2025 at 10:22 AM, the surveyor checked the bathroom sink's hot water by placing their hand under the water. The water was hot, and the surveyor had to quickly remove their hand from under the water. During an interview on 09/29/2025 at 10:40 AM, the Director of Environmental Services stated that Resident #39 requested the water in their room to be at 125 degrees Fahrenheit to wash their clothing in the bathroom sink. The Director of Environmental Services stated if the water temperature was not to the resident's liking, the resident would make a big scene, yell, scream, and throw self on the floor. The Director of Environmental Services stated they accommodated the resident's request by increasing the water temperature. There is no documented evidence the comprehensive care plan included the resident's behavior of washing their clothes in the bathroom sink and requesting hotter water. During an observation on 09/29/2025 at 10:45 AM, the Director of Environmental Services tested the water temperature in Resident #39's bathroom with an infrared laser thermometer. The water temperature was found to be at 136.2 degrees Fahrenheit. After obtaining the water temperature, the Director of Environmental Services placed their hand under the sink water and quickly pulled their hand out and stated, too hot.'' During an interview and observation on 09/29/2025 at 10:50 AM, the Director of Environmental Services stated the temperature reading of 136.2 degrees Fahrenheit is too hot and above the regulatory requirement. The water temperature was supposed to be at 110 degrees Fahrenheit for resident sinks and shower rooms. The Director of Environmental Services stated they had to go to the boiler room to adjust the water temperature and then quickly left to go to the second-floor elevator despite the surveyor's request to measure the water temperature of other rooms on the unit. The Director of Environmental Services was observed adjusting the mixing valves in the basement. The Director of Environmental Services stated they check Resident #39's sink water temperature every day and document their findings on a log sheet. They keep two (2) separate logs, one (1) for the facility and one (1) for Resident #39's room. They pick random rooms to check the water temperature to document on the facility water temperature log. The Director of Environmental Services stated the water temperature for Resident #39's room was already checked this morning; however, they could not recall the temperature readings for that morning and would look for the temperature logs to verify. The facility was unable to provide documented water temperature logs for September 2025 for the entire facility upon multiple requests made on 09/29/2025. Resident #39's water temperature logs were not made available on 09/29/2025. During an observation on 09/29/2025 at 1:05 PM, in the presence of the Director of Environmental Services, Resident #39's bathroom sink temperature was found to be at 123 degrees Fahrenheit utilizing the original infrared thermometer that was used at 10:50 AM. The Director of Environmental Services stated that the thermometer was broken, and they were going to utilize another thermometer. The Director of Environmental Services used two (2) other thermometers to measure the water temperature in Resident #39's bathroom sink, which read 127 degrees Fahrenheit with both thermometers. The Director of Environmental Services stated that it appeared all three (3) infrared thermometers were broken. During an observation on 09/29/2025 at 1:30 PM, the Director of Environmental Services tested water temperatures for two (2) additional room sinks. room [ROOM NUMBER]'s sink water temperature was 117 degrees Fahrenheit, and room [ROOM NUMBER]'s sink water temperature was114 degrees Fahrenheit.During an interview on 09/29/2025 at 2:15 PM, Certified Nursing Assistant #4 stated Resident #39 had behaviors of washing their clothes in their bathroom. The resident was not on specific monitoring for their behavior. During an interview on 09/29/2025 at 2:22 PM, Certified Nursing Assistant #5 stated Resident #39 had a behavior of washing their clothes in the toilet in their bathroom. Certified Nursing Assistant #5 stated Resident #39 required one-person assistance for toileting. Certified Nursing Assistant #5 stated the water in the bathroom sink comes out too hot, so they have to remind the resident that the water gets hot, and they have to adjust the water temperature by turning on the cold water. They stated we adjust the water with the handles on the sink. During an interview on 09/29/2025 2:34 PM, Licensed Practical Nurse #1 stated the resident had behaviors such as refusing showers and washing their clothes in the bathroom sink in their room. Licensed Practical Nurse #1 stated they try to monitor the resident's behavior. During an interview on 09/30/2025 at 1:17 PM, Medical Doctor #1 stated they were aware of Resident #39's behavior of washing clothes in the bathroom sink. They stated they did not know that the resident was requesting hotter water for washing clothes. Medical Doctor #1 stated that a temperature of 136.2 degrees Fahrenheit is too hot and could cause significant burns. The Daily Domestic Hot Water Temperature Log Reading for Resident #39's room for September 2025 was provided on 09/30/2025 at 04:45 PM. The log indicated the water temperature ranged from 114 degrees Fahrenheit to 116 degrees Fahrenheit. The log did not include water temperatures for 09/13/2025, 09/14/2025, 09/16/2025, 09/17/2025, 09/19/2025, 09/20/2025, 09/21/2025, 09/25/2025, 09/27/2025, 09/28/2025, 09/29/2025 and 09/30/2025. The log indicated that the automatic faucet not working properly 09/27/2025.During an interview on 10/01/2025 at 10:27 AM, Certified Nursing Assistant #1 stated they were regularly assigned to Resident #39 during the 7:00 AM - 3:00 PM shift. Certified Nursing Assistant #1 stated Resident #39 washed their clothes in the bathroom sink and flushed the clothing in the toilet bowl. This caused a flood, and because of that, Environmental Services disabled the flushing system and put a commode in the resident's room. Certified Nurse Assistant #1 stated when they provide care to the resident in the room, Resident #39's bathroom sink water gets really hot, but they adjust the water temperature by turning on the cold water and the hot water at the same time to make sure the resident does not burn their hands. Certified Nurse Assistant #1 stated Resident #39 was not aware of what is hot and what is cold, and they had to warn Resident #39 that the sink water was hot and for them to be careful. Certified Nurse Assistant #1 stated they reported to the Director of the Environmental Services about the sink water being too hot but could not recall when. During an interview on 10/01/2025 at 12:15 PM, Licensed Practical Nurse Unit Manager #1 stated they knew that Resident #39 washed their clothes in the bathroom sink and rinsed them in the toilet bowl; however, they did not know that Resident #39 preferred hotter water. They assumed everyone was monitoring Resident #39's behavior of washing their clothes in the bathroom. Licensed Practical Nurse Unit Manager #1 stated they did not know that the water temperature in the resident's room was too hot. During an interview on 10/01/2025 at 12:33 PM, the Administrator stated Resident #39 was not coherent to demand the water temperature of at least 125 degrees Fahrenheit. The Administrator stated they were not made aware of Resident #39's preferred water temperature; however, they knew that the resident was washing their clothes in the bathroom sink and that Resident #39 had the right to do so. The Administrator stated the nurses and Certified Nursing Assistants were supposed to monitor the resident for safety. The Administrator stated the Environmental Services department was supposed to monitor the water temperature and ensure the temperature was within regulatory guidelines. During an interview on 10/01/2025 at 3:00 PM, the Director of Nursing Services stated they have been working at the facility for less than two (2) months and were not aware of Resident #39's preference regarding the hotter water to wash their clothes in the bathroom. The Director of Nursing Services stated that Resident #39 had impaired cognitive function and could not verbalize the need for water temperature of 125 degrees Fahrenheit to wash their clothes. The Director of Nursing Services stated a water temperature of 136.2 degrees Fahrenheit was too hot and was not acceptable. 10NYCRR 415.12(h)(2)

Based on observations, record review, and interviews during the Recertification Survey initiated on 09/25/2025 and completed on 10/01/2025, the facility did not ensure that each resident had a right to a clean, comfortable, and homelike environment. This was identified for one (1) (Second floor) of two nursing floors; and for three (Resident#88, Resident#101, Resident#35) of five residents reviewed during the environmental facility task. Specifically, during the Resident Council meeting on 09/25/2025, two (2) (Resident#88, Resident#101) of the eight (8) residents in attendance complained about dirty shower rooms on the second floor. During observation, the second-floor shower room was found to be unsanitary, and the privacy curtains were in disrepair. The shower room also had a strong, foul odor. Additionally, Resident #39's bathroom was observed with a strong foul odor. The toilet bowl and portable commode in the bathroom contained urine and feces. The toilet's flushing mechanism was also non-functional.The finding is:The facility's policy titled Quality of Life-Homelike Environment, revised on 07/2024, documented that residents are provided with a safe, clean, comfortable, and homelike environment and are encouraged to use their personal belongings to the extent possible. The characteristics of the facility that reflect a personalized, home-like setting, including cleanliness and pleasant neutral scents.The Facility's policy titled Cleaning and Disinfecting of Environmental Surfaces, revised on 07/2024, documented that environmental surfaces will be cleaned and disinfected according to the current Centers for Disease Control recommendations for disinfection of healthcare facilities and the Occupational Safety and Health Administration's bloodborne pathogen standards. The policy documented that Resident Shower rooms must be cleaned three times daily and as needed. Resident rooms and personal bathrooms must be cleaned daily and as needed.During the Resident Council Meeting on 09/25/2025 at 11:30 AM, two (Resident #101, Resident #88) of eight residents in attendance complained about dirty shower rooms. A review of the Resident Council Meeting minutes for 06/25/2025 and 07/30/2025 documented resident complaints regarding the shower rooms not being cleaned. During an observation on 09/29/2025 at 6:39 AM, the second-floor shower room was found to be unsanitary. Conditions included: a dirty floor, dirty gloves on the floor, a hairbrush in the sink, and an incontinent brief on the sink counter. The used garbage can did not have a liner, two toilet bowls contained urine, and three privacy curtain rod clips were broken. The room also had a strong, foul odor.During multiple observations on 09/29/2025 at 10:22 AM, 10:45 AM, and 01:04 PM, Resident #39's room and bathroom had a strong, foul, feces and urine odor. The portable commode and the toilet were filled with feces and urine. During an interview and observation on 09/29/2025 at 10:45 AM, the Director of Environmental Services stated the flushing mechanism for Resident #39's bathroom toilet was disabled due to the resident's behavior of flushing their clothes, which would cause flooding in the room. The Director of Environmental Services stated the condition of the resident's bathroom was disgusting, and they had to get out of the bathroom to breathe due to the unbearable odor. The Director of Environmental Services stated that no one ever reported to them that the resident was utilizing the toilet in their room after the flushing mechanism was disabled. The Director of Environmental Services stated that the condition of the resident's toilet was disgusting, and it should have been cleaned. During an interview on 10/01/2025 at 10:27 AM, Certified Nursing Assistant #1 stated Resident #39 flushed their clothes in the toilet and caused flooding in the room. Certified Nursing Assistant #1 stated that the Director of Environmental Services disabled the flushing mechanism in Resident #39's bathroom toilet to prevent flooding. Certified Nursing Assistant #1 stated that the feces and urine in the portable commode and the toilet cause a strong foul odor in the resident's room. Certified Nursing Assistant #1 stated they clean the commode as much as they can and throw the fecal material in other resident rooms and sometimes in the unit shower room. Certified Nursing Assistant #1 stated the Environmental Services Staff knew that the resident was utilizing the toilet with the disabled flushing mechanism and did nothing about it. During an interview on 10/01/2025 at 12:15 PM, Licensed Practical Nurse Unit Manager #1 stated, Certified Nurses Assistants are responsible for making sure the shower rooms are clean after they finish providing the shower to the residents. Licensed Practical Nurse Unit Manager #1 stated they checked the shower room at 6:40 AM on 09/29/2025, and the shower room was clean. Licensed Practical Nurse Unit Manager #1 stated Resident#39's toilet flushing system was disabled due to Resident#39's behavior of flushing clothes in the toilet, which caused flooding. During an Interview on 10/01/2025 at 12:25 PM, the Administrator stated they added a full time 3:00 PM to 11:00 PM shift housekeeper staff due to the complaints brought up during the resident council meeting. The Administrator stated there have been no complaints after the full time evening housekeeping staff was hired. The Administrator stated the maintenance department should make sure all shower curtains are working properly. The Administrator stated that the Director of Environmental Services disabled the toilet flushing mechanism, and the resident was provided a portable commode. The Administrator stated they were not notified that Resident #39 was still using the disabled toilet. The Administrator stated the Housekeepers should flush and clean the resident's toilet regularly every day and as needed to maintain the resident's dignity.During an interview on 10/01/2025 at 12:56 PM, Housekeeper #1 stated that shower rooms were cleaned three times a day. Housekeeper #1 stated there were housekeepers scheduled to work seven (7) days a week during the 7:00 AM to 3:00 PM and 3:00 PM to 11:00 PM shifts, and there should be no reason the shower rooms were dirty. They stated the Maintenance Department was responsible for fixing the shower curtains. They stated they did not realize the second-floor shower curtain clips were broken.During an interview on 10/01/2025 at 3:00 PM, the Director of Nursing Services stated the resident's bathroom should be cleaned regularly to maintain the resident's dignity. 10 NYCRR 415.5(h)(2)

Based on observations, record review, and interviews during the Recertification Survey initiated on 09/25/2025 and completed on 10/01/2025, the facility did not ensure that each resident was treated with respect and dignity and cared for in a manner that promoted maintenance or enhancement of their quality of life. This was identified for one (1) (Resident #39) of two (2) residents reviewed for Dignity. Specifically, Resident #39 had a diagnosis of Schizophrenia and moderately impaired cognition, with behaviors including flushing their clothing in the toilet bowl, resulting in flooding in the room. After the resident caused flooding in their room, the flush mechanism in the resident's bathroom toilet was disabled, and the resident was provided with a portable commode. During observation, the resident's toilet and commode were found in an unsanitary condition, filled with fecal material. Additionally, the Director of Environmental Services was observed entering Resident #39's bathroom without knocking on the door while Resident #39 was using the bathroom.The finding is:The facility's dignity policy, revised on 11/12/2024, documented all residents will be treated with privacy and confidentiality. The facility will promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. All residents have the right to personal privacy and confidentiality of his or her personal clinical records. This includes, but is not limited to, accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and residents' groups. The Facility's policy titled Cleaning and Disinfecting of Environmental Surfaces, revised on 07/2024, documented that environmental surfaces will be cleaned and disinfected according to the current Centers for Disease Control recommendations for disinfection of healthcare facilities and the Occupational Safety and Health Administration's bloodborne pathogen standards. The policy documented that Resident Shower rooms must be cleaned three times daily and as needed. Resident rooms and personal bathrooms must be cleaned daily and as needed.The resident was admitted with diagnoses of Schizophrenia, Schizoaffective disorder, and Post-Traumatic Stress Disorder. The Quarterly Minimum Data Set, dated [DATE] documented a Brief Interview of Mental Status score of nine (9), which indicated the resident had moderately impaired cognition. The Quarterly Minimum Data Set documented that Resident #39 required substantial (helper does more than half the effort) assistance for toileting, supervision or touching assistance for personal hygiene, and substantial assistance with toilet transfers. Resident #39 was always continent with bowel and bladder. The behavior care plan initiated on 04/26/2024 documented Resident #39 displayed the following behaviors: puts inappropriate items in the toilet, which has resulted in flooding in the room, screams, talks very loudly, and refuses care. The interventions included, but were not limited to, psychiatric evaluation and follow-up as needed, and psychological evaluation and follow-up as needed.The Psychiatric Nurse Practitioner progress note dated 08/29/2025 documented the resident had paranoia with auditory hallucinations (hears voices when not present). The resident had a significant history of Schizophrenia with past treatments. The resident has erratic and unpredictable triggers that vary based on the resident's perception. The facility staff reported the resident exhibited persistent behaviors of using other peers' toilets to wash their clothes and attempting to flush items in the toilet. The resident was agitated with poor impulse control and denied the behavior of using the peers' toilet to wash clothes. During an observation on 09/29/2025 at 10:22 AM, Resident #39's room and bathroom had a strong foul feces and urine odor. The portable commode and the toilet were filled with feces and urine. The resident was sitting on the bed. The resident was wearing pants that were long and were soiled with brownish material. During an interview and observation on 09/29/2025 at 10:45 AM, the Director of Environmental Services stated the flushing mechanism for Resident #39's bathroom toilet was disabled due to the resident's behavior of flushing their clothes, which would cause flooding in the room. The Director of Environmental Services stated the condition of the resident's bathroom was disgusting, and they had to get out of the bathroom to breathe due to the unbearable odor. The Director of Environmental Services stated no one ever reported to them that the resident was utilizing the toilet in their room after the flushing mechanism was disabled. The Director of Environmental Services stated that the condition of the resident's toilet was disgusting, and it should have been cleaned. During an observation on 09/29/2025 at 1:04 PM, the Director of Environmental Services entered Resident #39's bathroom without knocking on the door. The resident was in the bathroom and shouted at the Director of Environmental Services. During an interview on 10/01/2025 at 10:27 AM, Certified Nursing Assistant #1 stated Resident #39 flushed their clothes in the toilet and caused flooding in the room. Certified Nursing Assistant #1 stated that the Director of Environmental Services disabled the flushing mechanism in Resident #39's bathroom toilet to prevent flooding. Certified Nursing Assistant #1 stated that the feces and urine in the portable commode and the toilet cause a strong foul odor in the resident's room. Certified Nursing Assistant #1 stated they clean the commode as much as they can and throw the fecal material in other resident rooms and sometimes in the unit shower room. Certified Nursing Assistant #1 stated the Environmental Services Staff knew that the resident was utilizing the toilet with the disabled flushing mechanism and did nothing about it. During an interview on 10/01/2025 at 12:15 PM, Licensed Practical Nurse Unit Manager #1 stated they knew the flushing mechanism in the resident's toilet was disabled by the Director of Environmental Services to prevent flooding. Licensed Practical Nurse Unit Manager #1 stated there was a portable commode in Resident #39's bathroom for Resident #39's toileting needs, and Certified Nurse Assistants were responsible for cleaning the portable commode. Licensed Practical Nurse Unit Manager #1 stated they did not know Resident #39 continued to utilize the toilet while it was disabled. During an interview on 10/01/2025 at 12:33 PM, the Administrator stated they were made aware that Resident #39 caused a flood in their room due to flushing their clothing in the toilet. The Administrator stated that the Director of Environmental Services disabled the toilet flushing mechanism, and the resident was provided a portable commode. The Administrator stated they were not notified that Resident #39 was still using the disabled toilet. The Administrator stated the Housekeepers should flush and clean the resident's toilet regularly every day and as needed to maintain the resident's dignity. During an interview on 10/01/2025 at 12:56 PM, Housekeeper #1 stated they did not know the resident was using the disabled toilet in their room. Housekeeper #1 stated they thought the resident was not using the toilet and could not remember when they last cleaned the bathroom before 09/29/2025 because the nurses and the Certified Nursing Assistants were responsible for cleaning Resident #39's portable commode. During an interview on 10/01/2025 at 3:00 PM, the Director of Nursing Services stated the resident's bathroom should be cleaned regularly to maintain the resident's dignity. 10 NYCRR 415.3(d)(1)(i)

Based on observation, record review, and interviews during the Recertification Survey initiated on 05/13/2025 and completed on 05/19/2025, the facility did not ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team to reflect each resident's preferences and status after each assessment. This was identified for one (Resident #24) of six residents reviewed for Accidents. Specifically, Resident #24 was identified as having a behavior of rolling out of bed onto the floor mat. The comprehensive care plan and the Certified Nursing Assistant Accountability Record were not updated to include the use of the floor mats as an intervention.The finding is:The facility policy titled Behaviors, dated 08/20/2025, documented that appropriate interventions may include environmental modifications, and all interventions will be documented and incorporated into the resident's individualized care plan.The facility policy titled Care Plans, dated 07/02/2025, documented that the care plan shall be reviewed and revised as changes in the resident's needs, strengths, and goals change, but not less than quarterly. The care plans, as appropriate, shall be revised to enhance interventions as residents' conditions change. This can include, but is not limited to, behavior changes, falls, changing conditions, warranting review of medications and treatments.The undated facility policy titled Fall Prevention documented that residents identified for falls will be assessed for protective devices, which include but are not limited to anti-skid mats, floor mats, and low beds.Resident #24 was admitted with diagnoses including Chronic Obstructive Pulmonary Disease (damage to the airways and other parts of the lungs, which leads to inflammation that blocks airflow and makes it hard to breathe), Cerebral Infarction (a medical condition where a portion of the brain tissue dies due to a lack of blood flow), Bipolar Disorder(a mental condition marked by alternating periods of elation and depression). The Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 5, indicating the resident had severe cognitive impairment. The Minimum Data Set further documented that the resident had one fall since admission/reentry without injury.A Comprehensive Care Plan titled Behavior, dated 08/12/2024, and last reviewed 09/23/2025, documented that Resident #24 had physical behavior of rolling onto the floor mat when they needed to be changed and then refused care from the staff. There was no documented evidence that the use of the floor mats was included as an intervention. A Comprehensive Care Plan titled Fall/Injury, dated 08/12/2024 and last reviewed 08/16/2025, documented that the resident had a fall from their wheelchair in the bathroom without injury on 07/01/2025. There was no documented evidence that the use of the floor mats was included as an intervention. The Fall Risk assessment dated [DATE] documented that Resident #24 was a high risk for falls.The Kardex (Certified Nursing Assistant instructions to care for Resident #24) did not document the use of floor mats.During an observation and interview on 09/25/2025 at 11:28 AM, Resident #24 was lying in bed and pointed to the floor mat at the bedside and stated they did not want it there, but the staff would not take it away. The resident denied ever falling out of bed.During an observation on 09/29/2025 at 1:09 PM, Resident #24 was not in their room, but a floor mat was observed lying against the wall.During an observation on 09/30/2025 at 7:15 AM, Resident #24 was observed in bed, sleeping. A floor mat was placed on the floor by the bed.During an interview on 09/30/2025 at 7:36 AM, Certified Nursing Assistant #2 stated the resident was on fall precautions and utilized a floor mat. Certified Nursing Assistant #2 stated the resident was incontinent of bladder, but at times, asked to be taken to the bathroom.During an interview on 09/30/2025 at 7:45 AM, Licensed Practical Nurse Manager #1 stated resident #24 had a behavior of throwing themselves on the floor when they did not want care. Licensed Practical Nurse Manager #1 stated there was no intervention added to the care plan for the use of the floor mat. There should be an intervention in the falls care plan for the use of the floor mat. Putting a floor mat on the floor by the bed is a nursing intervention. They were not sure why this was not added to the care plan. During an interview on 10/01/2025 at 10:20 AM, Certified Nursing Assistant #1 stated that floor mats were being used for Resident #24 when the resident was in bed and were removed when the resident was ready to get out of bed in the morning. During an interview on 10/01/2025 at 3:03 PM, the Assistant Director of Nursing Services stated that the floor mats are a nursing intervention, and it would be documented in the fall or injury as an intervention. The Nurses were responsible for updating the care plans and should have updated Resident #24's care plan to indicate the use of the floor mats.10 NYCRR 415.11(c)(1)

Based on observations, record review, and interviews conducted during the Recertification Survey initiated on 09/25/2025 and completed on 10/01/2025, the facility did not ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice. This was identified for one (1) (Resident #10) of one (1) resident reviewed for Respiratory Care. Specifically, Resident #10 had a physician's order to receive two liters of supplemental oxygen continuously via a nasal cannula; however, during an observation, the resident was receiving supplemental oxygen at four liters per minute.The finding is:The undated facility policy titled Oxygen Policy documented that nursing staff are to initiate and monitor oxygen therapy, perform assessments, document, and escalate concerns as applicable.The undated facility policy titled Chronic Obstructive Pulmonary Disease documented that oxygen is a medication and must be administered only with a licensed provider's order.Resident #10 was admitted with diagnoses that included Chronic Obstructive Pulmonary Disease (damage to the airways and other parts of the lungs, which leads to inflammation that blocks airflow and makes it hard to breathe), Hemiplegia (paralysis or severe weakness on one side of the body) affecting the right dominant side, and Heart Failure. The Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 12, which indicated the resident had moderate cognitive impairment. The Minimum Data Set further documented that the resident received oxygen therapy.A comprehensive care plan for respiratory status related to Chronic Obstructive Pulmonary Disease was initiated on 07/29/2024. The interventions included administering supplemental oxygen as per the physician's order.A physician's order renewed on 09/15/2025 and discontinued on 09/25/2025 at 2:45 PM documented supplemental oxygen at a rate of two liters per minute via nasal canula continuously for shortness of breath and dyspnea on exertion (shortness of breath or difficulty breathing during physical activity).The Treatment Administration Record for September 2025 documented the daily use of supplemental oxygen at a rate of two liters per minute via nasal canula, and continuous monitoring of the oxygen saturation for each shift.During an observation on 09/25/2025 at 1:38 PM, Resident #10 was observed sleeping in bed and receiving four liters of oxygen per minute via a nasal cannula.During an interview on 09/25/2025 at 1:47 PM, the Licensed Practical Nurse Unit Manager stated the nurse on duty was responsible for checking the oxygen setting for the residents utilizing supplemental oxygen.A physician's order initiated on 09/25/2025 at 2:45 PM documented to administer two to four liters of oxygen via nasal canula continuously for shortness of breath and dyspnea on exertion (shortness of breath or difficulty breathing during physical activity).During an observation on 09/29/2025 at 10:46 AM, Resident #10 was observed sleeping in a Geri chair in the hallway outside their bedroom. The resident was receiving supplemental oxygen at a rate of three liters per minute via nasal canula.During a re-interview on 09/30/2025 at 7:56 AM, the Licensed Practical Nurse Unit Manager stated that they should have been made aware that the resident required an increase in oxygen. Resident #10 was not able to change the oxygen flow rate themself. During an interview on 10/01/2025 at 3:00 PM, the Assistant Director of Nursing stated Resident #10, who has Chronic Obstructive Pulmonary Disease, should have supplemental oxygen administered as ordered by the Physician. The Registered Nurse on duty should assess the resident, and if the oxygen needs to be increased, the Physician should be notified.10 NYCRR 415.12(k)(6)

Based on observation, record review, and interviews conducted during the Recertification Survey initiated on 7/24/2024 and completed on 7/31/2024, the facility did not exercise reasonable care for the protection of the resident's property from loss or theft. This was identified for one (Resident #52) of one resident reviewed for grievances. Specifically, Resident #52's clothes were lost after the clothes were sent to the laundry. The facility was unable to determine the lost items because an inventory list of the resident's belongings was not maintained. The finding is: The Policy and Procedure dated 6/1/2024 for Resident's Personal Belonging documented The facility staff will take all practicable steps to safeguard residents' belongings. All resident property will be inventoried on a Resident's Personal Possessions Sheet, a copy of which will be maintained in the resident's medical record, along with the facility possessions book. The form is to be completed by facility staff upon admission/readmission or when any items are brought into the facility. It is the responsibility of the person(s) bringing in any such items, to make staff aware of these items and to bring these items to the appropriate staff: front desk receptionist, nurse, Certified Nurse Assistant. or any facility representative/designee. All clothing items will be appropriately inventoried and labeled by the facility. Resident # 52 had diagnoses that included Cerebral Palsy and Morbid (severe) Obesity. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) was 12, indicating moderately impaired cognition. The Minimum Data Set assessment also documented the resident had no behaviors. A grievance form dated 7/19/2024 documented the resident was alleging lost clothing. The social worker documented there is no inventory of the resident's clothes' on file and that housekeeping will search the laundry and the clothes will be reimbursed. The grievance form indicated that the resident's Pajamas and sweatpants were not found, the resident had other clothes to wear and the facility will order Pajamas and sweatpants for the resident. The Inventory form was given to the resident to complete. An observation of the resident's room on 7/29/2024 at 10:00 AM revealed Resident #52's clothing was being stored in the closet in their room. With the permission of the resident, the resident's closet was searched. All clothing was labeled with the resident's name except for one jersey and one sweat pants that were unlabeled. Resident #52 was interviewed on 7/29/2024 at 10:00 AM and stated their clothing was lost by the facility laundry. Some of the clothing was found; however, some of the clothing was still missing. The facility staff did not label their clothes and document them on an inventory list whenever they got new clothing. They are supposed to inventory my clothing. I came to the facility in 2018 and can not remember if they inventoried my clothes. A review of the resident's record lacked documented evidence of an inventory list indicating the resident's belongings. Social Worker # 1 was Interviewed on 7/29/2024 at 2:33 PM and stated the facility staff were still looking for the resident's lost items and that is why the resident was not reimbursed for the lost items. The staff was not able to find an inventory sheet that would indicate the amount of clothing the resident had. Social Worker #1 further stated that the resident was admitted in 2018 and the facility should have ensured an inventory sheet is maintained in the resident's record. The Director of Guest Services was interviewed on 7/29/2024 at 3:06 PM and stated Resident #52 was admitted to the facility in 2018 and the staff were not able to locate the resident's inventory sheet. The Administrator was Interviewed on 7/30/2024 at 12:40 PM and stated, we cannot explain why the resident does not have an inventory sheet. We are implementing an inventory list and ensuring it is accurate. 10 NYCRR 415.5(h)(2)

Based on observation, record review, and interviews conducted during the Recertification Survey and Abbreviated Survey (NY 00348285) initiated on 7/24/2024 and completed on 7/31/2024 the facility did not ensure that each resident was free from abuse. This was identified for one (Resident #68) of three residents reviewed for abuse. Specifically, Certified Nurse Assistant #4 had verbal arguments and threatened Resident #68 with physical harm. Resident #68 verbalized being scared and upset after the interaction with Certified Nursing Assistant #4. The finding is: The Policy and Procedure titled, Abuse Prevention last reviewed in 3/2024 documented that the resident has the right to be free from abuse, neglect, and misappropriation of resident property. Verbal abuse is defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include but are not limited to threats of unjustified retribution or punishment. In the event of suspicion of abuse being investigated, the staff member will be suspended until the investigation is complete. Resident # 68 was admitted with diagnoses including Morbid Severe Obesity, Anxiety disorder, and Major Depressive disorder. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #68 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. The resident had no behaviors indicated during the assessment period. The Comprehensive Care Plan (CCP) for abuse initiated on 7/6/2023 and last revised on 7/24/2024 documented that Resident #68 was at risk of being a victim of abuse, neglect, and /or mistreatment. Interventions included ensuring the resident was safe by removing the alleged abuser or moving the resident to a safe and supervised area. The Accident and Incident report dated 7/12/2024 documented that at approximately 10:00 PM on July 12, 2024, the nursing supervisor was called on the first floor by the charge nurse due to an altercation between Resident #68 and Certified Nurse Assistant #4. Resident #68 stated that Certified Nurse Assistant #4 threatened them by saying You are lucky, I f with you, otherwise I would have whooped your a s outside. Sit your a s down. Certified Nurse Assistant #4 was laughing while commanding the resident to sit down. Resident #68 stated they were scared. The investigation concluded that Resident #68 was a victim of mental and psychological harm caused by the interaction between the resident and Certified Nurse Assistant #4 and there was cause to believe alleged abuse had occurred. The incident was reported to the New York State Department of Health on 7/13/2024 and to the local Police Department. A review of Certified Nurse Assistant # 4 timecard revealed they remained on duty until 7/13/2024 at 6:03 AM. Registered Nurse Supervisor #2 was interviewed on 7/31/2024 at 11:46 AM and stated they witnessed Certified Nurse Assistant #4 loudly yelling and arguing with Resident #68. Registered Nurse Supervisor #2 stated Certified Nurse Assistant #4's behavior was not acceptable. The Registered Nurse Supervisor # 2 could not recall what words were used; however, directed Certified Nurse Assistant #4 to go to the nursing supervisor's office. Certified Nurse Assistant #4 had not gone to the supervisor's office as instructed and went to the day room instead to argue more with Resident #68. Resident # 68 was interviewed on 7/31/2024 at 3:46 PM and stated that Certified Nurse Assistant #4 yelled and cursed at them and told them You are lucky I F . with you, otherwise I would have whooped your a s outside. Resident #68 stated they were upset and scared. Registered Nurse Supervisor #2 witnessed Certified Nurse Assistant #4 being verbally abusive. When they (Resident #68) went to the day room, Certified Nurse Assistant #4 followed them into the day room and continued to curse and yell at them. Resident #68 stated Certified Nurse Assistant #4 was reassigned to a different side of the hall but remained on the unit until the end of the shift. The resident stated they were afraid that night. Certified Nurse Assistant #4 was interviewed on 7/31/2024 at 1:50 PM and stated Resident #68 started yelling at them and was making false allegations against them because they did not braid the resident's hair. Certified Nurse Assistant #4 stated they worked all night and left the unit at 6:00 AM on 7/13/2024. Certified Nurse Assistant #4 denied being loud and denied using curse words. Registered Nurse Supervisor #3 was interviewed on 7/31/2024 at 3:05 PM and stated Certified Nurse Assistant #4 and Resident #68 had a verbal argument on 7/13/2024. Registered Nurse Supervisor #3 stated they did not remove Certified Nursing Assistant #4 from the unit because it was only a verbal argument. Registered Nurse Supervisor #3 stated they did not witness the verbal argument between the resident and the Certified Nurse Assistant #4. Registered Nurse Supervisor #3 stated they chose to stay with Resident #68 because the resident was very upset after the altercation and the resident needed emotional support. The Director of Nursing Services (DNS) was interviewed on 7/31/2024 at 2:53 PM and stated Certified Nurse Assistant #4 was terminated because there were witnesses that revealed Certified Nurse Assistant #4 was verbally abusive towards Resident #68 on 7/13/2024. Certified Nurse Assistant #4 should have been immediately suspended after they threatened Resident #68 because the staff witnessed the verbal abuse. The Director of Nursing Services stated that Resident #68 was verbally abused and threatened by Certified Nursing Assistant #4. The incident was reported to the Department of Health and the local Police. 10 NYCRR 415.4(b)(1)(i)

Based on observation, interview, and record review, the facility failed to ensure an ongoing activities program was provided based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community. This was identified for one (Resident #59) of one resident reviewed for activities. Specifically, Resident #59 was observed on multiple occasions in their room without meaningful activities (activities as per resident preferences, such as stimulation/conversation, crafts and or newspaper/ magazine, television/music). Additionally, the facility did not offer evening activities for any resident. The finding is: A facility policy titled Recreation Programming, last revised 6/2024 documented the facility must provide, based on the comprehensive assessment, individualized care plan, and the preferences of each resident, an ongoing program of recreational services to support residents in their choice of activities. The recreational programs/activities are designed to meet the interests of and support the physical, cognitive, social, emotional/psychosocial, and spiritual well-being of each resident. Activities are not limited to formal activities being provided only by the recreation department. Monthly calendars of scheduled activities are posted in resident rooms and common areas. Supplies/equipment for recreational activities must be readily available for use in recreational programs/activities. Residents are reminded and/or encouraged to attend activities through verbal and written announcements (for example: overhead announcements, staff announcements in resident rooms/units, daily chronicles). Residents are escorted/transported to/from the activity as needed, prior to the scheduled start time of the activity. Track all activity participation. Resident #59 has diagnoses of Cancer, Arthritis, and Cataracts/Glaucoma or Macular Degeneration. The Annual Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 12 indicating moderate cognitive impairment. The resident had adequate hearing, speech, and vision. Resident #59 was dependent on activities of daily living, such as eating and transfer. The resident and or family/significant other did not participate in the assessment and goal setting. The Minimum Data Set documented that having books, newspapers, and magazines to read, being around animals such as pets, and participating in religious services or practices were not very important to Resident #59. The Minimum Data Set further documented that listening to music and keeping up with the news was somewhat important. Doing things with groups of people, and going outside to get fresh air when the weather is good was very important to Resident #59. A Physician's order initiated 11/2/2022 and renewed 7/26/2024 documented Activity: As Tolerated. A comprehensive care plan, titled Resident is an active participant in therapeutic recreation programs, effective 11/29/2023 and last reviewed/revised 7/2/2024, documented interventions including escorting the resident to activities, informing the resident of activities, inviting the resident to activities, and offering one to one visit for stimulation/conversation. A comprehensive care plan titled Recreation- Independent, effective 11/29/2023 reviewed/revised 7/2/2024, documented Resident #59 preferred independent leisure time activities and plans own day as evidenced by the selection of activities that coincide with personal interest. Interventions included but were not limited to encouraging and maintaining involvement in activities of interest, inviting, informing, and offering to escort to activities, and offering one-to-one recreation visits for socialization. A care plan review note dated 6/14/2024 documented the resident is on daily visits with recreation staff, strolling music, and pet therapy. A care plan review note dated 7/2/2024 documented the resident continues to receive and enjoy one to one visits. A Therapeutic Recreation Initial assessment dated [DATE] documented the resident's hobbies as bowling, listening to music, using of personal iPad and phone, and watching television and movies. The resident participated in activities on a regular basis including Bingo, Left-Right-Center, special events, and barbeques, and attended entertainment and socials. The resident is an active participant in large group recreation programs including special events, socials, and bingo. The resident accepts one to one visits from recreation staff, pet therapy, and strolling music. A Therapeutic Recreation assessment dated [DATE] documented Resident #59 preferred things with groups of people, go outside to get fresh air when the weather is good, listen to music, and keep up with the news. Resident #59 was observed in their room and was interviewed on 7/24/2024 at 10:31 AM. Resident #59 stated that recreation staff do not come into their room to visit them because they (Resident #59) were on enhanced barrier precautions. Resident #59 stated the facility only offers bingo on weekends. On weekdays, there are no activities scheduled after 3:00 PM. Resident #59 was observed on 7/29/2024 at 2:14 PM in their room without meaningful activity (per resident preferences, such as stimulation/conversation, crafts and or newspaper/ magazine, television/music). Resident #59 stated that no one comes to their room to provide recreational activities because of the enhanced barrier precaution sign posted outside their room. A review of the Recreation Calendar for the month of July 2024, reflected no activity programs after 3:00 PM for any day of the week. The weekend activities calendar documented the following: on Saturday a morning strolling coffee cart and a nail spa were scheduled on alternating weekends, a game of Left-Right-Center or a movie was scheduled in the afternoon, and a refreshment cart was scheduled at 3:00 PM. On Sunday, a morning strolling coffee cart was scheduled in the morning, a movie or a classic show and bingo on the first floor was scheduled in the afternoon, and refreshment care was scheduled at 3:00 PM. A review of Resident #59's attendance record for the period of 1/1/2024 through 7/31/2024, documented that the resident had limited participation in programs. The resident received only seven one to one visits, three live entertainment programs, and one resident council/food committee meeting, and the resident attended games/puzzles only nine times from 1/1/2024 through 7/31/2024. There is no documented evidence that the resident was offered or invited to activity programs and refused. Recreation Aide #1 was interviewed on 7/30/2024 at 11:07 AM and stated they were assigned to provide activities on the second-floor unit during the day including a strolling coffee cart. Today they did craft time with the residents where they gave out coloring sheets and crayons. For residents in their rooms, they conducted a one-to-one visit and offered art supplies to the residents. Recreation Aide #1 stated that Resident #59 used to like to go outside and come to socials and was mainly out of bed in the afternoons. Recreation Aide #1 stated they were not able to provide attendance records or refusal records for activity programs for Resident #59 and were unable to explain why one to one visits were not conducted for Resident #59 as per the resident's care plan. Recreation Aide #1 stated they were aware that there are no scheduled evening activities, and that the facility is trying to hire more staff. Recreation Aide #1 stated that there are no restrictions on visiting Resident #59. The Assistant Director of Recreation was interviewed on 7/30/2024 at 2:02 PM and stated Resident #59's participation in activity programs was limited as the resident wanted to do independent things in their rooms. The Assistant Director of Recreation confirmed that there were no activities after 3:00 PM and only limited activities were offered on the weekend. The Assistant Director of Recreation was unable to explain why Resident #59 only had seven one to one visits over a seven-month period. The Administrator was interviewed on 7/31/2024 at 9:11 AM and stated that residents are brought to the main dining room around 2:00 PM for activities programs such as games, or to go outdoors. The Administrator stated they no longer have evening recreation staff and are looking to hire the evening recreation staff. 10 NYCRR 415.5(f)(1)

Based on observations, record review, and staff interviews during the Recertification Survey initiated on 8/05/2024 and completed on 8/09/2024, the facility did not ensure that each resident received adequate supervision to prevent accidents. This was identified for one (Resident #38) of three residents reviewed for abuse. Specifically, Resident #241, with known history of peer-to-peer physical altercations and behaviors that annoy others such as yelling, crying, and wandering into other residents' rooms. Resident #241 was to be kept in the line of sight in a supervised area when out of bed as per their Comprehensive Care Plan (CCP). On 4/7/2024, the staff did not supervise Resident#241 as directed. Resident #241 wandered into Resident#38's room and threw the opened water bottle at Resident #38's face when Resident #38 asked Resident #241 to leave their room. Subsequently, both Resident #38 and Resident #241 were observed on the floor in Resident #38's room fighting with each other. The finding is: Resident # 241 was admitted to the facility with diagnoses of Vascular Dementia with agitation, restlessness, and Anxiety disorder. The Quarterly Minimum Data Set assessment dated [DATE] documented the resident had a Brief Interview of Mental Status score of 5, which indicated the resident had severely impaired cognition. The Minimum Data Set documented the resident had no behaviors. The Behavior Comprehensive Care Plan dated 11/5/2022 last revised on 4/2024 documented that Resident #241 had physical behavioral symptoms directed toward others as evidenced by hitting and grabbing. The care plan documented the resident also had physical behavioral symptoms not directed toward others as evidenced by pacing, rummaging, and exposing genitals. The interventions were documented to keep the resident in a supervised area when out of bed. The Peer Abuse Comprehensive Care Plan dated 4/27/2023 documented that the Resident had the potential to abuse others due to a previous history of altercations with other residents/history of abusing others, the resident expressed anger by threatening to physically strike out or break things. The resident also had the potential to be a victim of abuse due to behaviors that annoy others such as yelling, crying, and wandering into other resident's rooms. The interventions included but were not limited to keep the resident safe by removing from the area if being annoyed by another resident, close monitoring, place within a line of sight in a supervised area when awake, engage in activities that can positively channel behavior and reduce frustration, identify programs/independent activities that are a distraction for the resident. A review of the care plan progress notes revealed that Resident #241 had peer-to-peer altercations with other residents (other than Resident #38) on 4/28/2023, 5/14/2023, and 10/28/2023. Resident #38 was admitted to the facility with diagnoses of lack of coordination, Type two Diabetes Mellitus, and Essential Tremors. The Minimum Data Set, dated dated dated [DATE] documented the resident had a Brief Interview of Mental Status score of 15, which indicated the resident had intact cognition. Resident #38 had an impaired range of motion on one side of the upper extremity. The Abuse comprehensive care plan dated 2/16/2024 documented that Resident #38 was at risk of being a victim of abuse, neglect, and/or mistreatment. The interventions included to monitor mood and provide early intervention on changes, provide emotional support and reassurance, room change, upon a report of the alleged abuse, ensure the resident is safe by removing the alleged abuser or moving the resident to a safe and supervised area. Resident #38 was interviewed on 7/24/2024 at 10:16 AM and stated they (Resident #38) were physically assaulted by Resident #241 on 4/7/2024 while they were in their (Resident #38's) bedroom. Resident #38 stated Resident #241 came into their room and started hitting and punching Resident #38, then pushed them (Resident #38) onto the floor. Resident #38 stated the staff knew Resident #241 was a threat to all residents. The Accident and Incident Report dated 4/7/2024 documented that on 4/7/2024 at approximately 9:30 AM, Certified Nursing Assistant #6 walked into Resident #38's room after they (Certified Nursing Assistant #6) heard help and observed Resident #241 and Resident #38 on the floor fighting. Resident #241 was removed from Resident #38's room and both residents were assessed. Resident #38, who was alert and oriented, reported they (Resident #38) were in the bathroom brushing their teeth when they heard somebody outside the bathroom door. Resident #38 walked out of the bathroom and saw Resident #241 standing by Resident #38's bed next to their bedside table. Resident #38 told Resident #241 to leave and Resident #241 picked up an open bottle of water and threw the bottle in Resident #38's face. Resident #38 and Resident #241 started to fight, resulting in them both on the floor. Resident #241 was not able to give any statement due to cognitive impairment; however, Resident #241 said l need to fight more. Resident #241 was last seen sitting in the day room before the incident. The incident summary documented that there must be consistent staff observation for Resident #241. The summary concluded the resident to resident altercation was unpredictable and unavoidable due to Resident #241's diagnoses of [NAME] Matter Disease and Post Traumatic Stress Disorder. Certified Nursing Assistant #6 was interviewed on 7/31/2024 at 11:16 AM and stated they were assigned to Resident #241 on 4/7/2024. Resident #241 was confused, agitated, and had a history of hitting other residents. Certified Nursing Assistant #6 stated that prior to the altercation between Resident #241 and Resident #38, Resident #241 was sitting in the day room which was supervised by Resident Assistant #2. Certified Nursing Assistant #6 stated that they went on their break and when they returned, they heard Resident #38 yelling for help. Certified Nursing Assistant #6 stated they observed Resident #38 was on the floor in Resident #38's room and Resident #241 was bending over Resident #38. Certified Nursing Assistant #6 stated that all unit staff were responsible for supervising Resident #241 while the resident was ambulating in the hallway due to their (Resident #241) physically aggressive behavior. Licensed Practical Nurse #3 was interviewed on 7/31/2024 at 11:43 AM and stated that they were the medication nurse on the unit on 4/7/2024. Licensed Practical Nurse #3 stated they were aware that Resident #241 had a history of physical altercations with other residents. Licensed Practical Nurse #3 stated Residents who needed supervision are usually placed in the day room. Resident Assistants are assigned to monitor the residents in the day room. Resident #241 was supposed to be kept in the dining room for close supervision and to keep the resident in the line of sight at all times when awake. Licensed Practical Nurse #3 stated that they did not observe Resident #241 in the hallway prior to the incident because they (Licensed Practical Nurse #3) were administering medications to other residents. Resident Assistant #2 was interviewed on 7/31/2024 at 11:57 AM and stated they (Resident Assistant #2) are responsible for supervising the day room and answering the call bells on 4/7/2024. Resident Assistant #2 stated they are not responsible for monitoring the hallway. Resident Assistant #2 stated they were only responsible for supervising the residents who were in the day room. Resident Assistant #2 stated on 4/7/2024, Resident #241 was constantly walking in and out of the day room. When they observed Resident #241 leave the day room, they did not question or follow the resident because they did not want to agitate Resident #241. Resident Assistant #2 stated they did not alert any other staff member to supervise Resident #241 in the hallway because there was no staff present in the hallway or at the nursing station. Certified Nurse Assistant #7 was interviewed on 7/31/2024 at 12:24 PM and stated they were assigned to Resident #38 on 4/7/2024. Certified Nurse Assistant #7 stated they did not observe Resident #241 in the hallway and did not observe the altercation between Resident #241 and Resident #38 because they were off the unit for a couple of minutes. Certified Nurse Assistant # 7 stated all staff are supposed to supervise Resident #241 since Resident #241 had a history of going into other resident rooms and physically assaulting the residents. Registered Nurse Supervisor #4 was interviewed on 7/31/2024 at 12:30 PM and stated they were the unit supervisor on 4/7/2024. Registered Nurse Supervisor #4 stated they were aware Resident #241 wandered into the other resident rooms and hit other residents. Registered Nurse Supervisor #4 stated they were aware Resident #241 needed to be supervised and should remain in the line of sight at all times all the time when awake. Registered Nurse Supervisor #4 stated that they did not observe Resident #241 in the hallway or going into Resident #38's room because they (Registered Nurse Supervisor #4) were conducting rounds on the other side of the unit. Registered Nurse Supervisor #4 stated Resident Assistant #2 was assigned to supervise the day room and should have notified the nurse when Resident #241 exited the day room so the other staff could supervise the resident in the hallway. The Director of Nursing Services was interviewed on 7/31/2024 at 2:32 PM and stated the facility should have prevented the altercation between Resident #241 and Resident #38. The Director of Nursing Services stated Resident #241 should have been supervised and kept within the line of sight at all times when awake as per the resident's plan of care. The Director of Nursing Services stated that one Certified Nursing Assistant should have been dedicated to supervising Resident #241 at all times. 10 NYCRR 415.12(h)(2)

Based on observations, interviews, and record review during the recertification survey initiated on 7/24/2024 and completed on 7/31/2024, the facility did not ensure that each resident's medical record was maintained in accordance with accepted professional standards and practices. The facility did not maintain medical records for each resident that were complete and accurately documented. This was identified for one (Resident #74) of one resident reviewed for Respiratory Care. Specifically, Resident #74 was observed receiving oxygen therapy without a physician's order on multiple occasions (7/24/2024, 7/25/2024, 7/26/24 and 7/29/2024). The finding is: The facility's policy and procedure titled Respiratory Care, undated, documented to verify that there is a physician's order in place and review the physician's orders or facility protocol for oxygen administration. Resident #74 had diagnoses that included Chronic Obstructive Pulmonary Disease, Schizophrenia, and Mild Intermittent Asthma. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 9 which indicated the resident had moderate cognitive impairment. The physician's orders for July 2024 (interim and renewal orders) were reviewed and there was no documented evidence of an order for oxygen therapy. Resident #74 was observed in their room on 7/24/2024 at 10:28 AM, 7/25/2024 at 8:42 AM, and 7/26/2024 at 8:16 AM receiving oxygen therapy at 3 liters per minute. On 7/29/2024 at 10:14 AM the resident was observed in their room receiving oxygen therapy at 2 liters per minute from an oxygen concentrator via a nasal cannula. A physician's monthly medical note dated 7/19/2024 had no documented evidence that the resident was receiving oxygen therapy. A comprehensive care plan titled Alteration in Respiratory Status, effective date 4/13/2023, last reviewed 4/20/2024, documented the resident had altered respiratory status related to Chronic Obstructive Pulmonary Disease and Asthma, as evidenced by shortness of breath and the resident requires oxygen. The Licensed Practical Nurse Manager #1 was interviewed on 7/29/2024 at 10:33 AM and stated Resident #74 receives oxygen therapy daily; however, they were not able to find current physicians' orders for oxygen use for Resident #74. Nurse Practitioner #1 was interviewed on 7/29/2024 at 10:48 AM and stated Resident #74 used oxygen therapy at bedtime according to the resident. Nurse Practitioner #1 stated Resident #74 should have a physician's order for the use of oxygen therapy. The Director of Nursing Services was interviewed on 7/29/2024 at 11:04 AM and stated that if the resident needs oxygen therapy then a physician's order should have been obtained. Physician #2 was interviewed on 7/29/2024 at 1:42 PM and stated that with a diagnosis of Asthma or Chronic Obstructive Pulmonary Disease, a resident may sometimes need oxygen. Physician #2 stated that the oxygen order for Resident #74 was given as a verbal order and Physician #2 was unaware that Resident #74 did not have a written order for the use of oxygen therapy. 415.22(a)(1-4)

Based on observations, record review, and interviews conducted during a Focus Infection Control Survey on 1/03/2023, the facility failed to ensure that the facility maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and COVID-19 infections. Specifically, Resident #1, who was positive for COVID-19 infection and had a Physician's order for Droplet and Contact precautions, had a visitor who was not educated by the facility staff regarding the appropriate use of Personal Protective Equipment (PPE) when visiting the resident's room. Resident #1's visitor was observed entering the resident's room wearing only a surgical mask. The finding is: The facility policy titled, COVID-19 Visitation Plan, dated 4/12/2022 documented all visitors must wear a well-fitting mask of higher quality (i.e., surgical mask, KN95, N95) at all times during any visitation at the facility. All visitors will be made aware of the potential risk of visiting and the precautions necessary in order to visit the resident. Visitors must adhere to the core principles of infection prevention. Resident #1 was admitted to the facility on [DATE] with a diagnosis including positive for COVID-19 infection. The Physician orders dated 12/29/2022 documented to place Resident #1 on Droplet and Contact precautions due to positive COVID-19 infection. A visitor for Resident #1 was observed walking into Resident #1's room on 1/3/2023 at 11:35 AM wearing only a surgical mask. There was a sign outside Resident #1's room that documented to see the nurse. Resident #1's visitor was interviewed on 1/3/2023 immediately after the observation at 11:35 AM and stated they (visitor) were aware that Resident #1 was positive for COVID-19 infection. The visitor stated they (visitor) were not informed by anyone to wear PPE when visiting Resident # 1. The visitor stated that they (visitor) saw the sign that was posted outside the resident's room indicating to see the nurse. The visitor stated that they did not go to the nurse's station as the facility staff saw them (visitor) when they came into the unit and entered Resident #1's room. During a subsequent observation on 1/3/2023 at 12:15 PM Resident #1's visitor was observed in the resident's room wearing a KN95 mask and was observed feeding the resident. The visitor was not wearing a gown, gloves, or either an eye shield or goggles. Resident #1's visitor was again observed in Resident#1's room on 1/3/2023 at 4:20 PM. The visitor was wearing a KN95 mask. They (visitor) were sitting on Resident #1's bed and were talking to the resident. The resident was observed sitting in a wheelchair less than six feet away from the visitor. The visitor was not wearing a gown, gloves, or either an eye shield or goggles. The Front Desk Receptionist #1 was interviewed on 1/3/2023 at 11:45 AM and stated that each visitor gets tested for COVID-19 infection when they arrive at the facility to visit their loved ones. Receptionist #1 stated they (Receptionist #1) do not provide directions to the visitors regarding the use of PPE. Receptionist #1 stated they do not educate the visitors regarding wearing PPE while visiting a COVID-19 positive resident. The assigned Licensed Practical Nurse (LPN) #1 was interviewed on 1/3/2023 at 12:30 PM and stated they (LPN #1) were aware that Resident #1 was on Contact and Droplet precautions due to COVID-19 infection. LPN #1 stated that anyone who enters a COVID-19 positive resident's room should put on an N95 mask covered with a surgical mask, a gown, and an (LPN #1) eye shield or goggles. LPN #1 stated they did not know if they had to educate residents' visitors regarding the use of PPE. LPN #1 stated that COVID-19 infection has been around for more than three years, and the visitor should have known to wear an N95 mask prior to entering Resident #1's room. The Infection Control (IC) Nurse was interviewed on 1/3/2023 at 2:57 PM and stated there should be no visitors allowed on the COVID-19 unit unless the resident was terminal and required compassionate care visits. The IC stated visitors who are visiting terminally ill COVID-19 residents should wear full PPE including an N95 mask, a gown, gloves, and an eye shield or goggles. The IC stated that they were not aware of any visitors to the COVID-19 unit. The IC stated the receptionist should not allow visitors to visit the COVID-19 unit. The Director of Nursing Services (DNS) was interviewed on 1/3/2023 at 4:45 PM and stated that there was no restriction on visitation to the COVID-19 units. The DNS stated that the visitors should be informed by the Receptionist to wear the appropriate PPE when visiting the residents who are positive for COVID-19 infection. The DNS stated they (DNS) were not aware that the visitor for Resident #1 was not wearing appropriate PPE. 10 NYCRR 415.19(a)(1-3)

Based on observations, record review, and interviews during the Recertification Survey initiated on 9/18/2022 and completed on 9/23/2022, the facility did not ensure sufficient nursing staff to provide nursing services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. This was identified for one of two nursing units. Specifically, 1) The facility nursing staffing assignments did not reflect the staffing needs as indicated in the facility assessment for the Certified Nursing Assistants (CNA), 2) during an initial tour of the 1st-floor nursing unit conducted on 9/18/2022 at 10:30 AM, Resident #266, who was cognitively intact, complained that they were sitting in a soiled diaper for a long time. Resident #266 stated they soiled themselves soon after they finished their breakfast (the breakfast time for the resident's unit was between 6:45 AM-7:45 AM) 3) During an interview with Resident #63, who was cognitively intact, the resident complained that their left foot wound treatment was not completed for two days due to lack of adequate staffing. The findings are: 1) The Facility Assessment last reviewed on 9/1/2022 documented the facility provides care to 120 residents divided by 2 units (60 residents per unit). The Facility Assessment documented that there should be a minimum of 8 Certified Nursing Assistants (CNA)s assigned during the 6 AM to 2 PM and during the 2 PM to 10 PM shift. There should be 4 CNAs assigned during the 10 PM to 6 AM shift. A review of the facility's Staffing sheets from 7/17/2022- 9/23/2022 revealed the following: -On 7/17/2022 and 7/21/2022 during the 2 PM to 10 PM the facility had a total of 5 CNAs scheduled to work for both units. The Facility Assessment indicated a need for 8 CNAs during the 2 PM-10 PM shift. -On 7/18/2022, 7/19/2022, 7/22/2022, 7/23/2022, 9/11/2022, 9/12/2022, 9/17/2022 during the 2 PM to 10 PM shift the facility had a total of 6 CNAs scheduled to work for both the units. The facility assessment indicated a need for 8 CNAs during the 2 PM-10 PM shift. -On 8/6/2022 during the 2 PM to 10 PM shift the facility had a total of 4.5 CNAs scheduled to work for both units. The facility assessment indicated a need for 8 CNAs during the 2 PM-10 PM shift. -On 9/1/2022 and 9/2/2022 during the 6 AM to 2 PM shift the facility had a total of 6 CNAs scheduled to work for both units. The facility assessment indicated a need for 8 CNAs during the 6 AM-2 PM shift. Resident # 36 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 12 indicating moderately impaired cognition. The MDS documented the resident was always incontinent of bowel and bladder and was totally dependent on staff for personal hygiene. Resident #36 was interviewed on 9/18/2022 at 12:33 PM their diaper is not changed timely due to poor staff. Stated they waited hours to get their diaper changed. Resident #7 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 15 indicating intact cognition The MDS documented the resident was frequently incontinent of bowel and bladder and required extensive assistance of one staff member for personal hygiene. Resident #7 was interviewed on 9/19/2022 at 1:19 PM and stated that the facility staff takes hours to answer the call bell. Anonymous CNA #3 was interviewed on 9/22/2022 at 11:35 AM and stated the facility is short of staff. Some days 60 residents had only one CNA to care for them. CNA #3 stated that the facility had many residents who need assistance with care and the staff is unable to provide assistance or care to those residents because of short staffing levels. CNA #3 stated it is difficult to get the residents out of bed, especially those requiring the Hoyer lift transfers, who need two staff members' assistance. CNA #3 further stated that at times they (CNA #3) are unable to turn and position residents every two hours because of short staffing. The Director of Nursing Services was interviewed on 9/23/2022 at 4:07 PM and stated that the facility is having difficulty recruiting CNAs and at times the facility is short of staff. The DNS stated that some Physical Therapy (PT) staff are cross-trained to assist with toileting residents and to provide assistance to unit staff in getting the residents out of bed. The DNS stated that the goal is to decrease the wait time for the residents. Staffing Coordinator (SC) #1 was interviewed on 9/23/22 at 3:09 PM. The Staffing Coordinator stated that the Supervisor would be responsible for calling to replace staff on the late shifts and weekends. The Staffing coordinator stated that they do not work on the weekend and that they would not know who called in until Monday. The Staffing coordinator stated that when the facility is short-staffed the Staffing Coordinator would contact staff that are not scheduled to work and ask staff who are currently working if they were willing to cover a second shift. The Staffing Coordinator stated that sometimes they (Staffing Coordinator) are not able to get the required number of staff to work on the units. The Staffing Coordinator stated that the staffing should be as follows: 1st and 2nd Floor 6:00 AM-2:00 PM- 2 Unit Managers, 2 LPNs, and 6 CNAs on each floor. 2:00 PM-10:00 PM - 1 RN Supervisor, 2 LPN, and 5 CNAs on each floor. 10:00 PM - 6:00 AM 1 RN Supervisor, 1 LPN, and 3 CNAs on each floor. The Staffing Coordinator stated they (Staffing Coordinator) were not aware of the staffing levels reported in the facility assessment. The Administrator was interviewed on 9/23/2022 at 6 PM and stated the facility has a shortage of CNA staff. The Administrator stated they have been having difficulties hiring CNAs. The Administrator stated the facility has contracts with staffing agencies; however. some days the agencies are not able to fulfill the facility's staffing needs. 2) The facility Activity of Daily Living (ADL) Support policy revised 10/2019 documented residents will be provided with care, treatment, and services to ensure that their ADLs do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable. The policy further documented that appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident, and in accordance with the plan of care. Resident #266 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 15 which indicated the resident had intact cognition. The resident required extensive assistance of one staff member for toileting and was occasionally incontinent of bowel and bladder. A Comprehensive Care Plan (CCP) dated 9/12/2022 documented the resident has bladder incontinence. The interventions included but were not limited to encourage fluids during the day to promote prompted voiding and to monitor, document, and report to the Physician as needed (PRN) of any changes in incontinence. The Resident's toileting record was reviewed from 9/15/2022 to 9/23/2022 and there was no documentation of bowel or bladder incontinence recorded for 9/18/2022. During the initial tour of the 1st-floor nursing unit on 9/18/2022 at 10:30 AM Resident #266's call bell was observed to be ringing. Resident #266 stated that they had been sitting in a soiled diaper for a long time since. Resident #266 stated they soiled the brief soon after they finished their breakfast and needed to be changed (the 1st-floor unit breakfast times are between 6:45-7:45). The resident stated that they were last changed at 5:00 AM. Certified Nursing Assistant (CNA) #4, who cared for Resident #266 on 9/18/2022, was interviewed on 9/23/2022 at 12:39 PM. CNA #4 stated that they (CNA #4) were assigned to approximately 17 residents on 9/18/2022 on the 6:00 AM - 2:00 PM shift. CNA #4 stated that they normally work during the 2 PM-10 PM shift but picked up an extra shift because the facility was short-staffed. CNA #4 stated they started the morning care for Resident #266 just before 11:00 AM. CNA #4 stated that the resident was incontinent of bowel and bladder. CNA #4 could not recall if Resident #266 was incontinent of bowel on 9/18/2022. CNA #4 stated that they (CNA #4) saw the resident at the start of the shift and during breakfast and told the resident that they (CNA #4) would be back to care for them (Resident #266) after breakfast. CNA #4 stated prior to the COVID-19 Pandemic the facility had five CNAs on the 2:00 PM - 10:00 PM shift and six CNAs on the 6:00 AM - 2:00 PM shift. CNA #4 stated after the Pandemic they work with only three to four CNAs on the 2:00 PM-10:00 PM shift. The CNA stated that there might not be any documentation on the resident's bowel record on 9/18/2022 because they (CNA #4) did not have time. CNA #4 stated that they would have gotten to the resident sooner had there been more CNAs on the unit. The Director of Nursing Services (DNS) was interviewed on 9/23/2022 at 4:07 PM and stated that the facility was short-staffed on 9/18/2022 and there was only one nurse with a trainee and three CNAs on the 1st-floor nursing unit for fifty residents. 3) The facility Dressing Change policy revised 3/24/2010 documented treatment must be done at the scheduled time, check the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #63 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Significant change Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 15 which indicated the resident had intact cognition. The resident had no behavioral symptoms and does not reject care. The resident was at risk for developing pressure ulcers. The resident has a pressure ulcer-reducing device for bed and chair and application of ointment other than to feet. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Comprehensive Care Plan (CCP) for Alteration in Skin Integrity dated 9/8/2022 documented the resident had an actual pressure ulcer to the left lateral foot measuring (6-centimeter (cm) x 4 cm x 0 cm). Interventions included but were not limited to evaluate the wound weekly and as needed, document wound measurements, wound bed appearance, odor, drainage, and surrounding tissue, and to monitor the wound daily for signs and symptoms of infection. The Treatment Administration Record (TAR) for September 2022 was reviewed on 9/23/2022. There was no documented evidence that on 9/15/2022 and 9/17/2022 the treatment to the resident's left leg was administered. Resident #63 was interviewed on 9/19/2022 at 11:20 AM and stated that due to short staffing their wound care and dressing change was not completed for two days. The resident stated that their dressing was not completed on 9/15/2022 and 9/17/2022. Licensed Practical Nurse (LPN) #5 who cared for Resident #63 on 9/17/2022 was interviewed on 9/22/2022 at 5:35 PM. LPN #5 stated that they worked on 9/17/2022 and that they did not sign the TAR because they did not complete the resident's treatment. In a subsequent interview with LPN #5 on 9/23/2022 at 2:45 PM, LPN#5 stated that on 9/17/2022 on the 2:00 PM -10:00 PM shift one LPN called in sick and the Assistant Director of Nursing Services (ADNS) worked as a floor nurse on the long hallway, and they (LPN #5) worked the short hall. LPN #5 stated that the facility was also short of CNAs. LPN #5 stated they had two CNAs on the Unit, one of the CNAs worked until 8 PM and the other CNA worked the entire shift. LPN #5 stated they (LPN #5) were unable to complete the treatment because they (LPN #5) were helping the CNA. LPN #5 stated they also worked on the 10:00 PM-6:00 AM shift (on 9/17/2022 into 9/18/2022 night) with only one CNA because the other scheduled CNA called in sick and was not replaced. A Daily Staffing sheet dated 9/17/2022 documented that during the 2:00 PM-10:00 PM the ADNS worked from 7:00 AM-7:00 PM, one CNA called in sick, one CNA worked until 8:00 PM and one CNA worked the entire shift. On the 10:00 PM-7:00 AM shift one LPN, and one CNA called in sick and one CNA worked the entire shift LPN #6, who cared for Resident #63 on 9/15/2022, was interviewed on 9/23/2022 at 11:32 AM. LPN #6 stated they worked during the evening shift on 9/15/2022 because the evening nurse called in sick and they (LPN #6) had to work a double shift. LPN #6 stated that she did complete the treatment on 9/15/2022 on the 2:00 PM-10:00 PM shift and must have forgotten to sign the TAR. LPN #6 stated that the resident does not have a history of fabricating stories and does not talk much. The Director of Nursing Services (DNS) was interviewed on 9/23/2022 at 3:55 PM and stated LPN #5 should have reported to their supervisor that they (LPN #5) were unable to complete the treatment on 9/17/2022. The DNS stated that the Supervisor would either have assisted or designated someone to complete the treatment. The ADNS, who was the RN Supervisor on 9/17/2022 on the 2:00 PM - 10:00 PM shift, was interviewed on 9/23/2022 at 4:36 PM. The ADNS stated that they worked as a floor nurse on 9/17/2022. The ADNS stated that they (ADNS) were not aware that Resident #63's dressing change was not completed. The ADNS stated there were many residents with behaviors on the unit and the unit was very busy and they (ADNS) also had one new admission on that shift. The ADNS stated that the facility was down an RN Supervisor and that they (ADNS) were helping with supervision and medication pass until an RN relieved them at 8 PM from the unit duties. The RN stated that LPN #5 should have informed them that the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] 415.13(a)(1)(i-iii)

Based on observation, interviews, and record review during a Recertification Survey initiated on 9/18/2022 and completed on 9/23/2022, the facility did not ensure that medical care for each resident was effectively supervised by a Physician. This was identified for one (Resident #107) of five residents reviewed for unnecessary medications. Specifically, Resident #107's physician abruptly discontinued an antipsychotic medication ([MEDICATION(S)]) without tapering the dosage and did not provide instructions for staff to monitor for withdrawal symptoms. Furthermore, the Physician's assessment included a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The finding is: The Facility's policy on antipsychotic medications, dated 8/2019 documented that residents who use antipsychotic drugs shall receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. The Physician will order appropriate tapering of medications, as indicated. The Manufacturer's safety information for [MEDICATION(S)] documented elderly patients with dementia-related [CONDITION(S)] (having lost touch with reality due to confusion and memory loss) treated with this type of medicine [[MEDICATION(S)]] are at an increased risk of death. Stopping [MEDICATION(S)] abruptly will frequently evoke a wide range of withdrawal symptoms, generally referred to as [MEDICATION(S)] ([MEDICATION(S)]) Discontinuation Syndrome. If the decision to come off [MEDICATION(S)] is made, stopping should never be done abruptly unless to avert a life-threatening reaction such as Neuroleptic Malignant Syndrome (NMS-a rare reaction to antipsychotic drugs that treat [CONDITION(S)], [CONDITION(S)], and other mental health conditions). Resident #107 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] #107 had a Brief Interview for Mental Status (BIMS) score of 3, indicating severely impaired cognition. The MDS also documented that Resident #107 did not have any behavioral symptoms, rejection of care, or wandering. Additionally, the MDS documented that Resident #107 received antipsychotic medication 7 of the 7 days in the look-back period. Resident #107 was observed in bed on 9/18/2022 at 10:45 AM in their room. The resident was awake but unable to answer simple questions. The Level 1 admission screen dated 8/23/2022 documented the resident had no serious mental illness. The admission Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Physician's Admission assessment dated [DATE] documented the resident was admitted with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician documented that the resident was on [MEDICATION(S)] and recommended a psychiatric evaluation. The Physician further documented [Gradual Dose Reduction] GDR as per psych-dementia. A Psychiatry Consult dated 9/7/2022 documented the Primary Psychiatric diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident continued to receive 100 mg of [MEDICATION(S)] in the evening for Dementia. The Pharmacist Consult dated 9/9/2022 documented Resident # 107 receives [MEDICATION(S)] for Dementia, not appropriate for antipsychotic medications. Suggested alternatives: [CONDITION(S)], [CONDITION(S)], MDD, [CONDITION(S)], [CONDITION(S)]. Order psychiatric consult to monitor. A telephone physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The Physician assessments dated 9/3/2022, 9/5/2022, 9/6/2022, and 9/9/2022 documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The treatment plan included [MEDICATION(S)]. The Director of Nursing Services (DNS) was interviewed on 9/20/2022 at 1:10 PM and stated after discussing the resident with the physician on 9/19/2022, [MEDICATION(S)] was discontinued. The DNS stated that they (DNS) were not aware that the resident was on more than 50 mg of [MEDICATION(S)]. The DNS further stated there was no documented evidence the resident was monitored between 9/19 and 9/20/2022 after [MEDICATION(S)] was discontinued and there should be documentation that the resident was monitored after a [CONDITION(S)] medication is discontinued. The Medical Director was interviewed on 9/20/2022 at 2:12 PM and stated that they (Medical Director) gave the order to discontinue [MEDICATION(S)] for Resident #107; however, at the time they (Medical Director) were not aware that Resident #107 was receiving 150 mg of [MEDICATION(S)] per day. The Medical Director stated they (Medical Director) thought the resident was only receiving a total of 50 mg of [MEDICATION(S)]. The Medical Director stated that they (Medical Director) would not have discontinued 150 mg of [MEDICATION(S)] abruptly. The Medical Director stated if the [MEDICATION(S)] dosage is more than 50 mg, a GDR protocol has to be followed. If [MEDICATION(S)] medication is not gradually reduced, the resident can have serious cardiovascular concerns and other withdrawal symptoms. The nursing staff should have directions to monitor the resident's vital signs and other signs and symptoms of withdrawal from [MEDICATION(S)]. The Psychiatric Nurse Practitioner (NP) was interviewed on 9/21/2022 at 3:18 PM and stated the resident was admitted from the hospital without adequate indications for the use of [MEDICATION(S)]. The NP stated the resident never had a [CONDITION(S)] diagnosis. The NP stated that 150 mg of [MEDICATION(S)] cannot be abruptly stopped. The NP stated that if [MEDICATION(S)] is abruptly stopped then there is potential for harm including cardiac complications. The Attending Physician was interviewed on 9/23/2022 at 11:46 AM and stated the resident was on [MEDICATION(S)] because of inappropriate behavior, hallucinations, and Dementia. The Physician stated they (Physician) did not know the resident's psychiatric history and diagnosed the resident with [CONDITION(S)] diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician stated the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) category of Psychiatric diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Physician stated that the [CONDITION(S)] diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 415.15(b)(1)(i)(ii)

Based on observations, record review, and interviews during the Recertification Survey initiated on 9/18/2022 and completed on 9/23/2022, the facility did not ensure that a clean, comfortable, and homelike environment was maintained on one of two nursing units. Specifically, a vacant resident room was observed on 9/18/2022 and 9/19/2022 with a commode containing feces and urine with flies around the commode. The finding is: The Undated Facility's policy, titled Room Readiness, documented to provide a clean and safe environment for all residents. The Facility's policy dated 9/20/2022, titled Terminal Cleaning/Complete Room Cleaning, documented all resident rooms receive a terminal cleaning/completed room cleaning monthly, at the time of [resident] discharge, or as needed. During an environmental tour on 9/18/2022 at 9:40 AM, 10:15 AM, and 1 PM room 120 was observed with a dirty commode containing feces and urine. Flies were observed swarming around the commode. The room had a foul odor. LPN #4 was interviewed on 9/18/2022 at 9:39 AM and stated that the resident who resided in room 120 went to the hospital on Friday 9/16/2022 in the afternoon. Room 120 was observed again on 9/19/2022 at 9:40 AM, 10:20 AM, 12:10 PM, and 1:30 PM. The room had a foul odor. The commode was again observed containing feces and urine with flies in the room. The Director of Rehabilitation, who was near room 120 on 9/19/2022 at 12:10 PM during the above observation, also observed the commode containing feces, urine, and flies. The Director of Rehabilitation stated that the room should have been cleaned after the resident was transferred. The commode should have been emptied and cleaned. The Director of Rehabilitation stated they (Director of Rehabilitation) will report the observation to the head of housekeeping. The Certified Nurse Assistant (CNA) #1 was interviewed on 9/20/2022 at 4:43 PM and stated the resident who resided in room 120 was transferred to the hospital on 9/16/2022 during the evening shift. CNA #1 stated the CNA who was assigned to room 120 should have cleaned the commode and the housekeeper should have cleaned the room. The Environmental Service Director was interviewed on 09/23/2022 at 2:07 PM and stated they (Environmental Service Director) are in charge of the housekeeping, maintenance, and laundry services. The Environmental Service Director stated that the housekeeping staff members do not touch the commodes; only the CNAs clean the commodes. The Environmental Service Director stated the housekeeper should have notified the CNA if the commode needed to be emptied or cleaned. The Environmental Service Director stated the admission department is responsible to notify housekeeping when there is an admission or discharge. The admission department did not notify the housekeeping staff of the resident's discharge to the hospital so that the housekeeping staff could clean the room. CNA #4 was interviewed on 9/23/2022 at 3:41 PM and stated that they (CNA #4) worked on 9/16/2022 from 2 PM to 7 PM and usually empties the commode after the residents leave the facility after a resident leaves, but they were busy and were trying to get other tasks done. CNA #4 was not aware of the dirty commode in room 120. The Director of Nursing Services (DNS) was interviewed on 9/23/2022 at 4:26 PM and stated that on 9/19/2022 the Director of Rehabilitation informed them (DNS) about a dirty commode in room 120 that needed cleaning. The DNS stated that they (DNS) directed the housekeeper and nursing staff to clean the commode and the room [120]. The DNS stated that CNAs are expected to empty and clean the commodes. 415.5

Based on observation, record review, and interviews during the Recertification Survey initiated on 9/18/2022 and completed on 9/23/2022, the facility did not ensure that each resident's drug regimen remained free from unnecessary drugs. This was identified for one (Resident #107) of five residents reviewed for unnecessary medications. Specifically, Resident #107 with a diagnosis of Dementia was admitted to the facility on [DATE] and was prescribed [MEDICATION(S)] (an antipsychotic medication) without an appropriate diagnosis for the antipsychotic medication use. Subsequently, the Physician discontinued [MEDICATION(S)] abruptly on 9/19/2022 without tapering the medication or providing instructions for staff to monitor the resident for withdrawal symptoms. Additionally, the resident's Primary Care Physician diagnosed the resident with a new diagnosis of [CONDITION(S)] as documented in the Physician Assessment, after the resident was admitted to the facility from the hospital. The finding is: The Facility's policy on antipsychotic medications, dated 8/2019 documented that residents who use antipsychotic drugs shall receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. The Physician will order appropriate tapering of medications, as indicated. The Manufacturer's safety information for [MEDICATION(S)] documented elderly patients with dementia-related [CONDITION(S)] (having lost touch with reality due to confusion and memory loss) treated with this type of medicine [[MEDICATION(S)]] are at an increased risk of death. Stopping [MEDICATION(S)] abruptly will frequently evoke a wide range of withdrawal symptoms, generally referred to as [MEDICATION(S)] ([MEDICATION(S)]) Discontinuation Syndrome. If the decision to come off [MEDICATION(S)] is made, stopping should never be done abruptly unless to avert a life-threatening reaction such as Neuroleptic Malignant Syndrome (NMS-a rare reaction to antipsychotic drugs that treat [CONDITION(S)], [CONDITION(S)], and other mental health conditions). Resident #107 was admitted on [DATE] with diagnoses including Alzheimer's Dementia and Anxiety. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #107 had a Brief Interview for Mental Status (BIMS) score of 3, indicating severely impaired cognition. The MDS also documented that Resident #107 did not have any behavioral symptoms, rejection of care, or wandering. Additionally, the MDS documented that Resident #107 received antipsychotic medication 7 of the 7 days in the look-back period. Resident #107 was observed in bed on 9/18/2022 at 10:45 AM in their room. The resident was awake but unable to answer simple questions. The Level 1 admission screen dated 8/23/2022 documented the resident had no serious mental illness. The admission Physician orders dated 8/23/2022 documented to administer [MEDICATION(S)] ([MEDICATION(S)] [MEDICATION(S)]) Oral Tablet 100 milligrams (mg), give 1 tablet by mouth (PO) in the morning (am) and 1 tablet in the evening (pm) for Dementia and Psychiatric consult. The Physician's Admission assessment dated [DATE] documented the resident was admitted with a diagnosis of Dementia. The assessment did not include a diagnosis of [CONDITION(S)]. The physician documented that the resident was on [MEDICATION(S)] and recommended a psychiatric evaluation. The Physician further documented [Gradual Dose Reduction] GDR as per psych-dementia. A Psychiatry Consult dated 9/7/2022 documented the Primary Psychiatric diagnosis as Alzheimer's disease unspecified, and the recommendations were to decrease [MEDICATION(S)] to 50 mg PO in am and continue [MEDICATION(S)] 100 mg PO in pm (from 100 mg twice daily). The physician orders dated 9/7/2022 documented to decrease the morning dose of [MEDICATION(S)] Oral Tablet to 50 MG ([MEDICATION(S)] [MEDICATION(S)]); and the diagnosis was changed to Major Depressive Disorder (MDD). The resident continued to receive 100 mg of [MEDICATION(S)] in the evening for Dementia. The Pharmacist Consult dated 9/9/2022 documented Resident # 107 receives [MEDICATION(S)] for Dementia, not appropriate for antipsychotic medications. Suggested alternatives: [CONDITION(S)], [CONDITION(S)], MDD, [CONDITION(S)], [CONDITION(S)]. Order psychiatric consult to monitor. A telephone Physician's order dated 9/19/2022 at 1:48 PM, given by the medical director and received by the Director of Nursing Services (DNS), documented to discontinue both [MEDICATION(S)] morning dose (50 mg) and evening dose (100 mg), 10 days after the recommendation was provided by the Pharmacist. A review of the Medication Administration record (MAR) revealed Resident #107 did not receive [MEDICATION(S)] 100 mg on 9/19/22 at 6 PM and 9/20/22 at 10 AM (50 MG). The Physician assessments dated 9/3/2022, 9/5/2022, 9/6/2022, and 9/9/2022 documented diagnoses of [CONDITION(S)], Alzheimer's disease, and unspecified Dementia without behavioral disturbance. The treatment plan included [MEDICATION(S)]. The Director of Nursing Services (DNS) was interviewed on 9/20/2022 at 1:10 PM and stated after discussing the resident with the physician on 9/19/2022, [MEDICATION(S)] was discontinued. The DNS stated that they (DNS) were not aware that the resident was on more than 50 mg of [MEDICATION(S)]. The DNS further stated there was no documented evidence the resident was monitored between 9/19 and 9/20/2022 after [MEDICATION(S)] was discontinued and there should be documentation that the resident was monitored after a [CONDITION(S)] medication is discontinued. The Medical Director was interviewed on 9/20/2022 at 2:12 PM, and stated that they (Medical Director) gave the order to discontinue [MEDICATION(S)] for Resident #107; however, at the time they (Medical Director) were not aware that Resident #107 was receiving 150 mg of [MEDICATION(S)] per day. The Medical Director stated they (Medical Director) thought the resident was only receiving a total of 50 mg of [MEDICATION(S)]. The Medical Director stated that they (Medical Director) would not have discontinued 150 mg of [MEDICATION(S)] abruptly. The Medical Director stated if the [MEDICATION(S)] dosage is more than 50 mg, a GDR protocol has to be followed. If [MEDICATION(S)] medication is not gradually reduced, the resident can have serious cardiovascular concerns and other withdrawal symptoms. The nursing staff should have directions to monitor the resident's vital signs and other signs and symptoms of withdrawal from [MEDICATION(S)]. The Psychiatric Nurse Practitioner (NP) was interviewed on 9/21/2022 at 3:18 PM and stated the resident was admitted from the hospital without adequate indications for the use of [MEDICATION(S)]. The NP stated the resident never had a [CONDITION(S)] diagnosis. The NP stated that 150 mg of [MEDICATION(S)] cannot be abruptly stopped. The NP stated that if [MEDICATION(S)] is abruptly stopped then there is potential for harm including cardiac complications. The Attending Physician was interviewed on 9/23/2022 at 11:46 AM and stated the resident was on [MEDICATION(S)] because of inappropriate behavior, hallucinations, and Dementia. The Physician stated they (Physician) did not know the resident's psychiatric history and diagnosed the resident with [CONDITION(S)] diagnoses based on the resident's paranoia, hallucinations, and other behaviors. The physician stated the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) category of Psychiatric diagnoses criteria should have been used before diagnosing a resident with [CONDITION(S)]. The Physician stated that the [CONDITION(S)] diagnosis for Resident 107 was not appropriate. The physician also stated that they did not review level 1 and level 2 screens (mental illness history), that were completed by the hospital, to determine if the resident had a history of mental illness. 415.12(l)(2)(ii)

Based on observations, record review, and staff interviews during the Recertification Survey initiated on 9/18/2022 and completed on 9/23/2022, the facility did not ensure that the resident environment remains as free of accident hazards as possible. This was identified for three (Resident #265, # 56, and #65) of six residents reviewed for Accidents. Specifically, 1) A Physician ordered Potassium Chloride tablet, that was dissolved in a half cup of water, was observed unattended on Resident #265's bedside table. Resident #265 was unaware of any medication in the observed cup of water; 2) Resident # 56, who needed assistance with personal hygiene and shaving, was observed with used razors at their bedside 3) Resident # 65, who was identified as at risk for falls, was observed on multiple occasions walking without appropriate footwear. The finding is: 1) The facility's Medication Administration policy last revised on 12/2019 did not address protocols to be followed related to medications being left unattended at the resident's bedside. Resident #265 was admitted with diagnoses that included [CONDITION(S)], [CONDITION(S)] Accident, and Acute and Chronic [CONDITION(S)]. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score as 15 which indicated the resident's cognition was intact. The MDS documented the resident had no mood and no behavioral symptoms. A Baseline care plan dated 8/3/2022 documented that the resident was alert and cognitively intact and did not self-administer medication. A Physician's order dated 9/13/2022 documented to administer Potassium Chloride Extended Release (ER) 20 milliequivalent (mEq). Give 1 tablet by mouth one time a day for supplement. During an observation on the 1st-floor nursing unit on 9/18/2022 at 9:57 AM, Resident #265 was observed in bed. The resident was awake and alert and responded appropriately to the greeting. A half cup of water containing a white substance (Potassium Chloride tablet) was observed on Resident #265's bedside table. There was no staff member present in the resident's room. Resident #265 stated they (Resident #265) did not know what was in the cup. LPN #1 was observed with the medication cart down the hallway several rooms away from Resident #265's room. Licensed Practical Nurse (LPN) #1 was interviewed on 9/18/2022 at 9:59 AM. LPN #1 stated that the white substance in the cup was Potassium Chloride. LPN #1 stated that they placed the Potassium Chloride tablet in the cup of water to dissolve because the tablet was too large for the resident to swallow. LPN #1 stated that the resident was alert enough to take their medication and that they (LPN #1) thought the resident had consumed the water with the Potassium Chloride medication. LPN #1 stated that they (LPN #1) should not have left the medication at the bedside and should have waited in the resident's room until the resident had taken the medication. The Director of Nursing Services (DNS) was interviewed on 9/23/2022 at 3:49 PM and stated medication that needs to be dissolved should be mixed well before administering to the resident. The DNS further stated that medications should not be left at the resident's bedside and that LPN #1 should have stayed with the resident to ensure that Potassium Chloride was taken before leaving the room. 2) Resident #56 was admitted with diagnoses that included [CONDITION(S)] Disease, and Diabetic Mellitus. The Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #56 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. The MDS documented the resident required extensive assistance of one person for Personal hygiene which includes shaving. The MDS documented the resident had functional limitations in range of motion to the upper and one lower extremity. The Comprehensive Care Plan for Activity of Daily Living dated 5/11/2022 documented the resident required assistance with the Activity of Daily Living related to fracture, limited range of motion, and deconditioning. During an observation on 9/18/2022 at 10:21 AM Resident # 56 was observed in bed with only one side of their face shaved. There was a razor and a can of shaving cream on the nightstand next to Resident #56's bed. The Razor was observed with pieces of hair and some dried shaving cream. Resident #56 was interviewed on 9/18/2022 at 10:22 AM and stated that the razor and the shaving cream were their personal belongings. Resident #56 stated they (Resident #56) brought the razor and the shaving cream to the Facility and shaved themselves. Resident #56 stated that they could only shave the right of their face because they (Resident #56) were not able to reach the left side of their face. A review of Resident #56's medical record revealed there was no documented evidence that the facility assessed the resident if the resident could shave themselves independently. LPN #3 was interviewed on 9/21/2022 at 1:47 PM and stated it was not safe for Resident #56 to shave without assistance. LPN #3 stated that they (LPN #3) did not see Resident #56 using a razor. During a subsequent observation on 9/21/2022 at 2:03 PM with Licensed Practical Nurse (LPN) #3 two razors and a can of shaving cream were observed inside Resident #56's nightstand drawer when LPN #3 opened the drawers. Certified Nurse Assistant (CNA) #1 was interviewed on 9/21/2022 at 1:20 PM and stated it was not safe for Resident #56 to shave their (Resident #56) face themselves. CNA #1 stated that they did not see any razors in Resident #56 possession. CNA #1 stated they (CNA #1) shaved Resident #56 as needed. CNA#2 was interviewed on 9/21/2022 at 1:27 PM and stated that they never saw Resident #56 shaving themselves and that Resident #56 needed help with shaving. CNA#2 further stated they shave Resident #56 on shower days. The Director of Nursing Services (DNS) was interviewed on 9/23/2022 at 4:49 PM and stated that Resident #56 was assessed on admission, readmission, and quarterly. The DNS stated that it was not safe for Resident #56 to shave themselves without assistance. 3) Resident #65 was admitted with diagnoses that included Dementia, Diabetes Mellitus, and Hypertension. The Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #65 had severely impaired cognitive Skills for daily decision-making. The MDS documented that Resident #65 did not reject care. The Resident required extensive assistance of one staff member for transfer, walking in the room, walking in the corridor, and dressing. The MDS documented the resident was not steady and was only able to stabilize with staff assistance for walking. The MDS documented the resident utilized a wheelchair as a mobility device. The Comprehensive Care Plan dated 7/26/2022 for the Risk for Falls / has had an actual fall related to confusion documented interventions including but not limited to use of the Non-slip socks while out of bed. The fall risk evaluation dated 8/5/2022 at 9:10 PM documented that Resident #65 was at moderate risk for falls. Resident #65 was observed walking in the hallway by their room on 9/18/2022 at 10:00 AM and 10:30 AM wearing regular white socks. The Resident was again observed on 9/18/2022 at 12:37 PM and 12:47 PM by the nurses' station hallway. The resident was walking while wearing regular white socks. At 1:20 PM the resident was observed in bed and was wearing regular white socks. The Resident was observed walking in the hallway on 9/19/2022 at 10:45 AM wearing regular socks that were not non-skid socks. Certified Nursing Assistant (CNA) #1, who was the assigned CNA for Resident #65, was interviewed on 9/20/2022 at 4:43 PM and stated that Resident #65 was at risk for falls and was not allowed to walk with regular socks. CNA#1 further stated that Resident #65 gets themselves (Resident #65) out of their bed. CNA #1 stated sometimes Resident #65 took their shoes off and then forgets to put the shoes back on and gets out of bed. CNA #1 further stated that they knew Resident #65 was not allowed to walk with regular socks because it is not safe for the resident. CNA #2 was interviewed on 9/21/2022 at 1:23 PM and stated that Resident #65 should wear shoes when they (Resident #65) are out of bed. CNA #2 further stated that Resident #65 was at risk for falls and it was unsafe for Resident #65 to not wear nonskid socks when Resident #65 is out of bed. LPN #3 was interviewed on 9/21/2022 at 1:54 PM and stated they (LPN #3) did not know that Resident #65 was ambulating without nonskid socks. LPN #3 stated that Resident #65 ambulated on the unit and was not allowed to walk without nonskid socks or shoes. They (LPN #3) stated Resident #65 should always wear shoes when walking. LPN #3 stated that Resident #65 never used the wheelchair for locomotion on the unit. LPN #3 stated that the Facility had nonskid socks available on the unit for the residents who needed nonskid socks. The Director of Nursing Services (DNS) was interviewed on 9/23/2022 at 4:35 PM and stated that it was not acceptable that Resident #65 was walking around with no shoes or nonskid socks. The DNS stated that they will have the physical therapist and the occupational therapist evaluate Resident #65's for ambulation status. 415.12(h)(1)

Based on observation, record review and staff interview during the Recertification Survey, the facility did not ensure that a resident who is incontinent of bladder receives appropriate treatment and services to restore continence to the extent possible. This was identified for one (Resident #23) of one resident who was reviewed for bladder and bowel incontinence. Specifically, Resident #23 had a decline in bladder function from occasionally incontinent to frequently incontinent of bladder and there was no documented evidence that a bladder assessment was conducted to determine the cause of the decline. The finding is: Resident #23 was admitted to the facility in (MONTH) 2019 with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) Score as 13 which indicated intact cognition. The resident required extensive assist of one staff member for transfer and toileting and was frequently incontinent of bladder. A Quarterly MDS assessment dated [DATE] documented the resident's BIMS Score was 12 which indicated moderate cognitive impairment. The resident was occasionally incontinent of bladder and required extensive assist of one staff member for transfer and toileting. A physician progress notes [REDACTED]. The resident was occasionally incontinent of bladder and was now frequently incontinent of bladder. A Comprehensive Care Plan (CCP) dated 1/3/2020 documented the resident was frequently incontinent of Bladder. Interventions included to monitor, document, and report to the Physician as needed (PRN) any change in incontinence. A MDS note dated 1/3/2020 documented the resident has had a change in incontinence status. The resident was occasionally incontinent of bladder and frequently incontinent of bowel. The resident was now frequently incontinent of bowel and bladder and the Physician was notified. Resident #23 was interviewed on 1/8/2020 at 9:26 AM and stated she was continent of both bowel and bladder. The resident stated that she was not incontinent of urine, that she use regular under garments and that she does not have episodes of incontinence during the day or night. The day shift assigned Certified Nursing Assistant (CNA #1) was interviewed on 1/8/ at 10:30 AM and stated that it was her first time caring for the resident. The CNA stated earlier when she went in the resident's room, the resident was sleeping. The CNA stated later when she returned to assist the resident with care, the resident requested to have therapy assist her with care. The CNA further stated that the resident had not requested to be toileted. The 7:00 AM - 3:00 PM CNA #2 was interviewed on 1/9/2020 at 10:00 AM and stated that the resident was continent during the day, however, the resident was sometimes incontinent at night. The CNA stated that sometimes during morning care the resident was observed wearing a diaper and that at times the diaper was wet with urine. The CNA further stated that during the day the resident uses the bathroom. The MDS Registered Nurse (RN#3) was interviewed on 1/9/2020 at 11:53 AM and stated that the resident was assessed to have a decline in bladder function. The RN stated the data was gathered from the CNA documentation and that because the resident had seven or more episodes of incontinence during the seven day look back period according to the MDS guidelines, the resident was scored as frequently incontinent of urine. The RN stated that when a decline in a resident bladder function is identified, the physician is notified, the CNA task and the CCP is updated, and a note is entered in the resident's medical record. The RN stated the nurse completing the MDS assessment was responsible for notifying the Physician and completing the updates. The RN stated that the Physician was notified of the change in the resident's bladder function. The Physician was interviewed on 1/9/2020 at 12:40 PM and stated that the staff notified her of the decline in the resident's bladder function, that the resident was occasionally incontinent but was now frequently incontinent of bladder. T he Physician stated the resident had acute illnesses and was sent out to the hospital due to numbness to the hands and feet. The Physician stated that her notes may not have reflected why the resident had a decline in bladder function, however, in her mind there were other things going on with the resident at the time. The Physician stated that at the time she did not complete a bladder assessment for the resident. She stated that she intended to complete an assessment after the symptoms the resident was experiencing had subsided. The Director of Nursing Services (DNS) was interviewed on 1/9/2020 at 1:00 PM and stated when a resident is noted with a bladder decline the Physician is notified by Nursing and the Physician would give orders as needed. The DNS stated a bladder assessment was not completed by the Physician. The DNS further stated that the Physician has the obligation to address a decline in bladder function and to assess and evaluate the cause for the decline. 415.12(d)(2)

Based on observation, record review and interview during the recertification survey, the facility did not ensure that comprehensive person-centered care plans were developed or implemented for each resident. This was identified for one (Resident #71) of four residents reviewed for Discharge, one (Resident #101) of one resident reviewed for Dementia Care and one (Resident #67) of two residents reviewed for Accidents. Specifically, 1) Resident #71 did not have a discharge plan developed on 6/21/19 after it was identified that Resident #71 would be planning to return to the community. 2) Resident #101's did not have a person-centered care plan developed with specific interventions for Dementia Care. 3) Resident #67 had the intervention to wear a smoking apron while smoking and Resident # 67 was observed smoking without wearing a smoking apron on 1/6/20 at 1:25 PM. The findings are: 1) Resident #71 was admitted to the facility with the [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #71 had a Brief Interview for Mental Status (BIMS) Score of 13 indicating intact cognition. The Admission MDS documented that Resident #71 expected to be discharged to another facility/institution and wanted to meet with someone to discuss leaving the facility and returning to the community. The Quarterly MDS dated [DATE] documented that Resident #71 had an active discharge plan to return to the community. The discharge plan note dated 12/12/19 documented the service coordinator through an agency will be planning a visit to meet with the resident and finalize the needed paperwork. Record review on 1/8/20 revealed that there was no Discharge Care Plan developed for Resident #71. Resident #71 was interviewed on 1/8/20 at 10:06 AM. Resident # 71 stated that she has a housing application pending and was waiting since last month for the facility to provide documentation to the coordinator of the housing program. The Social Worker was interviewed on 1/9/20 at 1:32 PM. The Social Worker stated that she has been working with the Suffolk Independent Living Organization (SILO) program to coordinate Resident #71's discharge since 6/21/19, after the initial assessment date of 6/5/19. The social worker stated that the coordinator did not secure the housing unit since Resident #71 did not choose a final location. The Social Worker stated that she did not develop the discharge care plan and it should have been initiated on 6/21/19. The Director of Nursing Services (DNS) was interviewed on 1/10/20 at 12:40 PM. The DNS stated that she has known that Resident #71 had intentions of discharge and has even assisted with coordination. She stated that there should have been a Discharge care plan developed in the medical record once the SILO program application was initiated. 2) Resident #101 was admitted to the facility with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #101 had a Brief Interview for Mental Status (BIMS) Score of 6 indicating severely impaired cognition. The Dementia Care Plan dated 12/18/19 documented that Resident #101 had non-correctable impaired cognitive function or thought process related to Dementia. The intervention included to administer medications as ordered. There were no other interventions in place. Resident #101 was observed in the hallway self propelling in her wheelchair on 1/8/20 at 11:02 AM. Resident #101 was calling out a name, passing by the elevator and repeatedly saying to open the door so that she can go outside. A Licensed Practical Nurse (LPN) from the 2nd floor approached Resident #101 and redirected her back to her room. The Evening Registered Nurse (RN) was interviewed on 1/8/20 at 3:28 PM. The RN stated she developed the Dementia Care plan for Resident #101 and that she based the care plan on the resident's admission [DIAGNOSES REDACTED].#101 and the resident was oriented to person. The RN stated that she did not interview the family to gather additional information regarding the resident's condition and non-pharmacological interventions to assist with care. The RN stated that Resident #101's strengths are not reflected in the care plan. The Director of Nursing Services (DNS) was interviewed on 1/10/20 at 12:33 PM. The DNS stated that nursing staff should evaluate each resident as an individual, instead of by [DIAGNOSES REDACTED]. The DNS stated the Dementia Care plan for Resident #101 should have elaborated on interventions. 3) The facility smoking policy dated 8/2013 documented that all residents who smoke will have a smoking care plan and should include interventions in pace to ensure safe smoking by nursing/designee. If the resident requires a fire-retardant smoking apron, this is to be care planned. Any person providing smoking supervision must be instructed in smoking regulations prior to rendering such service. Resident #67 was admitted to the facility with the [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #67 used Tobacco. The Quarterly MDS dated [DATE] documented Resident #67 used a wheelchair and walker for mobility. The Smoking Evaluation dated 12/27/19 documented that Resident #67 was a smoker with cognitive loss who smokes 10+ times a day. The Smoking Evaluation documented that Resident #67 required the smoking apron and supervision to participate in smoking. The Smoking Care Plan dated 10/31/19 documented an intervention to provide Resident #67 with a smoking apron during designated smoking times was added to the care plan on 12/27/19. Resident #67 was observed smoking a cigarette without a smoking apron on 1/6/20 at 1:25 PM. At 1:27 PM the Recreation Aide placed an apron on Resident # 67. Resident #67 stated that she was not wearing an apron for a while and the aide just placed on her on because she had dropped a cigarette in the past. The Recreation Aide was interviewed on 1/6/20 at 1:34 PM. The aide stated that the apron was discontinued for a while but Resident # 67 dropped the cigarette on the ground. The team re-implemented the apron while the CNA was on vacation leave and she was not aware of the change. The CNA stated she was just informed by the Assistant Director of Recreation during the smoking break today. The aide then placed the smoking apron on Resident # 67 after it was brought it to her attention. The Assistant Director of Recreation was interviewed on 1/6/20 at 1:39 PM. The Assistant Director of Recreation stated that the resident requires the smoking apron for safety. She directed the Recreation Aide to place the apron on the resident when she observed the resident was not wearing a smoking apron. The Assistant Director of Recreation further stated the aide would be in-serviced to always check the apron list during smoking breaks. The Director of Recreation was interviewed on 1/7/20 at 2:39 PM. The DR stated that she conducted the smoking evaluation on 12/27/19 because Resident #67 was falling asleep at that time and was dropping the cigarette as she dozed off with the cigarette in her hand. Upon her evaluation, she determined that Resident #67 required the use of the apron as a precaution. Prior to the evaluation, she did not use the smoking apron. The Director of Recreation stated Resident #67 should have been wearing an apron at each smoking session from 12/27/19 to present and that the Recreation Aide should have placed the apron on Resident #67 prior to smoking. The Director of Nursing Services (DNS) was interviewed on 1/10/20 at 12:24 PM. The DNS stated that every resident who is a smoker is assessed upon admission to determine what interventions are needed for the resident. The DNS stated the Smoking Care Plan for Resident #67 should have been followed to ensure Resident #67's safety while smoking. 415.11(c)(1)

Based on observation, record review, and interviews during the Recertification Survey, the facility did not ensure that each resident's Comprehensive Care Plan (CCP) was reviewed and revised to meet each resident's current needs. This was identified for one (Resident # 45) of three residents reviewed for Mood and Behavior. Specifically, Resident # 45's Behavior CCP was not reviewed and revised to accurately describe the resident's current behaviors. Resident #45 preferred to have no sheets or pillows on his bed because the sheets and pillows make him feel too hot. Additionally, the resident preferred to keep multiple personal belongings on the bed. These behaviors were not identified on the resident's Behavior CCP. The finding is: Resident #45 has [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. On 1/6/20 at 9:10 AM, the resident was observed sitting on top of his bed with no sheets or a pillow. The left side of the resident's bed was filled with various objects such as two large radios, multiple sets of walkie talkies, numerous electric razors, and one stuffed animal. The resident was seated over to the right side of the bed because of the placement of these objects on the resident's bed. The resident was interviewed on 1/6/20 at 9:10 AM and stated that sheets and pillows make him too hot and he does not like them. The resident stated he was fine sleeping with half of the bed covered with his belongings. Review of the resident's Behavior CCP dated 1/29/16, and last revised on 11/28/18, was reviewed on 1/7/19 at 9:10 AM and revealed no documentation that the resident preferred to sleep in bed without sheets or a pillow and with their bed covered with personal objects. The Director of Social Services was interviewed on 1/7/19 at 9:30 AM and stated that sleeping without sheets and a pillow and having the bed covered with various objects was not normal behavior and should have been documented on the resident's Behavior CCP. The 2nd Floor Licensed Practical Nurse (LPN) Unit Nurse was interviewed on 1/9/20 at 12:15 PM and stated that the resident's Behavior CCP could have been revised to reflect the resident's behaviors during the last CCP meeting. The Director of Nursing Services (DNS) was interviewed on 1/9/20 at 1:10 PM and stated that if a resident exhibits certain behaviors, those behaviors should be documented on the resident's Behavior CCP. The DNS also stated that the Unit Nurse, the Registered Nurse (RN) Supervisor, the MDS Nurse, as well as herself can also review and update the CCPs at any time. 415.11(c)(2)(i-iii)

Based on record review and interviews during the Recertification Survey the facility did not ensure that each resident received proper treatment and assistive devices to maintain hearing abilities. This was evident for one (Resident #86) of three resident reviewed for communication. Specifically, Resident #86 had a physician's orders [REDACTED]. The finding is: Resident #86 has [DIAGNOSES REDACTED]. The 12/6/19 Quarterly Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS documented that the resident had highly impaired hearing. Hearing aides were not documented in the MDS. A Comprehensive Care Plan (CCP), intiated for Hearing Deficit on 11/19/15 and last updated 10/31/19, documented that the resident had a hearing deficit and used a right hearing aid. An intervention included to refer to Audiology for hearing consult as ordered. Review of the ENT report, dated 4/10/19, revealed that the resident had Chronic Otitis Externa of both ears. Instructions included [MEDICATION NAME] drops to both ears for 10 days and return to office in two months. A physician's orders [REDACTED]. A physician's orders [REDACTED]. The end date was 11/12/19. A Nurse Practitioner (NP) visit progress note dated 11/8/19 documented the resident was complaining of bilateral ear wax and decreased hearing and that bilateral ear wax had been evaluated previously by ENT with ear wax removal. The plan was to follow up with ENT for hearing test status [REDACTED]. Resident #86 was observed awake in bed on 1/6/20 at 10:30 AM. When the resident was spoken to he did not respond. The resident's assigned Certified Nursing Assistant (CNA) was interviewed on 1/9/20 at 9:26 AM. She stated the resident speaks very well, but the resident was very hard of hearing. She stated that she thought at one point the resident had a hearing aid, but she was not sure where it was. The resident was observed on 1/9/20 at 9:29 AM. The resident was awake in bed. The resident stated clearly, I can't hear you, everything is fine. There were no hearing aids observed in the resident's ears. The resident was observed on 1/9/20 at 1:41 PM. The Licensed Practical Nurse (LPN) medication nurse and the CNA were present. The resident was awake in bed. The resident was having difficulty hearing and the surveyor, LPN, and CNA had to raise their voices. The resident stated that he could not hear. A hearing aid was observed in a box on the bedside table. The LPN stated it was for the right ear. The resident stated that the hearing aid did not work and that the facility was supposed to be making an appointment for the resident to see a hearing specialist. The Unit Clerk and LPN Charge Nurse were interviewed concurrently on 1/9/20 at 1:45 PM. The unit clerk stated she makes the consult appointments after an order is placed. She stated the last time the resident went to the ENT specialist was 4/10/19, that there have been no other appointments made, and that the appointment following the 11/8/19 order for the ENT consult was never made. She stated she did not see the order. The LPN charge nurse stated the two-month follow up appointment that was recommended by the ENT specialist on 4/10/19 did not take place. The NP who ordered the consult on 11/8/19 was interviewed on 1/10/20 at 9:57 AM. She stated the resident has a bilateral hearing deficit and may need bilateral hearing aids. She stated the plan was for the resident to see an ENT specialist, and then the ENT would determine if the resident needed to see an audiologist. She stated she was not aware the ENT appointment following the 11/8/19 order was not made. She stated she did not follow up. She further stated that the resident was not sent back to the ENT as recommended after the 4/10/19 ENT appointment. The Director of Nursing Services (DNS) was interviewed on 1/10/20 at 10:11 AM. She stated she realized that there was a problem with consults when she became DNS. She stated there was a specific process that the unit nurse and unit clerk are supposed to follow and that she did not realize Resident #86 did not go to the ENT consult when it was ordered on [DATE]. The LPN Charge nurse was interviewed on 1/10/20 at 1:45 PM. She stated she entered the order for the 11/8/19 ENT consult into the electronic medical record. She stated the unit clerk did not make the appointment. 415.12(3)(b)

Based on record review and staff interviews during an abbreviated survey, the facility failed to ensure that necessary care and services were provided to maintain 2 ( #1 and #2) of 3 residents reviewed, at their highest practicable physical, mental and psychosocial well-being, in accordance with their comprehensive assessment and plan of care. Specifically, the facility failed to ensure: 1) Ensure residents on anticoagulation therapy were appropriately monitored. 2) Ensure residents were fully assessed (monitoring of clinical labs ordered) when there was a change in neurological status and that the physician was promptly made aware. These failures resulted in Resident # 1 becoming unresponsive and having an INR that was above 10.0 (Reference 1.0-2.0) at the hospital on [DATE]. The resident returned to the facility on [DATE]. The Resident became lethargic on 6/13/16 and was not transferred to the hospital until 6/16/16 upon request by the family. The resident was admitted to the hospital on [DATE], with a [DIAGNOSES REDACTED]. Complaint ID number: NY 259 The findings are: 1a) Resident # 1 is a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's Admission Minimum Data Set ((MDS) dated [DATE], documented Resident #1 as having short and long-term memory problems, and having moderately impaired cognition, usually understands and usually is understood. The MDS documented Resident #1 as needing extensive assistance with bed mobility, dressing, personal hygiene and toilet use; and needing total dependence with transfers and locomotion. The resident was non-ambulatory. Review of physician's orders [REDACTED]. The anticoagulation therapy was to prevent clot formation from the resident's mitral valve disease and/or [MEDICAL CONDITION] ([MEDICAL CONDITION] - clot formation in the deep veins of the lower extremities). There was no blood work - PT/INR levels (PT/INR levels are used to monitor the effectiveness of blood thinning drugs such as [MEDICATION NAME] ([MEDICATION NAME])) ordered by the physician on admission. Review of the Medication Administration Record (MAR) for May 2016 revealed that the Resident received [MEDICATION NAME] 3 mg daily from May 4 until May 28 2016 at 9 PM and Aspirin 81 mg daily at 8:30 AM. The Federal Drug Administration has issued a Black Box Warning for [MEDICATION NAME] noting additional concerns identified for elderly patients and their increased risk for bleeding. The warning is published in the American Hospital Formulary Service published by the American Society of Health System Pharmacists. The warning states (in part): Boxed Warning: Bleeding: May cause major or fatal bleeding. Risk factors for bleeding include high intensity anticoagulation (INR >4), over age [AGE] years, variable INRs, history of GI (Gastro-intestinal) bleeding, high blood pressure, [MEDICAL CONDITION] disease, serious [MEDICAL CONDITIONS], etc .Special populations: Elderly: The elderly may be more sensitive to anticoagulant therapy. Geriatric Considerations - Before committing an elderly patient to long-term anticoagulation therapy, the risk for bleeding complications secondary to falls, drug interactions, living situation, and cognitive status should be considered. A risk of bleeding complications has been associated with increased age. Adverse Reactions: Bleeding is the major adverse effect of [MEDICATION NAME] ([MEDICATION NAME]). Hemorrhage may occur at virtually any site. Risk is dependent on multiple variables, including the intensity of anticoagulation and patient susceptibility .Central nervous system: Coma, dizziness, fatigue, fever, headache, lethargy, malaise, pain, and stroke. A review of the lab report dated 5/9/16 (without a physician's orders [REDACTED].#1's PT was 30.0 (Reference Units Range 9.8-11.9 seconds on anticoagulation therapy) and his INR was 2.7 (Reference Units Range 1-2 on anticoagulation therapy). There were no changes to the resident's [MEDICATION NAME] dose. There was no documented evidence that the physician was made aware of the resident's INR level. There was no documented physician order [REDACTED]. The Assistant Director of Nursing Services (ADNS) was questioned on 6/19/16 at 4 PM about the lab collection on 5/9/16 and was not able to determine how the lab services collected the specimen without a physician's orders [REDACTED].>The initial Comprehensive Care Plan dated May 2016 identified that the Resident was at risk for bleeding secondary to anticoagulant use related to [MEDICAL CONDITION], A- fib and Coronary [MEDICAL CONDITION] (CAD). The Goal was for the Resident to be free of signs and symptoms of abnormal bleeding. Interventions included to Administer medications as prescribed, Monitor effectiveness of medications given and observe for adverse reactions, Monitor for signs and symptoms (s/s) of abnormal bleeding (skin bruising, bleeding gums, black stools, coffee ground like emesis; to monitor lab values and notify MD of abnormal findings (PT, PTT, INR). The Progress Notes dated 5/29/16 at 2:24 PM documented Note Text: Date/Time of actual observation/discussion/etc.: 05/29/2016 at 1:00 PM 140/71 69 18 97.5 4 small openings found on scrotum treatment applied. Noted to have copious amount of frank blood in diaper. MD notified ordered to discontinue (d/c) [MEDICATION NAME] and order PT/INR stat to be done. The Laboratory services collected a specimen on the resident on 5/29/16 at 3:10 PM which revealed an INR level greater than 10.0 and PT level greater than 100.0. This was reported to the facility on [DATE] at 11:56 PM. On 5/30/16 at 9 AM- the physician documented; patient transferred to hospital for Altered Mental Status (AMS) and [MEDICAL CONDITION]; labs revealed INR=10 & [MEDICATION NAME], aspirin was held; patient difficult to arouse by staff this am; all systems status guarded. On 5/30/16 at 10:59 AM, the progress note documented Resident was sent out to hospital around 9 AM, picked up by EMS ambulance resident was noted unresponsive family was notified awaiting [DIAGNOSES REDACTED]. At 3:30 PM, Resident admitted to hospital with AMS, Urine Retention, INR Greater than 10. An admission hospital note dated 5/30/16 documented the resident's INR was above 10, was given Vitamin K and is coming in for AMS and lethargy secondary to coagulopathy secondary to [MEDICATION NAME]. On 6/6/16 at 6:30 PM, the MD documented patient (pt) had [MEDICAL CONDITION] due to (d/t) Urinary Tract Infection [MEDICAL CONDITION] treated with [MEDICATION NAME] (an antibiotic) while in hospital; furthermore, pt had brain scan which revealed a communicating [DIAGNOSES REDACTED]; no neurosurgical interventions required at this time because apparently this is normal pressure [DIAGNOSES REDACTED]. The physician was interviewed on 6/19/16 at 3:40 PM and stated that it was an oversight that PT/INR levels were not ordered upon admission. He further stated that not properly monitoring these levels can cause bleeding and/or death. I should have done my checks and balances and this was missed. The nurse had not brought this to my attention. During an interview on 6/19/16 at 6:00 PM, the Registered Nurse (RN) manager stated that he does in-services for the facility and does assessments. He stated that he did not assess the resident's anticoagulant use and the need to ensure blood monitoring orders were in place at the time of the admission assessment. The Assistant Director of Nursing Services (ADNS) was interviewed on 6/19/16 at 4 PM and stated that there should have been orders for PT/INR ordered by the physician upon admission and nursing should have ensured PT/INR levels were ordered if the resident is on anticoagulant therapy. b) Resident # 1 was treated in the hospital and returned to the facility on [DATE] with documented orientation to Person Place and Time and intact with cognition on the nursing admission progress note. On 6/13/16, a nursing note documented vital signs: BP 139/83, T 97.5, P 98 respirations- Regular 18, O2 96.0 and Cognition: Resident is not oriented to person, place, or time. On 6/13/16 at 3:30 PM- the physician documented pt very listless & lethargic today; will start stat dose [MEDICATION NAME] follow by (f/b) [MEDICATION NAME] 1 gram twice daily (bid) x 3 days [MEDICAL CONDITION]; CXR, U/A, CBC, CMP in progress; all other systems status stable exam vital signs stable (vss). The physician ordered the labs on 6/13/16. Additionally on 6/13/16, the physician orders [REDACTED]. The resident remained in the facility and continued to receive treatment daily in the facility until 6/15/16 when the family requested to transfer the resident to the hospital. From 6/13/16- 6/15/16, the physician continued to treat the resident despite the resident showing no clinical signs of improvement. The physician notes did not include any documented lab values (that were ordered on 6/13). There was no documentation of the labs in the clinical record. Furthermore, neither the UA and the C&S nor the blood work were collected as ordered by the physician on 6/13/16. The physician was interviewed on 6/19/16 at 4:45 PM and stated the resident became lethargic. Due to his lethargy he was not able to take anything orally and antibiotics had to be given Intramuscular (IM). I tried to prevent hospitalization s at all costs. I tried to treat the resident prior to sending the resident to the hospital. This is why we decided to treat the resident with the IM antibiotics. I was not aware that the labs were not obtained and I was not waiting for the lab results to help me decide treatment. I did not know the significance of the labs as I was treating the resident. Hospital records documented the date of admission was 6/15/16. The resident was presented to the ER [MEDICAL CONDITION], a fever of 100.9, elevated white blood cells, [MEDICAL CONDITIONS], AMS and dehydration. The resident was treated with intravenous (IV) hydration, IV [MEDICATION NAME] and IV [MEDICATION NAME]. 2) Resident # 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician orders [REDACTED]. On 6/2/16, [MEDICATION NAME] was decreased to 2 mg daily. On 6/6/16, [MEDICATION NAME] was increased to 3 mg daily. No PT/INR orders were documented although PT/INR levels were collected from 5/26 until 6/18 without physician orders. These levels were not documented in the medical record and the lab reports were obtained onsite when the facility called the laboratory. The ADNS was interviewed on 6/19/16 at 6 PM and stated that there should have been labs documented in the MAR and labs should have been ordered by the physician. 415.12

Based on observation, record review and staff and resident interviews during the recertification survey the facility did not ensure that necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the plan of care was provided. This was evident for 1 of 2 residents reviewed for abuse. Specifically, Resident #201 was admitted with acute fractures of the spine and was not provided the proper care and services for the treatment of [REDACTED]. The resident complained that she was experiencing back pain while being held over on her side in bed when staff were providing care. The finding is: Resident #201 was admitted to the facility on [DATE] for short term rehabilitation. The resident has [DIAGNOSES REDACTED]. The Social Worker evaluation dated 7/21/15 documented a Brief Interview for Mental Status (BIMS) score of 13 (cognition intact). During an interview on 7/24/15 at 10:05 AM the resident complained that staff members were rough with her when pushing her over in the bed. The resident stated that it was very painful to her back as they were pushing her over and that it continued to hurt afterward and she would tell the staff to go easy because it hurt when they pushed on her back. The resident also stated that this had occurred several times and she could not remember the staff names. A Hospital Discharge Summary (HDS) dated 7/13/15 documented a [DIAGNOSES REDACTED]. The HDS also documented that the resident had a Neurosurgical Consultation and that a [MEDICATION NAME] Lumbar Sacral Orthosis (TLSO) brace was recommended. An Admission Nursing Evaluation (ANE) dated 7/20/15 had no documented [DIAGNOSES REDACTED]. The ANE documented that the resident required the assistance of 2 staff members with bed mobility. A Pain Assessment form (PAF) dated 7/20/15 documented that the resident had pain, that it was constant and made it hard to sleep at night. The PAF documented that the pain scale was a 10 (based on a scale of 1 to 10 in which 10 was the most pain) and that it was excruciating pain. The location of the resident's pain was not documented on the PAF. A Physician History and Physical dated 7/21/15 had no documentation that the resident had T 11, T 12 and L1 fractures. An Admission Of A Resident Policy dated 1/14/15 documented that the HDS is to be reviewed. There was no documented evidence in the medical record that the facility was aware that the resident had T 11, T 12 and L1 fractures and that the resident was provided the necessary care and services for the fractures. Review of the Medication Administration Record [REDACTED]. The resident received four doses of [MEDICATION NAME]: 7/21/15 at 10:07 PM; 7/23/15 at 10:30 AM and at 12:30 PM; and one dose on 7/26/15 with no time of administration recorded. Additionally, there was no monitoring of the resident's pain level pre and post medication administration, nor documentation of the site of the resident's pain. An interview was held with the Certified Nursing Assistant (CNA # 1) on 7/24/15 at 11:15 AM. CNA #1 stated that she and another CNA (CNA # 2) provided care to the resident on 7/21/15. CNA #1 also stated that CNA #2 held the resident over on her side so that CNA #1 could provide care. CNA #1 also stated that she followed her CCP to provide care and that she did not have any special instructions from the nurse for providing care to the resident. An interview was held on 7/24/15 at 12:30 PM with the 2 PM to 10:00 PM Licensed Practical Nurse (LPN) Unit Nurse who assisted in the admission assessment of the resident. The LPN stated that she was the resident's nurse and that she was not aware that the resident had T 11, T 12 and L1 fractures. The LPN also stated that she did not read the HDS. An interview was held on 7/24/15 at 1:00 PM with CNA #2 who helped CNA #1 provide care to the resident. CNA #2 stated that she held the resident on her side so that CNA #1 could provide care. The CNA held the resident over with her hands placed on the resident's back. CNA #2 was not aware of any special instructions about providing care to the resident. An interview was held on 7/30/15 at 11:30 AM with the resident's Physical Therapist (PT). The PT stated that he did an evaluation of the resident but did not review the HDS as part of the evaluation so he was not aware that the resident had T11, T12 and L1 fractures or that the HDS documented that a TLSO brace was recommended. The PT also stated that he gathers information to care for the resident from the PRI. An interview was held with the Registered Nurse (RN) Unit Manager on 7/30/15 at 12:00 PM. The RN stated that she reviews the Patient Review Instrument (PRI) and the hospital medication list on a newly admitted resident. The RN stated that she was not aware that the resident had T11, T12 and L1 fractures or that the HDS documented that a TLSO brace was recommended. An interview was held with the resident's Physician on 7/30/15 at 12:15 PM. The Physician stated that he was not aware that the resident had acute fractures of the T11, T12 and L1. An interview was held with the Director Of Nursing Services (DNS) on 7/30/15 at 1:00 PM. The DNS stated that she would expect the facility staff to read the HDS to determine the care needed to be provided to the resident. 415.12

Based on record review and staff/resident interviews during an abbreviated and partial extended survey, the facility failed to ensure that each resident was provided necessary care and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care, which resulted in an avoidable accident. Specifically, one (Resident #1) of 5 residents reviewed for accidents, with cognition impairment, was care planned to wear a reverse seat belt (restraint) with every 15 minute visual checks due to his attempts to ambulate without assistance. The facility staff failed to consistently implement 15 minute visual checks and supervise Resident #1. Subsequently, Resident #1 was found in the shower room by another resident (Resident #2) with the seat belt around his neck and without respirations or pulse. Resident # 1 was not supervised after 1:15 PM until he was found at 2:12 PM. The facility failed to ensure staff received proper training related to supervision and documentation of residents who required 15 minute visual checks. Key staff were not aware of the facility's policy to assign a back up when assigned staff were not available and the facility lacked an effective system to ensure the policy was consistently implemented. This resulted in actual harm for Resident #1 and the potential for serious harm for 5 residents on 15 minutes checks that is Immediate Jeopardy and Substandard Quality of Care. Immediate Jeopardy was removed on 7/19/13 prior to survey exit. Complaint ID Number: NY 132 The finding is: Resident #1 was [AGE] years old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The undated facility protocol titled, Resident Monitoring Protocol, documented when a resident "is on every 15 minutes checks, the Certified Nursing Assistant (CNA) and/any other nursing staff must document the residents' whereabouts as observed every 15 minutes. Assignment sheets must indicate who will be taking over monitoring of assigned residents during break periods." The Undated policy titled, Public Area Door Policy, documented any public room which does not have a resident must be closed and latched. This applies primarily to public areas with doors such as dayrooms, shower rooms, bathrooms, etc. The Comprehensive Care Plan (CCP) dated 3/21/13 documented alteration in mental status as evidenced by short and long term memory loss, impaired decision making and impaired judgment. Interventions included to provide cues and reminders, anticipate needs and provide care etc. The CCP dated 3/22/13 documented at risk for fall related to environmental factors (new environment), unsteady gait, and cognition/behavior (trying to get out of chair himself and unaware of his environment). Interventions included every 15 minutes watch, monitor activities, and anticipate resident's needs. The CCP dated 3/22/13 documented Resident #1 at risk for elopement as evidenced by confusion related to decreased cognition. Interventions included but not limited to assess resident for risk of elopement and place wander guard on resident etc. The CCP dated 3/23/13 documented inappropriate social behavior. Interventions included place resident in area where constant observation is possible. The Minimum Data Set ((MDS) dated [DATE] documented cognition skills for daily decision making as moderately impaired. The Physician's Interim Order dated 7/08/13 documented order for restraint: reverse seat belt. Reason: unaware of safety limitations; release every two hours for 15 minutes during meal time and whenever necessary. The Certified Nursing Aid Accountability Record (CNAAR) dated 7/20/13 documented restraint device: Reverse Seat Belt, high risk monitoring for falls, every 15 minutes checks. The CCP dated 7/1/13 updated on 7/8/13 documented: physical restraint, use of reverse seat belt for wandering, unaware of safety limitations and increased risk for falls. Interventions included reverse seat belt placed to wheel chair, apply restraint and release every two hours for15 minutes, evaluate need for continued use of restraint. The Re-Assessment of Restraint dated 7/8/13 documented alternates to restraint considered were every 15 minutes checks, supervised visits when out of bed, redirection, bed and chair alarm. Restraint team agreed to place reverse seat belt due to dementia, confusion and unsteady gait. The every 15 minutes check sheet dated 7/15/13 documented increased risk for falls and wandering as reason for 15 minutes checks. It lacked documented evidence that 15 minute checks were conducted after 1:15PM until resident was found in the shower room unresponsive at 2:12 PM. The Certified Nursing Assistant Assignment sheet dated 7/15/13 for 6AM-2PM and 2PM-10PM shift lacked documented evidence that another staff member was assigned to take over every 15 minute check/monitoring assignments when assigned staff is unavailable. Nursing Progress Note dated 7/15/13 documented that another resident reported that a resident was unresponsive in the bathroom, saw resident slouched in the chair with the seat belt across his neck, code blue was called. Physician's Progress Note (PPN) by Nurse Practitioner (NP) dated 7/15/13 documented patient was found unresponsive without pulse and respiration-no sign of life at 2:20PM. The Facility Investigation Summary (undated) documented that Resident "was apparently trying to toilet self and could not get out of his restraint. The chair sensor alarm did not sound most likely due to positioning of the Resident #1's position on the chair at the time he was found." The Closed Circuit Television Camera (CCTV) was observed on 7/18/13 at 9:15AM for 7/15/13 in presence of the Director of Nursing (DON). Resident #1 was observed self-propelling out of the Day Room (DR) at 1:28PM and LPN #1 was then seen placing the resident in front of the nursing station. At 1:33PM Resident #1 self propelled towards short hallway (where the shower room was). The CCTV did not capture short hallway and Resident #1 entering in to the shower room. During an interview with 7AM-3PM LPN#1 on 7/17/13 at 10:30AM, he stated that he went to the shower room when Resident #2 alerted them that Resident #1 was in the shower room with his seat belt around his neck. LPN#1 stated that Resident #1's head was partially on the chair with his body slouched down and the seat belt around his neck. LPN#1 stated that Resident #1 had no pulse or respiration and face was blue. LPN#1 stated that he was not aware that Resident #1 was on any monitoring or every 15 minutes watch. He also could not recall facility's restraint protocol. LPN#1 stated that the door to the shower room was supposed to be locked but was not sure who was supposed to check it. LPN#1 was not aware if any staff members were assigned to check shower rooms. During an interview with 6AM-2PM Certified Nursing Assistant (CNA) #1 on 7/17/13 at 10:54AM, he stated that he was assigned to Resident #1 on 7/15/13 and left him in the Dayroom (DR) at 1:15PM. CNA#1 stated that he did not check on Resident #1 for 15 minute visual checks after 1:15PM because he thought that the CNA assigned to the DR was supposed to be watching him. CNA#1 also stated that Resident #1was not supposed to come out of the DR because he tried to stand up constantly in spite of his seat belt. CNA#1 stated that the shower room door was supposed to be locked when not in use by the staff. CNA#1 stated that there was an assigned CNA to check the shower room, but no specific time assigned to perform the checks. During an interview with 6AM-2PM CNA#2 on 7/17/13 at 11:47AM, she stated that she was covering the DR from 1:30PM-1:45PM on 7/15/13 and did not remember seeing Resident #1 in the DR. CNA#2 stated, " We all work together, if the person assigned to resident is busy-all the other aides were responsible to watch the residents on 15 minutes watch." CNA#2 stated that there were no back up staff assigned when the assigned CNAs were unavailable for 15 minute watch/monitoring the residents. CNA#2 stated that the shower door was supposed to be locked at all times when not in use by the staff. During an interview with 6AM-2PM CNA#3 on 7/17/13 at 12:10PM, she stated that she was assigned to check the shower room for making sure it was clean. CNA#3 further stated that she last checked the shower room at 11:30AM and locked the door. There were no specific times assigned to check the shower room. CNA#3 also stated that CNA#1 was responsible for Resident #1's 15 minute checks. If the assigned CNA#1 was busy, everyone else on the unit was responsible to check on Resident #1. If Resident #1was in the DR, the DR CNA was responsible to watch him and complete the 15 minute checks including documentation. During an interview with 7AM-3PM LPN#2 on 7/17/13 at 1:09PM, she stated that Resident #1 was on 15 minute checks, and the assigned CNA was responsible for completing the 15 minutes monitoring/watch. LPN #2 further stated that Resident #1 was supposed to be supervised at all times because he would stand up out of his chair. During an interview with 8AM-4PM Registered Nurse Supervisor (RNS)#1 on 7/17/13 at 1:39PM, he stated that Resident #1 should have been monitored closely in a supervised area such as the DR or in the hallway where staff members were present. RNS#1 stated that he was not aware of facility's written protocol for monitoring residents requiring 15 minute visual checks. A subsequent interview with RNS#1 was conducted on 7/18/13 at 11:55AM and he stated that before the assigned CNAs left for break, they were to report to any other CNA to supervise/monitor residents who are on 15 minutes checks. The assigned CNA was to complete the documentation that visual checks were performed after returning from their break. RNS#1 also stated that the shower door was expected to be locked at all times. All staff were supposed to check the shower room lock throughout the day as they walk by the shower room. The RNS#1 stated that a specific employee was not assigned to check if the shower door was locked. During an interview with 8AM-4PM RNS#2 on 7/17/13 at 2:00PM, she stated that assigned CNAs are responsible for the 15 minutes checks. If the assigned CNAs are busy or on breaks they were to notify another CNA to complete the scheduled 15 minute checks. RNS#2 also stated that the shower room door was supposed to be locked at all times, there was no specific staff assigned to check the shower room doors. A subsequent interview with RNS#2 was conducted on 7/18/13 at 10:45AM; she stated that she was not aware of the facility's protocol for monitoring residents requiring every 15 minute checks. RNS#2 stated that there was no written assignment to indicate which staff would take over monitoring assignments when assigned staff was not available. During an interview with 2PM-10PM CNA#5 on 7/17/13 at 2:43PM; she stated that she was assigned to the DR at 2PM on 7/15/13 but did not see Resident #1 in the DR. CNA#5 further stated that she did not know which residents were to stay in the DR. CNA#5 also stated that there was no system in place regarding assigning residents who required 15 minute checks when their assigned CNAs were unavailable. During an interview with 2PM-10PM CNA#6 on 7/17/13 at 2:57PM, she stated that she was assigned to Resident #1 on 7/15/13 and did not complete the 15 minute checks as she was busy taking care of another resident. CNA#6 stated that the assigned CNAs were responsible for completing the 15 minutes checks for their assigned residents. CNA#6 also stated that the shower room door was supposed to be locked at all times. During an interview with 6AM-2PM CNA#10 on 7/18/13 at 11:05AM, she was assigned to the DR at 1:15PM-1:30PM but could not recall seeing Resident #1. CNA#10 stated that she was to stay in the DR to supervise the residents; she did not stop any resident from going out of the DR and did not report to anyone that any resident left the DR. CNA#10 stated that she was not aware that Resident #1 was on 15 minute checks. The assigned CNAs are responsible for completing the 15 minutes checks on their residents not the DR CNA. CNA#10 stated that she did not recall if any resident propelled out of the DR when she was covering the DR. An interview with 6AM-2PM CNA#7 was conducted on 7/18/13 at 12:15PM; she was assigned to cover the DR on 7/15/13 between 1:45-2:00PM. CNA#7 stated that she did not recall seeing Resident #1 in the DR; if the assigned CNA was busy he should have asked the DR CNA to make sure that Resident #1 stayed in the DR. CNA#7 stated that "only time we do 15 minute visual check for another CNA is when they are off the floor on their break." CNA#7 also stated that there was not a written assignment to take over the monitoring when the assigned CNAs were unavailable. During an interview with the Assistant Director of Nursing (ADON) on 7/18/13 at 1:19PM, she stated that the assigned CNAs are responsible for completing the 15 minute checks and if they go on break, they (assigned CNA) were to ask another staff member to cover the monitoring assignment. ADON further stated that the CNAs who performed the visual checks were to document on the 15 minute check sheets. If the residents who require 15 minute checks were in the DR, the assigned CNA was expected to go to the DR and complete the visual check and sign for the same. The ADON stated that the expectation for the DR CNA was to keep residents contained in the DR. The ADON also stated that the shower door was supposed to be checked; there was an assigned CNA for shower room check but there was no assigned time to check. During an interview with the Director of Nursing (DON) on 7/18/13 at 3:35PM; she stated that the assigned CNAs were responsible for 15 minute watch, if the assigned CNAs were to go on break or busy with other residents, they were expected to inform another CNA to take over their assignment. The DON stated that the DR assigned CNAs were expected to monitor residents on 15 minutes watch and sign for them after completing the DR coverage. The DON stated that the shower door should have been locked and Resident #1 should have been monitored closely. During an interview with the Administrator on 7/18/13 at 4:16PM, he stated that Resident #1 somehow got in to the shower room. Unbeknownst to the staff; the shower door was supposed to be locked when the door was closed. The administrator stated, "My understanding was that Resident #1 was allowed to wander on the unit because he had no history of elopement." The administrator also stated that he expected that staff would do 15 minute monitoring as required by the residents' plan of care. 415.12

Based on record review and staff interviews during an abbreviated and partial extended survey the Medical Director failed to ensure that the facility provided care in accordance with current standards of practice to meet the needs of residents. Specifically, the Medical Director failed to ensure that policies and procedures were implemented to ensure the appropriate assessment and monitoring of residents with a history of substance abuse and/or drug-seeking behavior. The Medical Director also failed to provide clinical guidance and oversight to identify, evaluate and address concerns regarding residents with histories of substance abuse and/or drug-seeking behavior. This failure resulted in Resident #1's overdose on two separate occasions within a period of one month. This resulted in actual harm to Resident #1 with the potential for serious harm that is Immediate Jeopardy for 12 residents who have substance abuse histories and/or drug-seeking behavior. Complaint Number: NY 136 Cross References: F 225 - Investigate & Report Allegations F 226 - Develop/Implement Abuse/Neglect Policies F 323 - Accidents & Supervision F 490 - Administration F 520 - Quality Assessment & Assurance The findings are: An interview was conducted with the Director of Nursing Services (DNS) on 5/31/13 at 1:44 PM. The DNS stated that the resident had drug-seeking behavior; she is not aware of a policy on how to handle residents with drug-seeking behavior. During a subsequent interview with the DNS on 6/3/13 at 2:30 PM the DNS stated that she has not been told of any suspicious drug activities or drugs being brought in to the facility by residents, visitors or staff. She, then, stated that she was aware of a discussion in Administration that had been brought forward by the NP about a suspicion of illegal drugs in the facility. "It's just hearsay; there is no need to investigate anything alleged and without proof." She further stated that there were no investigations into the incidents whereby Resident #1 was found unresponsive and with a [MEDICATION NAME] in his mouth. During an interview with the NP on 6/3/13 at 10:53 AM the NP stated that, for quite some time, nursing staff have reported to the NP the suspicion of one or two residents bringing narcotics in to the facility. He does not have any hard proof of this but believes there is a narcotic exchange going on in the facility. The NP stated that he believes his license is at stake treating residents who may be engaged in a narcotic exchange, so he reported his suspicion to the Medical Director. There are residents with substance abuse issues in the facility and the staff needs education regarding drug-seeking behavior. An interview was conducted with the Medical Director (MD) on 6/3/13 at 12:02 PM. The MD stated that he was the attending physician for Resident #1, who was a difficult patient to deal with; "he was mentally draining." The MD stated that the resident had drug-seeking behavior and it had been suggested to the MD to link the resident to the Veteran's Affairs for addiction help. This was not done; "It wouldn't cure him." The MD stated that the NP had come to him with a suspicion of drugs being brought into the facility; the MD told the Administrator. He is not aware of an investigation being done. The MD stated, "It is a speculation; we are not police offers." There are drug-seeking residents in the facility but he is not sure if there are any policies in place to deal with these residents' behaviors. An interview was conducted with the Psychiatrist on 6/5/13 at 4:12 PM. The Psychiatrist stated that he saw Resident #1 after the resident had overdosed twice. Resident #1 denied using [MEDICATION NAME]es and the Psychiatrist did not recommend any changes to the plan of care. The Psychiatrist further stated that he does not think it is his jurisdiction to tell a doctor how to practice medicine. However, "he (Resident #1) should have had counseling specific to drug-seeking behavior." 10 NYCRR 415.15 (a)

Based on resident and staff interviews and record review during an abbreviated and partial extended survey the facility failed to investigate resident misuse of narcotic medication and staff/resident complaints of distribution of illegal substances within the facility. Specifically, one (Resident #1) of 7 residents reviewed for abuse prohibition was found with empty non-prescribed narcotic medication packs in [DATE]. Facility staff, including key personnel, was reportedly aware but failed to investigate and implement interventions to protect the resident's health and safety. Subsequently, the resident was found unresponsive with a narcotic pain patch in his mouth on two separate occasions which were not investigated. On [DATE] the resident was again found unresponsive and was transferred to the hospital, where he was pronounced dead. In addition, the facility failed to report to other officials in accordance with State Law. The facility ' s failure to report and immediately investigate misuse of narcotic medications and allegations of narcotic exchange and to implement strategies to prevent abuse/neglect has the potential of jeopardizing the health and safety of 12 residents with histories of substance abuse. This resulted in the potential for serious harm that is Immediate Jeopardy and Substandard Quality of Care. Complaint Number: NY 136 Cross References: F 226 - Develop/Implement Abuse/Neglect Policies F 323 - Accidents & Supervision F 490 - Administration F 501 - Medical Director F 520 - Quality Assessment & Assurance The findings are: The Policy and Procedure on Abuse Prevention (PPAP) dated [DATE] documented that the facility will assess, care plan and monitor residents with self-injurious behaviors. The PPAP further documented that the facility will investigate all unusual incidents and monitor trends and/or patterns of occurrence via the Quality Assurance Committee in order to identify any suspicions of abuse. An interview was conducted with the Director of Nursing Services (DNS) on [DATE] at 1:44 PM. The DNS stated that a time line of Resident #1's stay in the facility was developed after receiving a call from the Department of Health but an investigation was not started into the resident ' s death; she is awaiting an autopsy result before beginning an investigation and is not sure if the death is suspicious. She does not suspect any illegal substances being brought into the facility. The DNS stated that she does not recall the resident being found with blister packs of [MEDICATION NAME]. The DNS stated that the resident had drug-seeking behavior; she is not aware of a policy on how to handle residents with drug-seeking behavior. An interview was conducted with the Nurse Practitioner (NP) on [DATE] at 2:45 PM. The NP stated that he had been treating Resident #1 but was never made aware of [MEDICATION NAME] blister packs being found in the resident's possession. The NP stated that, on [DATE] after the resident was sent out to the hospital, he heard nurses speaking about the resident having a [MEDICATION NAME] in his mouth. He was aware of the resident's previous two incidents of being found unresponsive with a [MEDICATION NAME] in his mouth but no staff would confirm a patch being found on [DATE]. The NP stated that he also was updated by the DNS and Administrator regarding the same suspicion but does not think any investigation was started. An interview was conducted with the Assistant Director of Nursing Services (ADNS) on [DATE] at 10:43 AM. The ADNS stated that, in [DATE], she had been told by one of the floor nurses that Resident #1 was found with empty blister packs of [MEDICATION NAME] which the nurses confiscated; she could not recall by whom she was told this. The ADNS stated she does incident investigations and there was no investigation into the empty blister packs; "They (the nurses) took care of it and it was referred to social work." The ADNS stated that she did not see the blister packs but "looking back there should have been an investigation." An interview was conducted with the Medical Director (MD) on [DATE] at 12:02 PM. The MD stated that he was the attending physician for Resident #1, who was a difficult patient to deal with; "he was mentally draining." The MD stated that the resident had drug-seeking behavior and it had been suggested to the MD to link the resident to the Veteran's Affairs for addiction help. This was not done; "It wouldn't cure him." The MD stated that the NP had come to him with a suspicion of drugs being brought into the facility; the MD told the Administrator. The MD stated that he is not aware of an investigation being done. The MD stated, "It is a speculation. We are not police officers." The MD further stated that there are drug-seeking residents in the facility but he is not sure if there are any policies in place to deal with these residents' behaviors. During a subsequent interview with the DNS on [DATE] at 2:30 PM the DNS stated that she has not been told of any suspicious drug activities or drugs being brought in to the facility by residents, visitors or staff. She, then, stated that she was aware of a discussion in Administration that had been brought forward by the NP regarding a suspicion of illegal drugs in the facility. "It's just hearsay." The DNS stated that there is no need to investigate anything alleged and without proof. She further stated that there were no investigations into the incidents whereby Resident #1 was found unresponsive and with a [MEDICATION NAME] in his mouth. During a subsequent interview with the ADNS on [DATE] at 2:00 PM the ADNS stated that she does the facility's A/I (accident/incident) investigations. The ADNS stated that she was aware of the incidents involving Resident #1 on [DATE], [DATE] and [DATE]. No investigations were done. The ADNS further stated, "An investigation is only warranted if there is harm to a resident." An interview was conducted with Resident #5 on [DATE] at 1:45 PM. Resident #5 stated that he has heard nursing staff talking about illegal drugs being brought in to the facility for a long time and is nervous about this. An interview was conducted with Resident #7 on [DATE] at 2:07 PM. Resident #7 stated that he has talked privately with the DNS several times in the past few months about residents having illegal drugs in the facility; the DNS told him to stop saying this. Resident #7 stated that, on the day Resident #1 died , he saw someone bring a black bag into Resident #1 and told the nurse at the desk and the DNS about it. Resident #7 stated that, on [DATE] after the surveyors left the facility, the Administrator threatened him with discharge if he spoke with the surveyors. Resident #7 further stated that he is "not afraid of discharge because something has to be done." During an interview with the Administrator on [DATE] at 12:28 PM the Administrator stated that the first time he heard about rumors of illegal drugs in the facility was on [DATE]; he believes this was after Resident #1 had a an overdose. He stated that no investigation was started and still uncertain whether or not to consider corrective actions; "I'm waiting for the Department of Health conclusions." 10 NYCRR 415.4(b)(1)(ii)

Based on resident and staff interviews and record review during an abbreviated and partial extended survey the facility failed to develop policies and procedures for residents with drug-seeking behaviors and to implement its abuse prohibition policies and procedures, designed to prevent resident abuse, neglect and protect residents from further abuse or neglect whenever identified. Specifically, one of seven residents reviewed for abuse prohibition had several incidents of drug-seeking behavior and, subsequently, required hospitalization and expired. The facility's failure to fully implement policies and procedures to prevent abuse and neglect has the potential of jeopardizing the health and safety of 12 residents with histories of substance abuse. This resulted in the potential for serious harm that is Immediate Jeopardy and Substandard Quality of Care. Complaint Number: NY 136 Cross References: F 225 - Investigate & Report Allegations F 323 - Accidents & Supervision F 490 - Administration F 501 - Medical Director F 520 - Quality Assessment & Assurance The findings are: The Policy and Procedure on Abuse Prevention (PPAP) dated [DATE] documented that the facility will assess, care plan and monitor residents with self injurious behaviors. The PPAP further documented that the facility will investigate all unusual incidents and monitor trends and/or patterns of occurrence via the Quality Assurance Committee in order to identify any suspicions of abuse. The facility did not have a policy and procedure for residents with drug-seeking behaviors. An interview was conducted with the Director of Nursing Services (DNS) on [DATE] at 1:44 PM. The DNS stated that a time line of Resident #1's stay in the facility was developed after receiving a call from the Department of Health but an investigation was not started into the resident's death; she is awaiting an autopsy result before beginning an investigation and is not sure if the death is suspicious. She does not suspect any illegal substances being brought into the facility. The DNS further stated that she does not recall the resident being found with blister packs of [MEDICATION NAME]. The resident had drug-seeking behavior; she is not aware of a policy on how to handle residents with drug-seeking behavior. An interview was conducted with the Nurse Practitioner (NP) on [DATE] at 2:45 PM. The NP stated that he had been treating Resident #1 but is never made aware of [MEDICATION NAME] blister packs being found in the resident's possession. On [DATE] after the resident was sent out to the hospital, he heard nurses speaking about the resident having a [MEDICATION NAME] in his mouth. He was aware of the resident's previous two incidents of being found unresponsive with a [MEDICATION NAME] in his mouth but no staff would confirm a patch being found on [DATE]. The NP further stated that he was updated by the DNS and Administrator regarding the same suspicion but does not think any investigation was started. An interview was conducted with the Assistant Director of Nursing Services (ADNS) on [DATE] at 10:43 AM. The ADNS stated that, in [DATE], she had been told by one of the floor nurses that Resident #1 was found with empty blister packs of [MEDICATION NAME] which the nurses confiscated. She does the incident investigations and there was no investigation into the empty blister packs; "They (the nurses) took care of it and it was referred to social work." The ADNS further stated that she did not see the blister packs but "looking back there should have been an investigation." An interview was conducted with the Medical Director (MD) on [DATE] at 12:02 PM. The MD stated that he was Resident #1's attending physician who was a difficult patient to deal with; "he was mentally draining; had drug-seeking behavior" and it had been suggested to the MD to link the resident to the Veteran's Affairs for addiction help. This was not done; "It wouldn't cure him." The MD stated that the NP had come to him with a suspicion of drugs being brought into the facility; the MD told the administrator. However, he is not aware of an investigation being done. The MD stated, "It is a speculation; we are not police officers." There are drug-seeking residents in the facility but he is not sure if there are any policies in place to deal with these residents' behaviors. During a subsequent interview with the DNS on [DATE] at 2:30 PM the DNS stated that she has not been told of any suspicious drug activities or drugs being brought in to the facility by residents, visitors or staff. She, then, stated that she was aware of a discussion in Administration that had been brought forward by the NP regarding a suspicion of illegal drugs in the facility. "It's just hearsay." The DNS stated that there is no need to investigate anything alleged and without proof. She further stated that there were no investigations into the incidents whereby Resident #1 was found unresponsive and with a [MEDICATION NAME] in his mouth. During a subsequent interview with the ADNS on [DATE] at 2:00 PM the ADNS stated that she does the facility's A/I (accident/incident) investigations. The ADNS stated that she was aware of the incidents involving Resident #1 on [DATE], [DATE] and [DATE]. No investigations were done. The ADNS further stated, "An investigation is only warranted if there is harm to a resident." An interview was conducted with Resident #5 on [DATE] at 1:45 PM. Resident #5 stated that he has heard nursing staff talking about illegal drugs being brought in to the facility for a long time and is nervous about this. An interview was conducted with Resident #7 on [DATE] at 2:07 PM. Resident #7 stated that he has talked privately with the DNS several times in the past few months about residents having illegal drugs in the facility; the DNS told him to stop saying this. Resident #7 stated that, on the day Resident #1 died , he saw someone bring a black bag into Resident #1 and told the nurse at the desk and the DNS about it. Resident #7 stated that, on [DATE] the Administrator threatened him with discharge if he spoke with the surveyors. Resident #7 further stated that he is "not afraid of discharge because something has to be done." During an interview with the Administrator on [DATE] at 12:28 PM, the Administrator stated that the first time he heard about rumors of illegal drugs in the facility was on [DATE]; he believes this was after Resident #1 had a an overdose. The Administrator further stated that no investigation was started and still uncertain whether or not to consider corrective actions; "I'm waiting for the Department of Health conclusions." 10 NYCRR 415.4(b)

Based on observation, interviews and record review during an abbreviated and partial extended survey, the facility failed to adequately monitor and supervise residents with known drug-seeking behaviors. Specifically, one (Resident #1) of seven residents reviewed with a known history of substance abuse was admitted to the facility with drug-seeking behaviors. A plan of care was not developed and implemented to address Resident #1's drug seeking behavior. The resident was found with empty non prescribed narcotic medication packs on [DATE]. Staff suspected illegal narcotic exchange within the facility but no investigations, assessments or changes to the resident's plan of care were made. Subsequently, Resident #1 was found unresponsive with a narcotic pain patch in his mouth on two separate occasions. On [DATE] the resident was again found unresponsive and was transferred to the hospital, where he was pronounced dead. This resulted in actual harm to Resident #1 and the potential for serious harm that is Immediate Jeopardy and Substandard Quality of Care for 12 residents with substance abuse histories within the facility. Complaint Number: NY 136 The findings are: The Policy and Procedure on Departure from Premises (PPDP) dated [DATE] documented that, upon a resident ' s return from out on pass, nursing must document the resident's condition, who the resident was accompanied by, medications returned including controlled substances and if the resident appears to be under influence of alcohol or drugs. The PPDP further documented that the facility presumes any AMA (against medical advice) departure to be a discharge from the facility. The Policy and Procedure on Abuse Prevention dated [DATE] documented that the facility will assess, care plan and monitor residents with self-injurious behaviors. The Policy and Procedure on Accident/Incident dated [DATE] documented that residents of the facility will be assessed on admission, re-admission or whenever a change in condition occurs. An individualized plan of care will be formulated that identifies risk factors and interventions. The Policy and Procedure on Behavior Monitoring-Drug Seeking and/or Drug Abuse dated [DATE] documented that nursing staff are required to document drug abuse related behavioral problems as occurrences happen and other disciplines report noticed behavior to the nurse for documentation. Resident #1 was [AGE] years old and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (an assessment tool) dated [DATE] documented that Resident #1 was cognitively intact. The Hospital Patient Review Instrument (PRI) dated [DATE] documented [DIAGNOSES REDACTED]. The facility's PRI Approval Form dated [DATE] documented "opiate dependence" under admission notes. The Nursing Progress Notes (NPN) dated [DATE] documented Resident #1's admission to the facility with a history of opiate dependency and polysubstance abuse. The Social Services Notes (SSN) dated [DATE] documented Resident #1's initial assessment for admission to the facility. The SSN lacked documented evidence of a history of substance abuse. The Pain Management Report of Consultation (PMRC) dated [DATE] documented that Resident #1 has a history of polysubstance abuse and verbally abusive when told that his pain medication cannot be increased. The PMRC documented that the "patient exhibits pain meds seeking behavior." The medical record lacked documented evidence of a behavioral plan of care for substance abuse or drug-seeking behavior. The NPN dated [DATE] (written by the [DATE] 12:00 Midnight to 8:00 AM nursing supervisor) documented that Resident #1 was outside smoking during unauthorized times and, per protocol, was searched for cigarettes. During the search medications were found: 25 empty blister packs of Oxycontin 20mg and various empty bottles of Tylenol PM (5). The medical doctor ordered toxicology screen. The resident was sent to the hospital and unhappy about being sent. The Nursing Unit Report (NUR) dated [DATE] for the 3:00 PM to 11:00 PM nursing shift documented that Resident #1 was sent to the hospital for a toxicology screen due to empty packs of oxycontin in room. The NUR dated [DATE] for the 11:00 PM to 7:00 AM nursing shift documented that Resident #1 was sent to the hospital for toxicology screen; was alert and oriented times three. The NPN dated [DATE] documented that Resident #1 returned from the hospital at 8:00 AM with recommendation for outside referral with PMR (Physical Medicine & Rehabilitation). Awaiting appointment date and time. The NUR dated [DATE] for the 7:00 AM to 3:00 PM nursing shift documented that Resident #1 returned from the hospital with no new orders. The Psychiatry Consultation Report (PCR) dated [DATE] documented that Resident #1 was seen because the resident was found with oxycontin that was not prescribed by the facility. The PCR documented that it is unclear if the resident has a history of substance use. No follow-up needed. There was no documented evidence of a facility investigation into the occurrence of [DATE]. The NPN dated [DATE] documented that Resident #1 was found on the floor, able to move all extremities. Resident able to stand and transferred to bed. Due to history urine to be obtained for toxicology screen as per NP (nurse practitioner). The medical record lacked documented evidence of an obtained urine specimen or that a toxicology screen was done. The Comprehensive Care Plan for Risk of Accident/Incident dated [DATE] documented an intervention of 15 minute close monitoring. The CNA Accountability Records for ,[DATE], ,[DATE] and ,[DATE] lacked documented evidence of instructions for monitoring Resident #1. The 15 Minute Monitoring Records from [DATE] to [DATE] documented that Resident #1 was monitored 26 out of 78 days. The NPN dated [DATE] documented that Resident #1 was found slouching in chair, not able to communicate properly; increased tremors, pupils fixed, increased sweating. MD (medical doctor) in to evaluate; send to hospital for possible drug overdose. Resident was asked to open his mouth and was found sucking on a 75mcg patch (fentanyl). The Medical Progress Notes (MPN) dated [DATE] documented that Resident #1 was slouched in the wheelchair, mumbling incoherent, confused. Assessment: Drug Overdose; Patient with fentanyl patch in mouth; RN notes patient buys his own tegaderm patches and just sticks patches on. Similar confused episode on Sunday. I suspect patient also had been sucking on patch then too. Send to hospital. Patient a danger to himself. The Resident Transfer Form (RTF) dated [DATE] documented that Resident was being transferred to the hospital after being found sucking on a fentanyl patch to rule out overdose; altered mental status; shaking. The RTF documented the resident's behavior as "cooperative, disruptive, belligerent, oriented x3." The Hospital Emergency Department Encounter and Treatment Patient Sheet dated [DATE] documented a primary discharge [DIAGNOSES REDACTED]. The NPN dated [DATE] documented that Resident #1 returned to the facility at 10:00 PM requesting placement of a new fentanyl patch. The patch was held until evaluation in the morning. The Medical Monthly Progress Notes dated [DATE] documented that Resident #1 was found unresponsive yesterday with fentanyl patch in mouth. Patient has a history of drug overdoses. Observe patient closely for drug overdose by self. Hold pain meds if patient is sedated. D/C (discontinue) Atarax for now. The PCR dated [DATE] documented that Resident #1 was seen by Psychiatry because he was observed with fentanyl patch in mouth. Patient has a history of oxycodone being found not prescribed and now this time caught with fentanyl patch. Diagnosis: [REDACTED]. No new orders; follow-up in three months. There was no documented evidence of a facility investigation into the occurrence of [DATE]. The MPN dated [DATE] documented that hospital toxicology results from [DATE] were received and positive for Methadone; Resident #1 is not on Methadone. Discussion held with patient, who is agreeable to random testing and resident contract discussed. The Release of Responsibility for Discharge Against Advice Form dated [DATE] documented that Resident #1 was being discharged AMA. The NPN dated [DATE] documented that Resident #1 was out of the facility to the VA (Veteran ' s Affairs); signed out AMA due to resident did not want to go with an aide. Resident returned later in the evening in good spirits. The MPN dated [DATE] documented that, after speaking with the Director of Nursing (DON), Administrator and patient, assessed request for change in pain med control to duragesic patch like prior. Patient signed contract with DON to not chew patch; will resume old pain course and monitor patient. Add Duragesic. The NPN dated [DATE] at 5:00 PM documented that Resident #1 was found lying in bed not responding to verbal or tactile stimuli. Diaphoretic; sternum rub done, not responding. Labored breathing. Duragesic 75mcg found in his mouth. 911 activated. First responders and police in; they assessed resident; he was not responding at first. After several attempts resident responded; became very angry. Resident stumbled to stretcher and was taken to hospital for rehab. MD made aware. The Hospital Aftercare Instructions dated [DATE] documented an Emergency Department [DIAGNOSES REDACTED]. The NPN dated [DATE] at 5:15 AM documented that Resident #1 returned to the facility unaccompanied; ER (emergency room ) [DIAGNOSES REDACTED]. The NPN dated [DATE] documented that Resident #1 admitted to removing his duragesic patch and placing it in his mouth; was going to suck it for approximately 10 to 15 minutes before replacing it but may have fallen asleep with the patch in his mouth and consequently ingesting a larger dose than planned. Resident verbalized understanding of the consequences of his actions and accepts the fact that he violated his contract; he is now being offered alternative PO (oral) pain medication. Duragesic discontinued; PO narcotic analgesics re-ordered. There was no documented evidence of a facility investigation into the occurrence of [DATE]. The NPN dated [DATE] documented that Resident #1 put his finger in the medication cup on top of Klonopin pill. Resident put Klonopin under his tongue, stating, "I'm trying to let the pill melt under my tongue." The NPN dated [DATE] documented that Resident #1 was administered two tablets of Percocet at 4:00 AM; requesting Percocet to be crushed and placed in medication cup without applesauce or pudding. Denies difficulty swallowing. Resident stated he wasn't given his medications at Midnight. Klonopin and Percocet were administered. The PCR dated [DATE] documented that Resident #1 was seen by Psychiatry for increased signs of depression, being found with meds in his room and fentanyl patch in his mouth. No behavioral issues reported. Diagnosis: [REDACTED]. The NPN dated [DATE] documented that Resident #1 was found unresponsive at 8:40 PM. Resident is not a DNR (Do Not Resuscitate); code blue called. Resident had no detectable pulse, blood pressure or respirations. CPR (cardiopulmonary resuscitation) started; 911 called. First responders on-site; CPR continued until 9:21 PM. Resident transferred to the hospital. The NPN dated [DATE] documented that Resident #1 expired in the hospital at 9:33 PM. An interview was conducted with the 8:00 AM to 4:00 PM Registered Nurse Supervisor (RNS #1) on [DATE] at 10:30 AM. RNS #1 stated that Resident #1 was easily agitated and would insist on going out alone. There is no written policy for residents going out on pass; nursing "should just eyeball" a resident upon return to the facility; "I don't think there ' s a requirement to document." Resident #1 did not have any out on pass restrictions. The resident did not have a care plan for substance abuse, denied using substances and claimed toxicologies were wrong. RNS #1 stated that there is no set protocol for monitoring substance abuse behaviors. "If you don't see anything (substances) there's no monitoring." An interview was conducted with a 7:00 AM to 3:00 PM Licensed Practical Nurse (LPN #1) on [DATE] at 1:30 PM. LPN #1 stated that, if a resident was gone for an extended period of time, she would document a resident's return to the facility but is not sure of any protocol. She would assign specific duties to CNAs (Certified Nursing Assistants) for a resident. There were no specific duties for CNAs to follow with regard to Resident #1; "He (Resident #1) wasn't monitored." An interview was conducted with the Social Worker (SW) on [DATE] at 11:30 AM. The SW stated that there are no specific assignments of residents to social workers but the SW knows Resident #1 had a substance abuse history. There are AA (Alcoholics Anonymous) meetings which a resident can go to; there are no meetings for narcotics support. The SW stated that she is not aware of any blister packs found in the resident's possession and first was made aware of an overdose of some type of over the counter medication on [DATE]. A contract was signed with the resident to not bring any non-prescribed medication into the facility. The SW stated that she is not sure if a policy exists on substance abuse or drug-seeking behavior. She would hope that nursing would notify social work if a drug is found in a resident's room and monitor the resident. The SW further stated that a resident can be referred to Psychology for counseling but is not aware of whether or not there is specialized counseling for substance abuse. An interview was conducted with the assigned 6:00 AM to 2:00 PM CNA #1 on [DATE] at 12:29 PM. CNA #1 stated that Resident #1 had fluctuating mood and had kept Tylenol PM in his room; CNA #1 reported this to nursing. A few months ago the resident was sent out to the hospital and the nurse told CNAs that the resident was drug-seeking. CNA #1 further stated that, when Resident #1 came back from the hospital, the resident was supposed to be on 15 minute checks but the checks weren't done all the time. The resident "came and went as he pleased." An interview was conducted with the Director of Nursing Services (DNS) on [DATE] at 1:44 PM. The DNS stated that a time line of Resident #1's stay in the facility was developed after receiving a call from the Department of Health but an investigation was not started into the resident's death; she is awaiting an autopsy result before beginning an investigation and is not sure if the death is suspicious. She does not suspect any illegal substances being brought into the facility. The DNS stated that she does not recall the resident being found with blister packs of oxycontin. The resident had drug-seeking behavior; she is not aware of a policy on how to handle residents with drug-seeking behavior. The DNS further stated that the resident was on 15 minute monitoring. An interview was conducted with the Nurse Practitioner (NP) on [DATE] at 2:45 PM. The NP stated that he had been treating Resident #1 but was never made aware of oxycontin blister packs being found in the resident's possession. On [DATE] after the resident was sent out to the hospital, he heard nurses speaking about the resident having a duragesic pain patch in his mouth. He was aware of the resident's previous two incidents of being found unresponsive with a duragesic pain patch in his mouth but no staff would confirm a patch being found on [DATE]. The NP further stated that he was updated by the DNS and Administrator regarding the same suspicion but does not think any investigation was started. An interview was conducted with the Administrator on [DATE] at 10:15 AM. The Administrator stated that Resident #1 never wanted any staff member to go with him to the Veteran's Affairs. The resident had an appointment there on [DATE]. The Administrator stated, "I was afraid he (Resident #1) would make a run; not come back. Since he is alert and oriented times three, I got him to sign AMA." The Administrator would not elaborate any further. An interview was conducted with the Assistant Director of Nursing Services (ADNS) on [DATE] at 10:43 AM. The ADNS stated that, in [DATE], she had been told by one of the floor nurses that Resident #1 was found with empty blister packs of oxycontin which the nurses confiscated; she could not recall by whom she was told this. The ADNS stated she does incident investigations and there was no investigation into the empty blister packs; "They (the nurses) took care of it and it was referred to social work." The ADNS also stated that she did not see the blister packs but "looking back there should have been an investigation." During a subsequent interview with the NP on [DATE] at 10:53 AM, the NP stated that, for quite some time, nursing staff have reported to the NP the suspicion of one or two residents bringing narcotics in to the facility. He does not have any hard proof of this but believes there is a narcotic exchange going on in the facility. The NP stated that he believes his license is at stake treating residents who may be engaged in a narcotic exchange, so he reported his suspicion to the Medical Director. The NP further stated that there are residents with substance abuse issues in the facility and the staff needs education regarding drug-seeking behavior. An interview was conducted with a 7:00 AM to 3:00 PM LPN #2 on [DATE] at 11:31 AM. LPN #2 stated that, on [DATE] around 8:40 PM, she went in to administer medications to Resident #1 and found the resident unresponsive. She immediately called a Code and the supervisor came to assess the resident. The resident often tried to pocket his medication; she tried to make sure that the resident would swallow medication in front of her. LPN #2 further stated that the resident would often leave the facility but she never signed the resident out on pass. An interview was conducted with the 4:00 PM to 12 Midnight RNS #2 on [DATE] at 11:30 AM. RNS #2 stated that, on [DATE], LPN #2 called a Code on Resident #1, who was unresponsive. The resident had no pulse and no blood pressure; CPR was started and continued until first responders arrived to take the resident to the hospital. RNS #2 stated that she does not recall seeing anything in the resident's mouth and does not recall being told about the resident pocketing his medications. She does not know if the resident had a plan of care for substance abuse or drug-seeking behavior. An interview was conducted with the Medical Director (MD) on [DATE] at 12:02 PM. The MD stated that he was the attending physician for Resident #1, who was a difficult patient to deal with; "he was mentally draining." The resident had drug-seeking behavior and it had been suggested to the MD to link the resident to the Veteran's Affairs for addiction help. This was not done; "It wouldn't cure him." The MD stated that the NP came to him with a suspicion of drugs being brought into the facility; the MD told the Administrator. The MD stated that he is not aware of an investigation being done. "It is a speculation; we are not police officers." The MD further stated that there are drug-seeking residents in the facility but he is not sure if there are any policies in place to deal with these residents' behaviors. An interview was conducted with a 6:00 AM to 2:00 PM CNA #2 on [DATE] at 1:45 PM. CNA #2 stated that he has not personally seen anyone bring non-prescribed medication in to the facility but there has been talk of drugs between residents for a long time. Resident #1 was not monitored and went out on his own a lot. During a subsequent interview with the DNS on [DATE] at 2:30 PM, the DNS stated that she has not been told of any suspicious drug activities or drugs being brought in to the facility by residents, visitors or staff. She, then, stated that she was aware of a discussion in Administration that had been brought forward by the NP regarding a suspicion of illegal drugs in the facility. "It's just hearsay." The DNS further stated that there is no need to investigate anything alleged and without proof. There were no investigations into the incidents whereby Resident #1 was found unresponsive and with a fentanyl patch in his mouth. An interview was conducted with a 4:00 PM to 12 Midnight RN #1. RN #1 stated that she recalls a recreation aide searching Resident #1's room on [DATE] after the resident was found smoking outside of the smoking times. The recreation aide found blister packs of oxycontin and brought them to the nursing desk. RN #1 saw the blister packs and documented this on the 24 hour report; she did not assess the resident and does not recall what happened to the blister packs. RN #1 stated, "I probably would have given it to my supervisor." An interview was conducted with a 4:00 PM to 12 Midnight RNS #3 on [DATE] at 12:15 PM. RNS #3 stated that she was aware of 25 blister packs of oxycontin being found in Resident #1's room on [DATE]. She did not actually see the blister packs and does not know where they went. She did not physically assess the resident because it was after 10:00 PM and coming towards the end of her shift. She told the supervisor of the next shift about the finding and the resident was sent out to the hospital overnight. RNS #3 documented that the resident was sent out to the hospital for a toxicology screen on her shift "because that was the plan." RNS #3 stated that she told the supervisor of the next shift that the blister packs were found. "That was the extent of my investigation. If it was not at the end of my shift I would have called the Administrator and brought it to his attention. Unless something is urgent I refer it to a colleague." RNS #3 further stated that the resident did not have any behavioral contracts. With regard to Resident #1's out on pass privileges; "Independence is important; he had liberties to go to town alone." An interview was conducted with a 4:00 PM to 12 Midnight RNS #4 on [DATE] at 12:25 PM. RNS #4 stated that, on [DATE], she was called by overhead page to Resident #1's room. The resident was unresponsive and had a duragesic patch in his mouth. She sent the resident out to the hospital as a 911 emergency. RNS #4 further stated that she did not suspect any drug-seeking activities and did not start an investigation. She called the ADNS to advise her of the incident. During a subsequent interview with the ADNS on [DATE] at 2:00 PM, the ADNS stated that she does the facility's A/I (accident/incident) investigations.She stated that she was aware of the incidents involving Resident #1 on [DATE], [DATE] and [DATE]. No investigations were done. The ADNS further stated, "An investigation is only warranted if there is harm to a resident." An interview was conducted with a Recreation Aide (RA #1) on [DATE] at 1:38 PM, RA #1 stated that, on [DATE], she had to search Resident #1's room because the resident had violated smoking policy. She found empty medication blister packs and immediately brought them to the nurses at the nursing desk. RA #1 stated that she doesn't think Resident #1 had any monitoring restrictions. An interview was conducted with Resident #5 on [DATE] at 1:45 PM, Resident #5 stated that he has heard nursing staff talking about illegal drugs being brought in to the facility for a long time and is nervous about this. An interview was conducted with Resident #7 on [DATE] at 2:07 PM, Resident #7 stated that he has talked privately with the DNS several times in the past few months about residents having illegal drugs in the facility; the DNS told him to stop saying this. Resident #7 stated that, on the day Resident #1 died , he saw someone bring a black bag into Resident #1 and told the nurse at the desk and the DNS about it. Resident #7 stated that, on [DATE] after the surveyors left the facility, the Administrator threatened him with discharge if he spoke with the surveyors. Resident #7 further stated he is "not afraid of discharge because something has to be done." An interview was conducted with a RA #2 on [DATE] at 2:32 PM. RA #2 stated that there have been times when she thinks residents are using marijuana during smoking sessions. RA #2 stated that she will usually tell nursing because "I don't know what else to do." An interview was conducted with the Psychiatrist on [DATE] at 4:12 PM. The Psychiatrist stated that he saw Resident #1 after the resident had overdosed twice. Resident #1 denied using fentanyl patches and the Psychiatrist did not recommend any changes to the plan of care. The Psychiatrist stated that he does not think it is his jurisdiction to tell a doctor how to practice medicine. The Psychiatrist further stated, "he (Resident #1) should have had counseling specific to drug-seeking behavior." An interview was conducted with a 3:00 PM to 11:00 PM LPN #3 on [DATE] at 10:14 AM. LPN #3 stated that she was working on [DATE] when blister packs of oxycontin were found in Resident #1's belongings. LPN #3 stated that a recreation aide brought the blister packs to the nursing desk. The supervisor was called, RNS #3 took the blister packs and LPN #3 never heard another thing about the incident. No staff assessed the resident. An interview was conducted with a 2:00 PM to 10:00 PM CNA #3 on [DATE] at 11:03 AM. CNA #3 stated that she cared for Resident #1 on her shift. She does not remember the resident ever being on 15 minute monitoring. CNA #3 stated "she was the resident's regular CNA. No one ever told me of him overdosing on anything." The resident went out on his own every evening. During a subsequent interview with the Administrator on [DATE] at 12:28 PM, the Administrator stated that the first time he heard about rumors of illegal drugs in the facility was on [DATE]; he believes this was after Resident #1 had an overdose. He stated that no investigation was started and still uncertain whether or not to consider corrective actions; "I'm waiting for the Department of Health conclusions." 10 NYCRR 415.12 (h) (1) (2)

Based on record review and staff interviews during the abbreviated and partial extended survey, it was determined that the administration failed to administer the facility in a manner that maintained each resident's highest practicable level of physical, mental and psychosocial well being. Specifically, the facility's administration failed to ensure that there was adequate monitoring and supervision of residents with substance abuse histories and/or drug-seeking behavior. The Administration failed to perform investigations to determine the root cause of three prior instances of misuse of narcotic medications, two of which resulted in Resident #1's overdoses requiring hospitalization . The Administration failed to identify system failures related to residents with a history of substance abuse and drug-seeking behavior. On 5/2/13 Resident #1 was again found unresponsive, transferred to the hospital and was pronounced dead. This resulted in actual harm to Resident #1 with the potential for serious harm that is Immediate Jeopardy for 12 residents who have substance abuse histories and/or drug-seeking behavior. Complaint Number: NY 136 Cross References: F 225 - Investigate & Report Allegations F 226 - Develop/Implement Abuse/Neglect Policies F 323 - Accidents & Supervision F 501 - Medical Director F 520 - Quality Assessment & Assurance The findings are: An interview was conducted with the Director of Nursing Services (DNS) on 5/31/13 at 1:44 PM. The DNS stated that a time line of Resident #1's stay in the facility was developed after receiving a call from the Department of Health but an investigation was not started into the resident's death; she is awaiting an autopsy result before beginning an investigation and is not sure if the death is suspicious. She does not suspect any illegal substances being brought into the facility. The DNS stated that she does not recall the resident being found with blister packs of [MEDICATION NAME]. The resident had drug-seeking behavior. The DNS further stated that she is not aware of a policy on how to handle residents with drug-seeking behavior. An interview was conducted with the Nurse Practitioner (NP) on 5/31/13 at 2:45 PM. The NP stated that he had been treating Resident #1 but was never made aware of [MEDICATION NAME] blister packs being found in the resident's possession. On 5/2/13 after the resident was sent out to the hospital, he heard nurses speaking about the resident having a [MEDICATION NAME] in his mouth. He was aware of the resident's previous two incidents of being found unresponsive with a [MEDICATION NAME] in his mouth but no staff would confirm a patch being found on 5/2/13. The NP further stated that he was updated by the DNS and Administrator regarding the same suspicion but does not think any investigation was started. An interview was conducted with the Assistant Director of Nursing Services (ADNS) on 6/3/13 at 10:43 AM. The ADNS stated that, in December 2012, she had been told by one of the floor nurses that Resident #1 was found with empty blister packs of [MEDICATION NAME] which the nurses confiscated; she could not recall by whom she was told. The ADNS also stated that she does incident investigations and there was no investigation into the empty blister packs; "They (the nurses) took care of it and it was referred to social work." She stated that she did not see the blister packs but "looking back there should have been an investigation." During a subsequent interview with the NP on 6/3/13 at 10:53 AM, the NP stated that, for quite some time, nursing staff have reported to the NP the suspicion of one or two residents bringing narcotics in to the facility. He does not have any hard proof of this but believes there is a narcotic exchange going on in the facility. The NP stated that he believes his license is at stake treating residents who may be engaged in a narcotic exchange, so the NP reported his suspicion to the Medical Director. There are residents with substance abuse issues in the facility and the staff needs education regarding drug-seeking behavior. An interview was conducted with the Medical Director (MD) on 6/3/13 at 12:02 PM. The MD stated that he was Resident #1's attending physician; Resident #1 was a difficult patient to deal with; "he was mentally draining." The resident had drug-seeking behavior and it had been suggested to the MD to link the resident to the Veteran's Affairs for addiction help. This was not done; "It wouldn't cure him." The MD stated that the NP came to him with a suspicion of drugs being brought into the facility; the MD told the Administrator and he is not aware of an investigation being done. "It is a speculation; we are not police officers." The MD further stated that there are drug-seeking residents in the facility but he is not sure if there are any policies in place to deal with these residents ' behaviors. During a subsequent interview with the DNS on 6/3/13 at 2:30 PM, the DNS stated that she has not been told of any suspicious drug activities or drugs being brought in to the facility by residents, visitors or staff. The DNS, then, stated that she was aware of a discussion in Administration that had been brought forward by the NP regarding a suspicion of illegal drugs in the facility. "It's just hearsay; there is no need to investigate anything alleged and without proof." She further stated that there were no investigations into the incidents whereby Resident #1 was found unresponsive and with a [MEDICATION NAME] in his mouth. During a subsequent interview with the ADNS on 6/5/13 at 2:00 PM, the ADNS stated that she does the facility's A/I (accident/incident) investigations. The ADNS stated that she was aware of the incidents involving Resident #1 on 12/16/12, 3/20/13 and 4/11/13. No investigations were done. The ADNS further stated, "An investigation is only warranted if there is harm to a resident." An interview was conducted with the Psychiatrist on 6/5/13 at 4:12 PM. The Psychiatrist stated that he saw Resident #1 after the resident had overdosed twice. Resident #1 denied using [MEDICATION NAME]es and the Psychiatrist did not recommend any changes to the plan of care. The Psychiatrist stated that he does not think it is his jurisdiction to tell a doctor how to practice medicine. However, "he (Resident #1) should have had counseling specific to drug-seeking behavior." During an interview with the Administrator on 6/6/13 at 12:28 PM, the Administrator stated that the first time he heard about rumors of illegal drugs in the facility was on 4/16/13; he believes this was after Resident #1 had an overdose. No investigation was started and he is still uncertain whether or not to consider corrective actions; "I'm waiting for the Department of Health conclusions." 10 NYCRR 415.26

Based on record review and staff interviews during an abbreviated and partial extended survey the facility failed to provide a quality assessment and assurance program that functioned to develop and implement appropriate plans of action to readily identify issues with the potential to cause serious harm to the health and safety of residents with a history of substance abuse and/or drug-seeking behavior. Specifically, the QAA Committee failed to conduct quality assessment and assurance to ensure the development and implementation of policies and procedures to readily identify and address issues related to the monitoring and supervision of residents with known histories of substance abuse. The QAA Committee also failed to identify system failures related to residents with histories of substance abuse in order to determine the root cause and prevent further instances of neglect. This resulted in actual harm to Resident #1 and the potential for serious harm that is Immediate Jeopardy for 12 residents who have substance abuse histories and/or drug-seeking behavior. Complaint Number: NY 136 Cross References: F 225 - Investigate & Report Allegations F 226 - Develop/Implement Abuse/Neglect Policies F 323 - Accidents & Supervision F 490 - Administration F 501 - Medical Director The findings are: An interview was conducted with the Director of Nursing Services (DNS) on 5/31/13 at 1:44 PM. The DNS stated that a time line of Resident #1's stay in the facility was developed after receiving a call from the Department of Health but an investigation was not started into the resident's death; she is awaiting an autopsy result before beginning an investigation and is not sure if the death is suspicious. She does not suspect any illegal substances being brought into the facility. The DNS stated that she does not recall the resident being found with blister packs of [MEDICATION NAME]. The DNS stated that the resident had drug-seeking behavior; she is not aware of a policy on how to handle residents with drug-seeking behavior. An interview was conducted with the Nurse Practitioner (NP) on 5/31/13 at 2:45 PM. The NP stated that he had been treating Resident #1 but was never made aware of [MEDICATION NAME] blister packs being found in the resident's possession. The NP stated that, on 5/2/13 after the resident was sent out to the hospital, he heard nurses speaking about the resident having a [MEDICATION NAME] in his mouth. He was aware of the resident ' s previous two incidents of being found unresponsive with a [MEDICATION NAME] in his mouth but no staff would confirm a patch being found on 5/2/13. The NP stated that he also was updated by the DNS and Administrator regarding the same suspicion but does not think any investigation was started. An interview was conducted with the Assistant Director of Nursing Services (ADNS) on 6/3/13 at 10:43 AM. The ADNS stated that, in December 2012, she had been told by one of the floor nurses that Resident #1 was found with empty blister packs of [MEDICATION NAME] which the nurses confiscated; she could not recall by whom she was told. The ADNS stated she does incident investigations and there was no investigation into the empty blister packs; "They (the nurses) took care of it and it was referred to social work." She not see the blister packs but "looking back there should have been an investigation." During a subsequent interview with the NP on 6/3/13 at 10:53 AM, the NP stated that, for quite some time, nursing staff have reported to the NP the suspicion of one or two residents bringing narcotics in to the facility. He does not have any hard proof of this but believes there is a narcotic exchange going on in the facility. The NP stated that he believes his license is at stake treating residents who may be engaged in a narcotic exchange, so he reported his suspicion to the Medical Director. The NP further stated that there are residents with substance abuse issues in the facility and the staff needs education regarding drug-seeking behavior. An interview was conducted with the Medical Director (MD) on 6/3/13 at 12:02 PM. The MD stated that he was the attending physician for Resident #1, who was a difficult patient to deal with; "he was mentally draining." The resident had drug-seeking behavior and it had been suggested to the MD to link the resident to the Veteran's Affairs for addiction help. This was not done; "It wouldn't cure him." The MD stated that the NP came to him with a suspicion of drugs being brought into the facility; he told the Administrator. The MD stated that he is not aware of an investigation being done. "It is a speculation; we are not police officers." The MD further stated that there are drug-seeking residents in the facility but he is not sure if there are any policies in place to deal with these residents' behaviors. During a subsequent interview with the DNS on 6/3/13 at 2:30 PM, the DNS stated that she has not been told of any suspicious drug activities or drugs being brought in to the facility by residents, visitors or staff. The DNS, then, stated that she was aware of a discussion in Administration that had been brought forward by the NP regarding a suspicion of illegal drugs in the facility. "It's just hearsay; there is no need to investigate anything alleged and without proof." She further stated that there were no investigations into the incidents whereby Resident #1 was found unresponsive and with a [MEDICATION NAME] in his mouth. During a subsequent interview with the ADNS on 6/5/13 at 2:00 PM, the ADNS stated that she does the facility's A/I (accident/incident) investigations. She was aware of the incidents involving Resident #1 on 12/16/12, 3/20/13 and 4/11/13. No investigations were done. The ADNS further stated, "An investigation is only warranted if there is harm to a resident." During an interview with the Administrator on 6/6/13 at 12:28 PM the, Administrator stated that the first time he heard about rumors of illegal drugs in the facility was on 4/16/13; he believes this was after Resident #1 had an overdose. No investigation was started and still uncertain whether or not to consider corrective actions; "I'm waiting for the Department of Health conclusions." The Administrator further stated that he believes the facility has a QA for drug-seeking behavior but he does not know what it is. 10 NYCRR 415.27(a-c)