Every finding on record at The Five Towns Premier Rehabilitation & Nursing Ce

Based on record review and interviews during the survey, the facility failed to ensure that all alleged allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated. This was identified for one (Resident #6) of two residents reviewed for accidents. Specifically, Resident #6 had an unwitnessed fall on 11/15/2025 that resulted in injuries. The facility's accident and incident investigation report did not include statements from all staff involved. Additionally, the staff statements that were obtained were inconsistent and did not accurately indicate staff's response to the incident. Incident #2706534The findings include: The facility policy titled Accident and Incident, dated 02/2026, documented it is the policy of the facility to maintain a resident environment that is as free of accident hazards as possible and to provide adequate supervision and assistive devices to prevent avoidable accidents, and to promptly respond to, report, investigate, and document all accidents and incidents in accordance with state and federal regulations. An incident report is completed promptly, documenting the date, time, location, description, witnesses, resident condition, interventions, and notifications and ensuring that all documentation is factual and objective. Resident #6 was admitted with diagnoses including muscle weakness, gait and mobility abnormality, and depression. The 11/03/2025 admission Minimum Data Set assessment documented a Brief Interview for Mental Status score of 14, indicating the resident was cognitively intact. There were no recent falls documented. A nursing progress note dated 11/15/2025 at 08:18 AM, written by Registered Nurse #7 (the charge nurse on the 7:00 AM-3:00 PM shift) documented that at approximately 7:19AM, the writer was informed by the unit nurse (Licensed Practical Nurse #1) that Resident #6 was on the floor. Resident #6 was observed on the floor, on the left side of the bed, in a supine (on back) position. A pillow was under the resident's head. Resident #6 was observed with swelling on their forehead (measuring 4.0 centimeters x 4.0 centimeters) and nose with minimal bleeding from both nostrils. Bilateral knees were also noted with redness. The resident stated that they used the restroom and when going back to bed, they tripped, fell, and hit their head. Registered Nurse Supervisor #6 (the nursing supervisor) and the Physician were notified with order to send resident to the hospital for Computerized Tomography (CT) scan of the head. Review of the 11/15/2025 Occurrence Report indicated that Licensed Practical Nurse #1 reported the resident's fall to Registered Nurse #7; however, there was no statement obtained from Licensed Practical Nurse #1. Additionally, the Certified Nursing Assistant question sheet did not indicate name of the certified nursing assistant and had illegible signature at the bottom of the sheet making it difficult to discern which staff had filled out the sheet. The Certified Nursing Assistant question sheet. indicated that prior to the unwitnessed fall the resident was last seen in their room in bed watching television at 07:10 AM. During an interview on 06/10/2026 at 11:20 AM, Licensed Practical Nurse #1 stated they did not recall the 11/15/2025 incident; Licensed Practical Nurse #1 stated if they had reported the incident, there is a documented investigative statement that they would have to provide regarding what they saw and know about the incident as per the facility protocol. During a telephone interview on 6/10/2026 at 11:50 AM, Certified Nursing Assistant #6 (who was assigned to Resident #6 on 11/15/2026 during the 7:00 AM-3:00 PM shift) stated they did not remember the incident on11/15/2025 or the affected resident. During an interview on 06/10/26 at 12:30 PM, Registered Nurse #7 (charge nurse) stated on 11/15/2025 Licensed Practical Nurse #1 informed them of Resident #6's unwitnessed fall. Registered Nurse #7 could not recall the time the incident was reported to them. Registered Nurse #7 stated they went to the resident's room and assessed the resident. Registered Nurse #7 stated they do not do the investigations; they just write a progress note and write their statement. During an interview on 6/10/2026 at 12:50 PM, Registered Nurse #8 (consultant) stated they did not recall the incident; however, whenever the facility needed assistance with occurrence reports, they would help in ensuring that all the necessary interviews and statements were obtained. They then would write the investigative summaries. The facility staff were responsible for gathering all the interview statements. Registered Nurse #8 stated that the investigative summary cannot be completed without all the details in place and Licensed Practical Nurse #1 should have provided a statement to thoroughly investigate the unwitnessed fall. Registered Nurse #8 stated the Certified Nursing Assistant's name should have been included on the Certified Nursing Assistant question sheet. Registered Nurse #8 had no explanation as to why the summary was completed without Licensed Practical Nurse #1's statement and with the Certified Nursing Assistant's name being left out of the questionnaire and the signature scribbled out. During an interview on 06/10/2026 at 1:15 PM, the Director of Nursing Services stated they are the risk manager; they stated they did not work at the facility in November 2025 and never met the consultant (Registered Nurse #8). The Director of Nursing Services stated they would have expected a statement from the staff member who found the resident on the floor, for instance what the staff member did, what time did they observe the resident etc. During a re-interview on 06/10/2026 at 2:40 PM, the Director of Nursing Services stated they just spoke to Licensed Practical Nurse #1. Licensed Practical Nurse #1 said that on 11/15/2025 they were at the nursing station when Certified Nursing Assistant #6 reported to them that Resident #6 was on the floor. Licensed Practical Nurse #1 did not go to see the resident and informed Registered Nurse #7 about the incident. The Director of Nursing Services stated the Occurrence Report was incomplete and did not accurately reflect the sequence of events regarding Resident #6's unwitnessed fall on 11/15/2025. During a re-interview on 06/25/2026 at 11:40 AM, Licensed Practical Nurse #1 stated that on 11/15/2025 they were at the nursing station and were getting ready to leave because their shift was over. Certified Nursing Assistant #6 told them that they saw Resident #6 on the floor and Licensed Practical Nurse #1 notified Registered Nurse #7 of the incident. 10 New York State Code Rules and Regulations 415.4(b)(3)

Based on record review and staff interviews, the facility failed to ensure a resident requiring dialysis services received such services consistent with professional standard of practice. This was identified for one (Resident #3) of three residents reviewed for dialysis. Specifically, Resident #3, who receives dialysis treatment at the facility three times per week, was not provided dialysis treatment on their scheduled day on 06/20/2026 due to lack of communication between the facility staff and the dialysis center staff.The findings include:The facility's policy titled, Dialysis last revised on 01/2020 documented that the facility will ensure that all residents who need hemodialysis treatment will receive the services as ordered by the Attending Physician. A dialysis communication tool will be initiated by the unit Nurse, and all pertinent information will be communicated between dialysis and the Nursing unit through the communication tool. Notify the dialysis center of any changes in the resident's condition, new medications, abnormal laboratory results from test done at the facility. If a resident refuses to attend dialysis, the unit Nurse will inform the dialysis center for possible rescheduling, the attending physician and the social worker and will document the refusal in the medical record.Resident #3 was admitted with diagnoses including sepsis (the body's response to a life-threatening infection), type two diabetes (high blood sugar) and pneumonia (infection in one or both lungs). An Annual Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated that Resident #3 had intact cognition. The Annual Minimum Data Set (MDS) documented Resident #3 received dialysis treatment. A physician's order dated 06/19/2025 documented hemodialysis (most common type of dialysis where blood is pumped out of the body through vascular (blood vessel) access, filtered by a machine and then returned to the body) every Monday, Wednesday and Friday at the facility's in-house dialysis center. A Comprehensive Care Plan (CCP) dated 07/01/2025 titled Dialysis documented interventions including monitoring dialysis access site for signs and symptoms of infections, communication will occur between skilled Nursing staff and hemodialysis center related to the care needs of residents and providing renal (special diet for residents with chronic kidney disease and kidney failure) diet as per physician's order.Nursing Progress Note dated 06/19/2025 at 10:47 PM documented that the facility received an order from the discharging hospital that Resident #3 needed a blood transfusion on 06/20/2025 due to a hemoglobin (iron rich protein that carries oxygen from the lungs to the rest of the body) level of 7.5 grams per deciliter (normal range 12.0-15.5 grams per deciliter) and hematocrit (blood test that measures the percentage of red blood cells in your total blood volume) level of 24.7 percent (normal range 41-50 percent). Physician #2 was notified and gave instructions that Resident #3 needed to be evaluated in the morning.A review of the Physician's order for June 2025 indicated no orders for blood transfusion.A Medical Progress Note dated 06/20/2025 at 11:44 AM documented that Physician #1had seen Resident #3 and gave instructions to Registered Nurse #1 to repeat the complete blood count level on 06/23/2025.The dialysis communication tool dated 06/20/2025 documented that Resident #3 had scheduled blood transfusion on 06/20/2025 and Resident #3 was rescheduled for dialysis on 06/21/2025 at 10:00 AM.A review of the electronic medical record indicated no documentation related to the resident not receiving the dialysis treatment on 06/20/2026.During an interview on 06/10/2026 at 11:47 AM, Physician #1 stated that they saw Resident #3 on 06/20/2025 and determine that blood transfusion was not necessary and gave orders to Registered #1 to repeat the complete blood count on 06/23/2025 for Resident #3. Physician #1 stated they reviewed the hospital discharge summary and determined that the resident's hemoglobin level was stable. Physician #1 stated they were not aware Resident #3 did not receive their scheduled for dialysis treatment on 06/20/2025.During an interview on 06/10/2026 at 1:07 PM, the Director of Nursing Services stated that they were not the facility's Director of Nursing Services in June 2025. The Director of Nursing Services stated that the facility staff should have coordinated with the dialysis staff to reschedule the resident's dialysis treatment that was originally scheduled for 06/20/2025. The Director of Nursing Services stated that they expect communication between Nursing and dialysis staff for any changes in the resident's condition.During an interview on 06/10/2026 at 1:20 PM, the Dialysis Director stated that Resident #3 did not receive their dialysis treatment on 06/20/2025 because Resident #3 was scheduled to receive blood transfusion that day. The Dialysis Director stated that the dialysis center is open until 8:00PM-9:00 PM and the dialysis center is flexible with scheduling the in-house residents for the dialysis treatments. The Dialysis Director stated that the facility staff did not coordinate with the dialysis staff that Resident #3's blood transfusion was cancelled, otherwise they (dialysis staff) would have scheduled the dialysis treatment for Resident #3 on 06/20/2025.During an interview on 06/16/2026 at 12:51 PM, Registered Nurse #1 stated they did not know why dialysis staff were not contacted to reschedule Resident #3's dialysis treatment, after the physician had recommended canceling the blood transfusion.10 New York Code Rules and Regulations 415.12

Based on record review and staff interviews, the facility failed to ensure that the resident's Designated Representative was notified when the need to start a new form of treatment was identified. This was identified for one (Resident #5) of three residents reviewed for Notification of Change. Specifically, Resident #5 was started on amoxicillin 875 milligrams-potassium clavulanate 125 milligrams (an antibiotic to treat infections) on 08/07/2025 for cough. There was no documented evidence that Resident #5's designated representative was notified of the resident's change in condition and the need to start a new treatment of antibiotic until 08/12/2025.Complaint #2663274The findings include:The facility policy titled, Change in Condition last revised on 05/2026 documented that it is the facility's policy to identify and communicate changes in condition to the Physician and other team members to implement interventions to prevent further deterioration and possible event of hospitalization. The resident's family/health care agent will be notified about the change in conditions.Resident #5 was admitted with diagnoses including chronic kidney disease, hypertension (high blood pressure), and atelectasis (lung collapse). The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 6, which indicated that Resident #5 had severe cognitive impairment. The Quarterly Minimum Data Set (MDS) assessment documented an active diagnosis of respiratory failure and chronic lung disease. A Nursing Progress Note dated 08/07/2025 documented Resident #5 had occasional productive cough with no shortness of breath. Physician #2 was notified and had ordered antibiotics.A Physician's Order dated 08/07/2025 documented Amoxicillin 875 milligrams-potassium clavulanate 125 milligrams, one tablet twice a day for seven days for cough. A Comprehensive Care Plan (CCP) titled, Infection: Cough dated 08/11/2025 documented interventions including administering medications as ordered by the Physician, monitoring for signs and symptoms of side effects of antibiotics, and monitoring vital signs as ordered. An Electronic Medication Administration Record (EMAR) dated 08/07/2025 documented Amoxicillin 875 milligrams-potassium clavulanate 125 milligrams one tablet twice a day for seven days for cough. The Electronic Medication Administration Record indicated that from 08/07/2025 until 08/14/2025 Resident #5 received the antibiotics as prescribed by the Physician. During an interview on 06/11/2026 at 12:15 PM, Licensed Practical Nurse #14, the medication nurse, stated that the charge nurse was responsible for notifying the resident representatives related to any changes in the resident's condition. Licensed Practical Nurse #14 stated they wrote a progress note in the resident's medical record indicating the antibiotic was administered; however, they did not call the resident's designated representative.During an interview on 06/11/2026 at 12:25 PM, Registered Nurse #13, the charge nurse, stated that they were responsible for notifying the resident representative of any changes in resident's condition and treatment. Registered Nurse #13 stated when they first received the antibiotics order for Resident #5, they forgot to notify Resident #5's designated representative regarding the change in resident's condition and the new antibiotic orders. During an interview on 06/11/2026 at 3:15 PM, Physician #2 stated that the physicians do not call the designated representatives unless there is a request from the family or designated representative for a phone call or if they (Physician #2) needed clarification regarding the resident's history or allergies. Physician #2 stated they did not know the facility's policy on notification for any changes in residents' condition. During an interview on 06/11/2026 at 3:47 PM, the Director of Nursing Services stated that nurses should notify residents designated representatives for changes in the resident's condition in a timely manner and there should be proper documentation regarding the notification.10 New York Code Rules and Regulations 415.3(f)(2)(ii)(c)

Based on observation, interviews and record review during an abbreviated survey conducted (complaint# 2633955) the facility failed to ensure one (1) (Resident #1) of three (3) residents received treatment and care in accordance with professional standards of practice and the comprehensive care plan. Specifically, on 09/30/2025, Resident #1 fell out of bed. Registered Nurse Supervisor #1 assessed Resident #1 and assisted lifting them into bed using a Hoyer lift. Registered Nurse Supervisor #1 failed to document the fall in Resident #1's Electronic Medical Record, failed to complete a facility Occurrence Report, failed to notify Physician of the fall, and failed to notify Resident #1's family. As a result, Resident #1 was not monitored for pain or injury by the facility following the fall and the physician did not see Resident #1 for follow-up. On 10/02/2025 Resident #1 developed bruising on their right lateral thigh and decreased range of motion due to pain. Resident #1 was sent to the hospital and diagnosed with a fractured right femur. This resulted in actual harm that is not Immediate Jeopardy.The findings are: The Facility Accident/Incident Report Policy dated 03/2025 documented Registered Nurse Supervisor will report occurrence to the physician and notify family, document treatment orders on the Occurrence Report, and review/revise the Comprehensive Care Plan.Resident #1 was admitted on [DATE] with diagnoses that include chronic kidney disease, (a long-term condition where the kidneys become damaged and gradually lose their ability to filter waste and fluid from the blood), Diabetes Type II (a condition where the body either doesn't make enough insulin or doesn't use it properly), and Major Depressive Disorder. On 09/19/2025, a Minimum Data Set (a resident assessment tool) Brief Interview of Mental Status was completed for Resident #1 and documented a score of 7, indicating severe cognitive impairment.The facility Occurrence Report for Resident #1 dated 10/02/2025 documented Resident #1 fell out of bed on 09/30/2025 and presented with visible bruising on the right lower extremity on 10/02/2025. The Medical Doctor #1 was contacted, and Resident #1 was sent to hospital. Resident #1 was diagnosed with a right fracture of the femur (leg bone).The facility 5-day Report dated 10/09/2025 documented the Director of Nursing and the Assistant Director of Nursing stated that Registered Nurse Supervisor #1 did not report any falls involving Resident #1 to them until 10/02/2025. Registered Nurse Supervisor #1 informed both that they forgot to document and report the incident. Registered Nurse Supervisor #1 has no prior history of not documenting or reporting accidents or incidents. Registered Nurse Supervisor #1 has no prior disciplinary action related to this nature in their file. Nursing Progress Note for Resident #1 written by Registered Nurse Supervisor #1 dated 10/02/2025 at 7:27 PM documented Late entry: 09/30/25, at approximately 11:00 AM, Licensed Practical Nurse #1 notified the writer to assess a resident who had a fall in the room. Upon entering the room, resident was observed lying on their back on top of the floor mat by the left side of the bed, head resting on pillow, feet towards the foot of bed direction. The floor is dry, with adequate lighting and clutter free. Resident #1 is wearing a night gown but with no socks on. Resident alert but a poor historian stated, I don't know what happened, I rolled over the bed and fell. As per Certified Nursing Assistant #2, the resident was placed to their left side, turned around to get the brief but suddenly the resident rolled over and landed on the floor mat. Initial assessment was conducted, all range of motion is at baseline but did not complain of any new pain and did not show any signs of visible pain or discomfort. Resident denied hitting their head, loss of consciousness and respiratory distress. Resident was transferred back to the bed using the Hoyer lift with the help of three (3) staff. Skin assessment was done with no swelling, redness, bruising and skin opening noted.Nurse Practitioner Note dated 10/02/2025 at 2:06 PM documented staff reports Resident #1 with discoloration of skin along the right side of resident's leg. Resident #1 seen lying in bed in no acute distress. Upon assessment, resident noted with blue and purple discoloration to side of right leg with swelling above the knee. Resident shows signs of pain with palpation to area. No recent falls reported. Resident currently on Eliquis 2.5mg (blood thinner) twice a day. Resident was sent to emergency department for further evaluation with scans. Primary care provider and family member made aware.During an interview with Certified Nursing Assistant #2 on 11/06/2025 at 10:33 AM, they stated they discovered bruising on Resident #1 on 10/02/2025. They went to provide care with another aide as Resident #1 was a two-person assist. They observed discoloration on right leg and showed Licensed Practical Nurse #2. During a telephone interview on 11/06/2025 at 10:23 AM with Certified Nursing Assistant #1, they stated they were assigned to Resident #1 on 09/30/2025 at 11:00AM. Resident #1 was screaming. Certified Nursing Assistant #1 went to the room and Resident #1 had feces on their hands. Certified Nursing Assistant #1 was going to get somebody to assist but Resident #1 fell before they returned to the room. They stated they had not yet provided care and were going to get additional staff to assist them. They Immediately got Registered Nurse Supervisor #1. During an interview with Registered Nurse Supervisor #1 on 11/06/2025 at 10:42 AM, they stated a fall was reported to them by Certified Nursing Assistant #1 on 09/30/2025 at 11:00 AM. They went to Resident #1's room and saw them on the floor mat, assessed them and used the Hoyer lift (mechanical lift) to move them back to the bed. No loss of consciousness. Range of motion was within normal limits, skin assessment was negative for marks or bruising, no complaint of pain. Registered Nurse Supervisor #1 stated they were not able to notify anybody of the fall as they were dealing with a discharge and admission at the time of the fall. They were not able to notify physician or family of the fall. The unit nurse Licensed Practical Nurse #1 was present. Registered Nurse Supervisor #1 stated they were supposed to notify Optum (a Nurse Practitioner Service) Nurse Practitioner or the Primary Care Physician. They further stated following the incident the facility provided them with in-service, and they were suspended for three (3) days while the facility did the investigation. They did not document their assessment anywhere at the time. They did not notify the Nurse Practitioner, Medical Doctor, family, Director of Nursing or Assistant Director of Nursing of the resident's fall. During an interview with the Director of Nursing on 11/06/2025 at 10:58 AM, they stated Registered Nurse Supervisor #1 received a letter in their file, was suspended pending the outcome of the investigation, and was provided in-service training on documenting and reporting incidents. The Director of Nursing stated on 10/02/2025, they were informed by Registered Nurse Supervisor #1 that Resident #1 had a discoloration on their leg. They did not observe any documentation that would indicate a cause. Registered Nurse Supervisor #1 came down and explained they did not document the fall that occurred on 09/30/2025. Registered Nurse Supervisor #1 stated they did do an assessment. During this assessment they observed no bruising or pain. They had intentions to document but simply forgot. Registered Nurse Supervisor #1 was removed from the schedule. Regarding the assessment at the time, there were no obvious signs of a fracture or no new pain, and the interventions would have been the same. There was no obvious reason to believe Resident #1 had a fracture. The Director of Nursing stated they spoke with Medical Doctor #1, and they stated there would have been no different outcome if the fall had been reported since there was no pain or discoloration at the time. If there was no pain they would have just monitored. The Director of Nursing stated that this incident should have been reported and documented right away. If an incident happens, it is an expectation to provide a report. There was no emergency at the time of the incident that led to the delay and no staffing issues at the time of the incident.During an interview with the Administrator on 11/06/2025 at 1:40 PM, they stated when a resident falls, they would be added to the daily report and monitored. Registered Nurse Supervisor #1 should have notified the physician and the family. Registered Nurse Supervisor #1 failed to follow policy. During a telephone interview with Medical Doctor #1 on 11/06/2025 at 12:04 PM, they stated Resident #1 has osteoporosis (porous, brittle bones) and osteopenia (low bone density), is bedbound and on Eliquis (a blood thinner). They further stated they were notified by a nurse of the fall on 09/30/2025 but do not recall which nurse and could not provide a reason why they did not document. At the time, what was reported was they fell out of bed onto pad, no pain or bruising. Two days later, they were notified of the bruising, so they ordered Resident #1 to be sent to the hospital. 10 NYCRR 415.12

Based on observation, record review, and staff interviews during the Recertification Survey initiated on 11/20/2024 and completed on 11/26/2024, the facility did not ensure a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This was identified for one (Resident #19) of three residents reviewed for Pressure Ulcers. Specifically, during Resident #19's wound care observation on 11/25/2024, Licensed Practical Nurse #1 did not apply the physician-ordered treatment to the wound and the peri-wound (the skin around the wound) area. The finding is: The facility's policy titled Aseptic Dressing Technique, dated 1/2024, documented for the nurses to review the current physician's order for specific treatment instructions and apply treatment as ordered. The facility's policy titled Medication Administration dated 1/2024, documented the licensed nurse assures the six rights: right resident, right medication, right dose, right time, right route, and right documentation. Compare the medication administration record against the prescription label. Always check three times prior to administration of medication. The facility's policy titled Pressure Ulcer and Wound Management dated 1/2024, documented it is the policy of the facility to comply with the New York State Department of Health related to pressure ulcers and prevention. A resident with pressure ulcers receives the necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing. Resident #19 was admitted with diagnoses including Dependence on the Ventilator, Diabetes Mellitus, and Stage 4 (full-thickness tissue loss with exposed bone, tendon, or muscle visible within the wound) Pressure Ulcer to the Right Buttock. The 11/7/2024 Quarterly Minimum Data Set assessment documented no Brief Interview for Mental Status score as the resident had severely impaired cognitive skills for daily decision-making. The Minimum Data Set assessment documented the resident had a Stage 4 pressure ulcer. A Comprehensive Care Plan titled Presence of Stage 4 of Right Buttock, effective 8/21/2024 and last updated 11/21/2024, documented Stage 4 pressure ulcer to the right buttock measuring 2.3 centimeters in length, 2 centimeters in width, and 0.5 centimeters in depth with undermining (an undermining wound where the damage under the tissue is larger than what appears at the surface) measuring 2 centimeters deep. The wound bed was noted with 100% pink granulation (new tissue as the wound heals) tissue and moderate serous (pale yellow) drainage. A physician's order dated 11/19/2024 documented: cleanse the right buttock pressure ulcer with normal saline, apply Puracol Plus AG (collagen with silver dressing- collagen is a protein that encourages wound healing and silver is an antimicrobial agent), and cover with a dry protective dressing daily and as needed. A physician's order dated 11/21/2024 documented: cleanse the right buttock pressure ulcer with normal saline, apply Clotrimazole (antifungal medication) 1% topical cream to the peri-wound of right buttock pressure ulcer, and then apply treatment to the wound bed. During Resident #19's wound care observation on 11/25/2024 at 10:13 AM, Licensed Practical Nurse #1 was performing the treatment and was assisted by Certified Nursing Assistant #1. The packaging of the collagen wound dressing used during the wound care did not indicate silver as an ingredient. Licensed Practical Nurse #1 stated the treatment dressing included silver as an ingredient and then applied the dressing to the wound. Licensed Practical Nurse #1 did not apply the Clotrimazole cream to the peri-wound and stated they were unaware that Resident #19 had a treatment order for the peri-wound. Licensed Practical Nurse #1 then completed the wound care and applied the dry protective dressing. During an interview on 11/25/2024 at 10:30 AM, Registered Nurse #1, who was another treatment nurse on the unit, reviewed the wound treatment product packaging box for the wound care dressing that Licensed Practical Nurse #1 had applied to Resident #19's wound. Registered Nurse #1 confirmed the treatment product did not include silver as an ingredient. A review of the packaging box revealed that the label provided by the Pharmacy affixed to the box documented: collagen wound dressing by topical route to right buttock, cleanse with normal saline, pat dry, apply Puracol Plus AG, then dry [cover with] protective dressing; however, the treatment product was a generic manufacturer of the collagen product and there was no indication that the product contained silver as an ingredient. The order was refilled as a new order on 11/19/2024. During an interview on 11/25/2024 at 10:52 AM, Pharmacist #1 stated the wound care product that was supplied to the facility by the pharmacy for Resident #19 did not contain silver as one of the ingredients. Pharmacist #1 stated they were not sure why this product was sent to the facility mislabeled, and that they would have to look into it. During an interview on 11/25/2024 at 2:29 PM, the Wound Care Registered Nurse stated the resident's right buttock pressure ulcer peri-wound area was inflamed and that is why the Clotrimazole cream was prescribed. The Wound Care Registered Nurse stated that peri-wound treatment and the actual wound treatment should be applied during the wound care and the order was written that way. The Wound Care Registered Nurse stated Licensed Practical Nurse #1 should have checked the wound product packaging to ensure that the actual product was consistent with the physician's order. Licensed Practical Nurse #1 should have notified their supervisor if the treatment product sent by the pharmacy did not match the physician's orders. During an interview on 11/26/2024 at 8:28 AM, the Director of Nursing Services stated the nurses are supposed to follow the physician's orders and follow the rights of medication administration. All of the treatments (the periwound and the wound) should have been done at the same time and the nurse was expected to know that there was a periwound treatment. The Director of Nursing Services that Licensed Practical Nurse #1 was supposed to check the wound care treatment product box and make sure the product consistent with the physician's orders was being used. 10 NYCRR 415.12(c)(1)

Based on record review and interviews during the recertification survey initiated on 11/20/2024 and completed on 11/26/2024, the facility did not ensure that the Minimum Data Set assessment accurately reflected each resident's status. This was identified for one (Resident #190) of three residents reviewed for Communication. Specifically, Resident #109 utilized hearing aids as per the physician's orders; however, the annual Minimum Data Set assessment for Resident #109, dated 8/17/2024, did not accurately reflect the use of hearing aids or other hearing appliances. The finding is: The facility policy titled MDS Assessments, dated 1/2024 documented that the Resident Assessment Coordinator was responsible for ensuring the Interdisciplinary Team conducted timely and appropriate resident assessments. All persons who have completed any portion of the MDS Resident Assessment Form must sign the document attesting to the accuracy of such information. Resident #190 had diagnoses that included bilateral Hearing Loss. Resident #190's Quarterly Minimum Data Set assessment, dated 5/18/2024 documented a Brief Interview for Mental Status score of 14, which indicated the resident was cognitively intact. The Minimum Data Set assessment documented the resident had moderate hearing difficulty (the speaker has to increase their volume and speak distinctly) and the resident did not use a hearing aid or other hearing appliance. The Annual Minimum Data Set assessment, dated 8/17/2024 documented a Brief Interview for Mental Status score of 14, which indicated the resident was cognitively intact. The Minimum Data Set assessment documented the resident had moderate hearing difficulty (the speaker has to increase their volume and speak distinctly) and the resident did not use a hearing aid or other hearing appliance. A comprehensive care plan titled Communication: Hearing Deficit, effective 11/03/2022 last reviewed on 11/17/2024 documented that the resident was using a hearing aid. The interventions included decreasing background noise when speaking to the resident; staff to speak slowly, clearly, and loudly while facing the resident, and asking the resident to recap what was said to verify understanding. A physician's order dated 12/31/2023 and last renewed 6/17/2024 documented hearing aid (bilateral) insert in A.M. A Physician's order dated 7/29/2024 documented hearing aid (left) insert in A.M. A Physician's order dated 8/2/2024 documented hearing aid (right) insert in A.M. During an interview on 11/25/2024 at 2:14 PM Minimum Data Set Coordinator stated the hearing section of the assessment tool is completed by the Minimum Data Set Assessor. They further stated that the Minimum Data Set was coded no for the use of a hearing aid. The Minimum Data Set Coordinator stated the Minimum Data Set was coded incorrectly because the resident was utilizing the hearing aides during the assessment period. The Minimum Data Set Assessor was not available for interview. During an interview on 11/26/2024 at 9:09 AM, the Director of Nursing Services stated that the Minimum Data Set Assessors should review the medical record and code the Minimum Data Set accurately. NYCRR 415.11(b)

Based on observation, record review, and interviews during the Recertification Survey initiated on 11/20/2024 and completed on 11/26/2024, the facility did not maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. This was identified for one (Resident #19) of three residents reviewed for Pressure Ulcers. Specifically, during Resident #19's wound care observation on 11/25/2024, Licensed Practical Nurse #1 placed rested the normal saline soaked gauze pads directly on the exposed skin of the resident's right hip and then used the same gauze pads to cleanse the resident's right buttock pressure ulcer. The finding is: The facility policy titled Aseptic Dressing Technique, dated 1/2024 documented that aseptic technique (practices that prevent the spread of germs and contamination with microorganisms) is to be performed during all dressing changes and/or treatments unless otherwise indicated by the Physician. A clean barrier is placed on the over-bed table to protect the equipment from contamination. Resident #19 was admitted with diagnoses including Dependence on the Ventilator, Diabetes Mellitus, and Stage 4 (full-thickness tissue loss with exposed bone, tendon, or muscle visible within the wound) Pressure Ulcer to the Right Buttock. The 11/7/2024 Quarterly Minimum Data Set assessment documented no Brief Interview for Mental Status score as the resident had severely impaired cognitive skills for daily decision-making. The Minimum Data Set assessment documented the resident had a Stage 4 pressure ulcer. A Comprehensive Care Plan titled Presence of Stage 4 of Right Buttock, effective 8/21/2024 and last updated 11/21/2024 documented Stage 4 pressure ulcer to the right buttock measuring 2.3 centimeters in length, 2 centimeters in width, and 0.5 centimeters in depth with undermining (an undermining wound where the damage under the tissue is larger than what appears at the surface) measuring 2 centimeters deep. The wound bed was noted with 100% pink granulation (new tissue as the wound heals) tissue and moderate serous (pale yellow) drainage. A physician's order dated 11/19/2024 documented: cleanse the right buttock pressure ulcer with normal saline, apply Puracol Plus AG (collagen dressing with silver-collagen is a protein that encourages wound healing and silver is an antimicrobial agent), and then apply dry protective dressing daily and as needed. During Resident #19's wound care observation on 11/25/2024 at 10:13 AM, Licensed Practical Nurse #1, who was assisted by Certified Nursing Assistant #1, prepared the wound care supplies outside of the resident's room at the treatment cart. Licensed Practical Nurse #1 placed all of the supplies, including the normal saline-soaked gauze pads and dry gauze pads, on a barrier that was on a Styrofoam tray. The nurse brought the tray to the resident's bedside and placed the tray on the overbed table, but did not sanitize the overbed table Licensed Practical Nurse #1 turned Resident #19 on their left side, removed the dressing from the right buttock wound, washed their hands, and changed their gloves. Licensed Practical Nurse #1 took the normal saline-soaked gauze pads from the Styrofoam tray and placed them directly on the exposed skin of the resident's right hip. Licensed Practical Nurse #1 then used these pads to cleanse the resident's right buttock wound. This infection control breach was brought to Licensed Practical Nurse #1's attention by the surveyor; however, Licensed Practical Nurse #1 continued the treatment and did not re-cleanse the wound. During an interview on 11/25/2024 at 12:23 PM, the Registered Nurse Infection Preventionist/Nurse Educator stated it was not appropriate for Licensed Practical Nurse #1 to place the normal saline soaked gauze pads on the resident's hip and then use those same gauze pads to cleanse the wound. The hip is not considered a clean area. The goal of wound care is to maintain an aseptic technique and placing the normal saline soaked gauze pads on the resident's hip did not maintain an aseptic technique. During an interview on 11/25/2024 at 2:29 PM, the Registered Nurse Wound Care Nurse stated it would not be appropriate to rest the normal saline soaked gauze pads on the resident's hip and then clean the wound with those same gauze pads. During wound care, all of the supplies should be kept on the tray. During an interview on 11/26/2024 at 8:28 AM, the Director of Nursing Services stated it was inappropriate for the nurse to put the normal saline soaked gauze on the resident's hip and then use those gauze pads to cleanse the wound. The nurse did not maintain an aseptic technique and has received educational counseling. 10 NYCRR 415.19(a) (1-3)

Based on record review and interview during the recertification survey initiated on 11/20/2024 and completed on 11/26/2024, the facility did not ensure to store, prepare, distribute, and serve food in accordance with professional standards for food safety. This was evident during Kitchen and Dining Tasks. Specifically, during the kitchen tour on 11/20/2024 tuna salad dated 11/12/2024 was observed in the walk-in refrigerator. Additionally, the temperature of the egg salad, macaroni salad, and potato salad served during the lunch meal was above acceptable standards for safe serving temperatures. The finding is: The undated facility policy and procedure titled Food Storage Temperatures and Storage Life Guidelines documented that foods will be stored at appropriate temperatures and for a specified duration to assure freshness and nutritional adequacy. The facility policy and procedure titled Food Handling and Storage, dated 3/2024, documented that all aspects of food handling from receiving and storing are done according to guidelines and monitored to keep foods free from harmful microorganisms, and contaminants and ensure the quality and freshness are preserved. Items that are opened, need to be labeled with an open date and must be used within the appropriate time frame. Prepared foods must be labeled with the date of preparation, kept covered, and stored appropriately. All refrigerated foods, such as tuna salad, egg salad, etc., will be discarded after 72 hours. The undated facility policy and procedure titled Taking Temperature of Food Items documented food temperatures will be monitored and recorded during preparation, holding, and service to ensure compliance with food safety standards. Temperature standards: cold foods are maintained at or below 41 degrees Fahrenheit. Cold food holding temperatures are measured every two hours during storage or serving. Check and record food temperatures just before service. If temperatures fall outside safe ranges, immediately reheat, chill, or discard the food. Record all temperature readings in the designated food temperature log, including date, time, food item, temperature reading, and corrective action (if any). During the kitchen tour on 11/20/2024 at 9:21 AM with the Food Service Director, a container of tuna salad dated 11/12/2024 was observed in the kitchen refrigerator. A dining observation was conducted on the third floor on 11/20/2024 at 12:04 PM. Dietary Aide #1 was observed serving the lunch meal utilizing individual resident trays that were prepared with sandwiches and other side dishes such as egg salad, potato salad, and or macaroni salad. During an interview on 11/20/2024 at 12:08 PM, Dietary Aide #1 stated that the sandwiches, egg salad, potato salad, and macaroni salad were placed on the trays in the kitchen, prior to delivery to the unit. The food temperature is taken by the Cooks in the kitchen, and they (Dietary Aide #1) do not take the temperatures of either the hot or cold foods on the unit. On 11/20/2024 at 12:29 PM, the Executive Chef took the temperatures of the side dishes. The following results were obtained: The egg salad temperature was 68 degrees Fahrenheit, the potato salad temperature was 65 degrees Fahrenheit, and the macaroni salad temperature was 62 degrees Fahrenheit. The Executive Chef was immediately interviewed and stated that the food temperature recorded was high and was not in the appropriate range. During an interview on 11/20/2024 at 12:50 PM, the Dietary Supervisor stated the facility did not maintain temperature logs for the cold food items. During an interview on 11/20/24 at 12:51 PM, the First [NAME] stated they checked the hot food temperatures before sending the meals to the units. They further stated that they do not take cold food temperatures unless the cold food is the main entree. During an interview on 11/20/2024 at 12:58 PM, the Food Service Director the food temperatures obtained during observation on the unit were in the danger zone (the temperature range where bacteria grow most rapidly) and the food was not safe to serve. During an additional interview on 11/26/2024 at 9:56 AM, the Food Service Director stated all refrigerated foods, such as tuna salad, egg salad, etc., should be discarded after 72 hours. 10 NYCRR 415.14(h)

Based on observation, record review, and interviews during the Recertification Survey initiated on 11/20/2024 and completed on 11/26/2024, the facility did not ensure that it provided pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. This was identified for one (Resident #19) of three residents reviewed for Pressure Ulcers. Specifically, Resident #19 had a physician's order for a collagen wound treatment product that included silver as an ingredient. The treatment product delivered by the Pharmacy had a label affixed to the box by the pharmacy that corresponded with the physician's order (included silver as an ingredient); however, the actual wound care product provided did not include silver as an ingredient. The finding is: The facility's policy titled Pharmacy Services dated 1/2024, documented the facility has contracted with the pharmacy to provide pharmacy and prescription delivery services. The pharmacy will provide a continuum of pharmaceutical services to the facility and essential medication and services for the facility. Resident #19 was admitted with diagnoses including Dependence on the Ventilator, Diabetes Mellitus, and Stage 4 (full-thickness tissue loss with exposed bone, tendon, or muscle visible within the wound) Pressure Ulcer to Right Buttock. The 11/7/2024 Quarterly Minimum Data Set assessment documented no Brief Interview for Mental Status score as the resident had severely impaired cognitive skills for daily decision-making. The Minimum Data Set assessment documented the resident had a Stage 4 pressure ulcer. A Comprehensive Care Plan titled Presence of Stage 4 of Right Buttock effective 8/21/2024 and last updated 11/21/2024, documented an intervention to provide treatments as ordered by the physician. An update on 11/21/2024 included a treatment of collagen with silver alginate. A physician's order dated 11/19/2024 documented: cleanse the right buttock pressure ulcer with normal saline, apply Puracol Plus AG (collagen with silver dressing- collagen is a protein that encourages wound healing and silver is an antimicrobial agent), and cover with a dry protective dressing daily and as needed. During Resident #19's wound care observation on 11/25/2024 at 10:13 AM, Licensed Practical Nurse #1 was performing the treatment and was assisted by Certified Nursing Assistant #1. The packaging of the collagen wound dressing used during the wound care did not indicate silver as an ingredient. Licensed Practical Nurse #1 stated the treatment dressing included silver as an ingredient and then applied the dressing to the wound. Licensed Practical Nurse #1 then completed the wound care and applied the dry protective dressing. During an interview on 11/25/2024 at 10:30 AM, Registered Nurse #1 (another treatment nurse on the unit) reviewed the wound treatment product packaging box for the wound care dressing that Licensed Practical Nurse #1 had applied to Resident #19's wound. Registered Nurse #1 confirmed the treatment product did not include silver as an ingredient. A review of the packaging box revealed that the label provided by the pharmacy affixed to the box documented: collagen wound dressing by topical route to right buttock, cleanse with normal saline, pat dry, apply Puracol Plus AG then dry protective dressing. The order was refilled as a new order on 11/19/2024. The treatment product was a generic manufacturer of the collagen product (not Puracol) and there was no indication that the product contained silver as an ingredient. During an interview on 11/25/2024 at 10:52 AM, Pharmacist #1 stated the wound care product supplied by the pharmacy for Resident #19 did not have silver as one of the ingredients. Pharmacist #1 stated they were not sure why this product was sent to the facility mislabeled, and would have to look into it. During an interview on 11/26/2024 at 8:28 AM, the Director of Nursing Services stated treatment product box was mislabeled by the Pharmacy. The Director of Nursing Services stated even though the label affixed by the Pharmacy indicated silver as one of the ingredients, the actual treatment product delivered did not include silver. The Director of Nursing Services stated the treatment nurse should have checked the product box and notified the supervisor. 10 NYCRR 415.18(d)

Based on observation, record review, and interviews during the Recertification Survey initiated on 2/9/23 and completed on 2/15/23 the facility did not ensure that resident records were accurately documented in accordance with professional standards of practice. This was identified for one resident (Resident #72) of three residents reviewed for Respiratory Care. Specifically, the facility did not have documented evidence that Colostomy care was provided to Resident #72 as per the facility protocol. The finding is: The facility policy titled Colostomy care dated 9/2022 included to document changes and any unusual observation in the Electronic Medical Record (EMR). Resident # 72 was admitted with diagnoses that include End-Stage Renal Disease, Bilateral Above Knee Amputation (AKA), and Paraplegia. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 15 indicating the resident had intact cognition. The resident required extensive assistance of two persons for toileting and utilized ostomy appliances. The Comprehensive Care Plan (CCP) titled Elimination: Ostomy Care, Effective 5/21/2018 and last reviewed on 12/6/2022 documented alteration in elimination related to Ostomy care as manifested by the presence of Colostomy. The interventions included to assess the Ostomy site every shift for redness or skin breakdown; monitor Ostomy for occlusion/obstruction; provide Ostomy care two times per shift and as needed and report to the physician if there is no bowel movement in 3 days. The Physician's (MD) order dated 2/7/2022 and last renewed on 1/7/2023 documented Colostomy Care two times per shift and as needed. The Treatment Administration Record (TAR) for January 2023 and February 2023 was reviewed and revealed the following: In January 2023, on 22 of 93 occasions, once on the 7 AM-3PM shift and 21 times on the 3PM-11 PM shift, the TAR lacked documented evidence that the staff provided colostomy care to Resident #72. In February 2023, on 6 of 40 occasions, on the 3PM-11 PM shift, the TAR lacked documented evidence that the staff provided colostomy care to Resident #72. On 2/14/2023 at 10:52 AM, colostomy care observation was conducted by Registered Nurse (RN) #10. The Ostomy stoma (colostomy opening) was well formed, and the surrounding skin was observed to be intact and clean. Licensed Practical Nurse (LPN) #1 was interviewed on 2/14/2023 at 9:52 AM and stated they (LPN #1) worked on 2/5/2023 and 2/10/2023 and were assigned to Resident #72. LPN #1 stated there are no treatment nurses during the evening shift and therefore all the treatments were completed by the nurse who is administering the medications. LPN #1 stated that Resident #72 is alert and oriented and informs the staff when the colostomy bag is full with fecal material or gas. LPN #1 stated they completed the colostomy care for Resident #72; however, did not sign the TAR because they were too busy administering medications and treatments to the 37 residents that were assigned to them. LPN #2 was interviewed on 2/14/2023 at 11:41 AM and stated they worked on 2/7/2023 during the 3 PM-11 PM shift. LPN #2 stated that there is a treatment nurse assigned to the unit during the morning shift; however, in the evening shift the medication nurse completes the medication administration and treatments for the entire unit. LPN #2 stated Resident #72 is alert and oriented and calls the nurses for their colostomy care. LPN #2 stated that they could not specifically recall why they (LPN #2) did not sign the TAR for the provision of colostomy care on 2/7/2023. LPN #3 was interviewed on 2/14/2023 at 12:05 PM and stated that they had worked on Unit 4 on 2/8/2023 and had worked only once on the unit prior. LPN #3 stated that they were busy completing the medication administration and therefore did not provide colostomy care to Resident #72. LPN #3 stated the 3 PM-11 PM Registered Nurse (RN) #6 Supervisor had completed the treatments on the unit on 2/8/2023 to assist LPN #3. The Director of Nursing Services (DNS) was interviewed on 2/14/2023 at 12:25 PM and stated that the staff should sign the TAR after the treatments are completed. If there the signatures are missing on the TAR, it could be that the staff completed the treatment and did not sign for the completion of the treatment, or that the staff did not administer the treatment. The DNS stated that staff should have signed the TAR if the treatments were completed. RN #6 was interviewed on 2/15/2023 at 9:40 AM and stated they work the 3 PM-11 PM shift as the Nursing Supervisor and usually help the nurses on the unit with treatments when the nurses are busy. RN #6 stated they recall completing Resident #72's treatments on many occasions. RN #6 stated they did not know why they (RN #6) did not sign the TAR and should have once the colostomy care was rendered to Resident #72. 10NYCRR 415.22(a)(1-4)

Based on record review and interviews during the Recertification Survey initiated on 2/9/2023 and completed on 2/15/2023 the facility did not ensure the services provided or arranged by the facility, as outlined by the comprehensive care plan, met professional standards of quality. This was identified for one (Resident #565) of one resident reviewed for insulin usage. Specifically, Resident #565, who had diagnosis of Diabetes Mellitus (DM), had physician's orders to receive insulin as a standing dosage with sliding scale coverage. The facility staff did not identify the site of the insulin administration for the daily insulin administration (standing order), did not identify the amount of insulin administered, or identify the site of the insulin administration for the sliding scale coverage on multiple occasions. The finding is: The facility policy titled Insulin Administration and Sliding Scare Management, dated 3/2020 and last updated on 4/2022, documented to administer insulin coverage as ordered by the Primary Care Provider. Record insulin coverage administered and the site of the injection in the Electronic Administration Record. Resident #565 was admitted with diagnoses that include Diabetes Mellitus (DM), End Stage Renal Disease, and Diabetic Neuropathy. The Admission 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 MDS documented the resident received insulin injections seven of seven days in look-back period and had two insulin orders changed in the last seven days. The Comprehensive Care Plan (CCP) for DM effective 1/04/2023 documented the resident has elevated blood glucose level secondary to a diagnosis of DM. Interventions included but were not limited to administer daily injections as ordered by the Physician (MD). Monitor blood glucose level as ordered. The Physician's orders documented to administer insulin as follows: -On 1/8/2023 at 1:49 PM Admelog SoloStar U-100 Insulin lispro 100 unit/milliliter (mL) subcutaneous pen, inject 6 units by subcutaneous route 3 times per day. This order was discontinued on 1/9/2023. - On 1/9/2023 at 12:49 PM Admelog SoloStar U-100 Insulin lispro 100 unit/mL subcutaneous pen, inject by subcutaneous route three times daily as per the sliding scale. - On 1/13/2023 at 1:02 PM Lantus Solostar U-100 Insulin 100 unit/mL (3 mL) subcutaneous pen, inject 11 units by subcutaneous route once daily at bedtime. This order was discontinued on 1/19/2023. - On 1/16/2023 at 9:20 PM Admelog SoloStar U-100 Insulin lispro 100 unit/mL subcutaneous pen, inject 10 units by a subcutaneous route now. - On 1/17/2023 at 3:44 PM Admelog SoloStar U-100 Insulin lispro 100 unit/mL subcutaneous pen, inject 7 units by subcutaneous route 3 times per day before meals (in addition to the sliding scale). - On 1/19/2023 Lantus Solostar U-100 Insulin 100 unit/mL (3 mL) subcutaneous pen, inject 14 units by subcutaneous route once daily at bedtime. The Medication Administration Record (MAR) for January 2023 indicated that from January 4th through January 31, 2023, Insulin was administered as ordered by the MD for Resident # 565; however, the insulin injection administration site was not documented 112 times From January 10 through January 31, 2023, for the sliding scale coverage, the amount of insulin administered was not documented on 32 occasions. A review of the MAR for February 2023 from February 1st, 2023, through February 14, 2023, indicated Insulin was administered as ordered by the MD for Resident # 565; however, the insulin injection administration site was not documented 49 times. From February 1st, 2023, through February 14, 2023, for the sliding scale coverage, the amount of insulin administered was not documented 7 times. Registered Nurse (RN) #7, Unit Nurse Manager, was interviewed on 2/15/2023 at 10 AM. RN #7 stated the site of insulin injection and the amount of insulin administered should be documented on the MAR. RN #7 stated they were unsure why the site and the amount of insulin were not documented by the nurses. Licensed Practical Nurse (LPN) #6, medication nurse, was interviewed on 2/15/2023 at 12:19 PM and stated Resident #565's blood sugars are checked before breakfast and lunch. LPN #6 stated they administer the insulin as per the sliding scale and as ordered by the Physician. LPN #6 stated if the insulin injection site is not rotated it may cause muscle injury and can cause decreased insulin absorption. LPN #6 stated they were unable to state why the insulin site and or the amount of insulin administered was not documented in the MAR. LPN #7, medication nurse, was interviewed on 2/15/2023 at 12:30 PM and stated they (LPN #7) follow the Physician's orders to administer medications including insulin. LPN #7 stated that after the medication administration, they are supposed to document the amount administered and the site where the insulin was administered; however, sometimes the EMR lets you bypass without putting the site or the amount of insulin administered. LPN #7 stated that the insulin administration site should be rotated because if the insulin is administered to the same site without rotating the site, it may cause fat build-up that may affect insulin absorption. The Director of Nursing Services (DNS) was interviewed on 2/15/2023 at 11:55 AM and stated that the nurses are expected to administer the sliding scale coverage insulin as per the Physician's orders and then document the amount of insulin administered and the site where the insulin was administered. The DNS stated that for the standing insulin orders, the nurses are expected to administer the medication as per the Physician's orders and document the administration and the site of the insulin administration in the MAR. 10NYCRR 415.11(c)(3)(ii)

Based on record review and interviews during the Recertification Survey and Abbreviated Survey (NY00300997) initiated on 2/9/2023 and completed on 2/15/2023, the facility did not implement a comprehensive person-centered care plan for each resident to meet the resident's medical and nursing needs that are identified in the comprehensive assessment. This was identified for one (Resident #368) of five residents reviewed for Accidents. Specifically, Resident #368 required total assistance of two persons for bed mobility. On 8/9/2022, Resident #368 was found to have a left humerus (arm) fracture. During the facility investigation it was determined that the Certified Nursing Assistants (CNAs) caring for the resident did not follow the plan of care and utilized a draw sheet with one person assistance for bed mobility to move Resident #368 in bed rather than utilizing two-person assistance. The finding is: The facility's policy titled Activities of Daily Living (ADLs), last reviewed 8/2022, documented all residents will be given care for ADLs based on the amount of assistance needed. The nurse will pick up the order for transfers and ambulation as well as resident care needs for bathing, dressing, eating, and toileting on the CNA Accountability Record so that the CNA will be aware of the resident's care needs. Care plans will be initiated to reflect the resident's care needs for ADLs. Resident #368 was admitted with diagnoses including Diabetes Mellitus, Cerebrovascular Accident (CVA), and Dementia. The 6/1/2022 Quarterly Minimum Data Set (MDS) assessment documented no Brief Interview for Mental Status (BIMS) score as the resident had severely impaired cognitive skills for daily decision making. The MDS documented that the resident required total care for Activities of Daily Living (ADLs), including two-person physical assistance for bed mobility. A Comprehensive Care Plan (CCP) titled ADLs-Mobility, Ambulation, Transfers, effective 11/23/2021, and last revised on 8/9/2022, documented to provide two-person extensive assistance for bed mobility. The Resident Nursing Instructions (instructions provided to Certified Nursing Assistants (CNA) regarding resident care needs) as of 8/1/2022, documented the resident was totally dependent on staff for bed mobility, requiring two-person physical assistance. A nursing progress note dated 8/4/2022 documented Resident #368 as having left shoulder swelling, warmth, and tenderness. There was no identified trauma or fall. The physician was notified, and an x-ray was ordered. The x-ray results of the left shoulder were negative for fracture, dislocation, or subluxation (partial dislocation). A nursing progress note dated 8/8/2022 documented the resident had ecchymosis (bruising) to the left antecubital fossa (inner elbow area), with swelling and tenderness. The physician was notified, and x-rays were ordered. The x-ray revealed an acute to subacute distal humeral (arm) fracture. The resident was transferred to the hospital. A nursing progress note dated 8/9/2022 documented Resident #368 was admitted to the hospital with a left humerus fracture. The Accident and Incident (A/I) report dated 8/8/2022 included interviews with staff involved in Resident #368's care, going back 48 hours prior to when the shoulder swelling was originally identified on 8/4/2022. The A/I report did not identify any fall, trauma, or abuse and the origin of the humerus fracture was unknown. The A/I summary documented that CNAs (CNA #1, CNA #2, and CNA #3) utilized a draw sheet when turning the resident in bed. The CNAs received disciplinary action and one to one counseling. The A/I report documented that the CNAs were not following the resident's plan of care and were not utilizing two persons for bed mobility. CNA #2 was interviewed on 2/14/2023 at 10:40 AM. CNA #2 stated they (CNA #2) remember working alone and using a draw sheet to turn the resident. CNA #2 stated there was no one to help and that is why they (CNA #2) worked alone. As per the A/I report statement, CNA #2 worked with Resident #368 on 8/1/2022, 8/2/2022, and 8/3/2022 on the 11 PM-7 AM shift. CNA #1 was interviewed on 2/14/2023 at 11:40 AM. CNA #1 stated on 8/2/2022 they were assigned to Resident #368 and were looking for assistance to care for the resident from another staff member. CNA #1 stated they (CNA #1) could not find anyone and that is why they (CNA #1) used the draw sheet to position Resident #368 in bed. As per the A/I report statement, CNA #1 worked with Resident #368 on 8/2/2022 on the 7 AM-3 PM shift. The Registered Nurse (RN) #1 Risk Manager/Assistant Director of Nursing Services (ADNS) was interviewed on 2/14/2023 at 12:00 PM. RN #1 stated the CNAs who worked alone were given inservice education because Resident #368 was a two-person assist for bed mobility. RN #1 stated the cause of the fractured left humerus was unknown. RN #1 stated the A/I dated 8/8/2022 identified that the CNAs were not using two-person assistance for bed mobility to move the resident in bed. The Director of Nursing Services (DNS) was interviewed on 2/14/2023 at 12:15 PM. The DNS stated that during the investigation of Resident #368's injury, it was determined that there was a care plan violation. It was identified that the CNAs did not utilize two-person assistance for bed mobility for Resident #368. The DNS stated if the CNAs cannot find another staff member to help, then the CNA cannot turn and position the resident and perform bed mobility. The DNS further stated the CNA has to wait for someone to assist them. CNA #3 was interviewed on 2/15/2023 at 1:08 PM. CNA #3 stated they (CNA #3) provided care to Resident #368 alone. CNA #3 stated they (CNA #3) were advised by the nurse that the resident required two-person assistance for transfers and they (CNA #3) were not told that the resident needed two-person assistance for bed mobility. CNA #3 stated they (CNA #3) depended on report from the nurse because they are a float CNA, and are not assigned to any one specific unit. As per the A/I report statement, CNA #3 worked with Resident #368 on 8/4/2022 on the 11 PM - 7 AM shift. The RN Inservice Coordinator (RN#2) was interviewed on 2/15/2023 at 1:13 PM. RN #2 stated before providing care the CNAs are expected to get report from the unit nurse and review the Resident Nursing Instructions. 10NYCRR 415.11(c)(1)

Based on record review and interviews during the Recertification Survey and Abbreviated Survey (NY00300997) initiated on 2/9/2023 and completed on 2/15/2023, the facility did not ensure that all alleged violations involving injuries of unknown source were reported immediately, not later than 24 hours, if the events that caused the allegation did not involve abuse and did not result in serious bodily injury to the New York State Department of Health (NYSDOH). This was identified for one (Resident #368) of five resident reviewed for Accidents. Specifically, Resident #368 sustained a fractured left humerus that was identified by the facility on 8/9/2022. The origin of the injury was unknown. The facility did not report the injury to the NYSDOH until 8/12/2022. Additionally, the facility did not include in their report of 8/12/2022 to the NYSDOH that staff caring for Resident #368 were not following the resident's plan of care. The finding is: The facility's policy, titled Abuse Prevention, dated 3/22/2022, documented under the subtitle Reporting, all allegations must be immediately reported to the Administrator, and no later than 24 hours to the state survey agency if the events that caused the allegation do not involve abuse and do not result in a serious bodily injury. The policy did not include protocols for reporting injuries of unknown origin. Resident #368 was admitted with diagnoses including Diabetes Mellitus, Cerebrovascular Accident (CVA), and Dementia. The 6/1/2022 Quarterly Minimum Data Set (MDS) assessment documented no Brief Interview for Mental Status (BIMS) score as the resident had severely impaired cognitive skills for daily decision making. The MDS documented that the resident required total care for Activities of Daily Living (ADLs), including two-person physical assistance for bed mobility. A Comprehensive Care Plan (CCP) titled ADLs-Mobility, Ambulation, Transfers, effective 11/23/2021, and last revised on 8/9/2022, documented to provide two-person extensive assistance for bed mobility. The Resident Nursing Instructions (instructions provided to Certified Nursing Assistants (CNA) regarding resident care needs) as of 8/1/2022, documented the resident was totally dependent on staff for bed mobility, requiring two-person physical assistance. A nursing progress note dated 8/4/2022 documented Resident #368 as having left shoulder swelling, warmth, and tenderness. There was no identified trauma or fall. The physician was notified, and an x-ray was ordered. The x-ray results of the left shoulder were negative for fracture, dislocation, or subluxation. A nursing progress note dated 8/8/2022 documented the resident had ecchymosis (bruising) to left antecubital fossa (inner elbow area), with swelling and tenderness. The physician was notified, and x-rays were ordered. The x-ray revealed an acute to subacute distal humeral (arm) fracture. The resident was transferred to the hospital as per the physician's order. A nursing progress note dated 8/9/2022 documented Resident #368 was admitted to the hospital with a left humerus fracture. The Accident and Incident (A/I) report dated 8/8/2022 included interviews with staff involved in Resident #368's care, going back 48 hours prior to when the shoulder swelling was originally identified on 8/4/2022. The A/I report did not identify any fall, trauma, or abuse and the origin of the humerus fracture was unknown. The A/I summary documented that CNAs utilized a draw sheet when turning the resident in bed. The CNAs received disciplinary action and one to one counseling. The A/I report documented that the CNAs were not following the resident's plan of care and were not utilizing two persons for bed mobility. The facility provided evidence of an online submission to the NYSDOH dated 8/12/2022 at 3:34 PM regarding the incident that occurred on 8/4/2022 at 6:30 PM. The case number that was assigned to the submission was NY 00300555. A review of the intake record for case # NY 00300555 revealed the incident related to Resident #368 dated 8/4/2022 at 6:30 PM was submitted to the NYSDOH on 8/12/2022 at 3:34 PM. The facility reported that the incident was not the result of a care plan violation, and it was undetermined at the time if there was a reasonable cause to believe that abuse, neglect, or mistreatment occurred. The facility did not include that the CNAs were not following the resident's plan of care and were not utilizing two persons for bed mobility. The Registered Nurse (RN) #1 Risk Manager/Assistant Director of Nursing Services (ADNS) was interviewed on 2/14/2023 at 12:00 PM. RN #1 stated the CNAs who worked alone were given inservice education because Resident #368 was a two-person assist for bed mobility. RN #1 stated the cause of the fractured left humerus was unknown. The A/I dated 8/8/2022 identified that the CNAs were not using two-person assistance for bed mobility to move the resident in bed. RN #1 stated the Director of Nursing Services (DNS) is responsible for reporting incidents to the NYSDOH. The Director of Nursing Services (DNS) was interviewed on 2/14/2023 at 12:15 PM. The DNS stated the CNAs received inservice education because they worked alone, and Resident #368 required two-person assistance for bed mobility. The DNS provided an email that documented the incident was reported to the NYSDOH on 8/12/2022 at 3:34 PM. The DNS stated that during the investigation of Resident #368's injury, it was determined that there was a care plan violation. It was identified that the CNAs did not utilize two-person assistance for bed mobility. The DNS stated this discovery of noncompliance was made on 8/12/2022, and that is when the report was made to the NYSDOH. The DNS stated on 8/9/2022 when the fracture was identified, we knew it was an injury of unknown origin, but we did not suspect any abuse or a crime. The DNS further stated that once the facility identified the care plan violation on 8/12/2022, the incident was reported to the NYSDOH. The Administrator was interviewed on 2/15/2023 at 2:48 PM. The Administrator stated we reported the incident when there was a determination of non-compliance with the care plan. 10NYCRR 415.4 (b) (1) (ii)

Based on observation, record review and interviews during the Recertification Survey initiated on 2/9/2023 and completed on 2/15/2023 the facility failed to ensure that an Infection Prevention and Control Program (IPCP) designed to help prevent the development and transmission of infection was maintained. This was identified for one (Resident #315) of five residents reviewed for Pressure Ulcers. Specifically, during a wound care observation for Resident #315's Stage IV Pressure Ulcer, the Registered Nurse (RN) #8 did not perform hand hygiene after cleansing the wound and prior to donning (putting on) clean gloves. The finding is: The facility's Policy and Procedure for Aseptic Dressing Technique dated 7/2022 documented to apply new gloves and cleanse the wound from the center outward and to avoid touching wound directly with gloved hands. Then remove gloves and wash hands prior to applying treatment. Resident #315 had diagnoses that include Stage IV Sacral Pressure Ulcer (PU), and Hypertension. The Admission 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 bed mobility and total assistance of two staff members for transfers. The resident was always incontinent of bowel and bladder and was at risk for developing PUs. The resident had two Stage II PUs that were present on admission. A Comprehensive Care Plan (CCP) for Pressure Ulcer dated 1/2/2023 documented the resident had a Stage IV Pressure Ulcer to the Sacrum. Interventions included but were not limited to provide treatments as ordered by the Physician and to monitor the effectiveness of treatment/s ordered. A Physician's order dated 1/17/2023 documented to apply Medihoney (wound treatment) 100% topical paste. Cleanse Sacrum wound with normal saline (NS), pat dry, apply Medihoney then Calcium Alginate (a highly absorbent wound dressing) and cover with a dry protective dressing (DPD) daily and as needed (PRN). A wound care observation was conducted on 2/14/2023 at 9:15 AM with RN #8. RN #8 was observed to wash their hands then don (put on) clean gloves. RN #8 then removed the soiled dressing from the Sacral Stage IV wound. The dressing had a moderate amount of blood-tinged drainage. RN #8 discarded the dressing, washed their (RN #8) hands, and donned clean gloves. RN #8 was observed to cleanse the wound three times using new gauze each time starting from the center of the wound to the outer edge of the wound. After cleansing the wound RN #8 removed the dirty gloves then donned clean gloves without washing their (RN #8) hands. RN #8 then applied the Medihoney and the DPD to the resident's sacral wound with the same gloves. RN #8 was interviewed immediately on 2/14/2023 at 9:30 AM and stated they were educated to wash their hands after cleansing a wound. RN #8 stated after cleansing the wound they (RN #8) should have washed their hands and then donned clean gloves. RN #8 could not explain why they (RN #8) did not wash their hands after cleansing the wound. The Director of Nursing Services (DNS) was interviewed on 2/14/2023 at 10:00 AM and stated that RN #8 should have washed their hands after cleansing the wound and prior to donning a clean pair of gloves to prevent infection. The In-service Coordinator/Infection Control Preventionist was interviewed on 2/14/2023 at 11:12 AM. The Inservice Coordinator stated that RN #8 was educated to wash their hands after cleansing a wound prior to the observation made with the surveyor on 2/14/2023. A competency was completed with RN #8 on 9/7/2022 on Aseptic Dressing Technique that included hand washing after cleansing a wound. The Inservice Coordinator further stated that RN #8 should have washed their hands after cleansing the wound and prior to donning new gloves to prevent infection. 10NYCRR 415.19(b)(4)

Based on observations, record review, and staff interviews during the Recertification Survey initiated on 2/9/2023 and completed on 2/15/2023 the facility did not ensure that each resident received adequate supervision to prevent accidents. This was identified for one (Resident #10) of five residents reviewed for Accidents and for one (Resident #140) of seven residents reviewed for Nutrition. Specifically, 1) Resident #10, who had a diagnosis of Dysphagia and had a physician's order for Aspiration Precautions, was observed in bed eating their pureed breakfast meal with their finger. The resident was observed slouched in bed and there was no staff member in the vicinity to provide supervision. 2) Resident #140 who had a diagnosis of Dysphagia and a Physician's order for Aspiration Precautions was observed in bed with all food items on the breakfast tray opened in front of them. There was no staff in close proximity to provide supervision. The finding is: The facility policy for Aspiration Precautions, dated 1/2017 last revised in April 2022, documented it is the facility's responsibility, along with the interdisciplinary team, to provide optimum swallowing safety for the residents to reduce the risk of aspiration. For residents presenting with Aspiration Risk the following general swallowing guidelines should be followed: sit upright at meals as close to 90 degrees as possible and maintain an upright position for at least 30 minutes after the meal. Feed slowly; make sure swallow is completed before the next presentation of food is offered and staff will provide supervision as needed. 1) Resident #10 had diagnoses that include Alzheimer's Dementia, Dysphagia, failure to thrive, and Stage 3 Pressure Ulcer to the right buttock. The Significant Change Minimum Data Set (MDS) assessment dated [DATE] documented the resident had short and long-term memory problems and severely impaired cognitive skills for daily decision-making. The MDS documented the resident required extensive assistance of one person for eating. The MDS further documented the resident was holding food in their mouth/cheek; coughing/choking with meals/meds and had difficulty or pain swallowing. The Physician's (MD) order dated 12/12/2019 and last updated on 1/24/2023 documented the resident was placed on Aspiration Precautions. The order did not include reasons for the resident to be on Aspiration Precautions. The MD order dated 12/21/2021 and last updated on 1/24/2023 documented to provide the following diet: Puree consistency, allow bread, soft sandwiches, and banana with thin liquids. The Comprehensive Care Plan (CCP) for Nutritional Status, effective 2/9/2018 and last reviewed on 1/27/2023, documented the resident was at risk for alteration in nutritional and hydration status related to Alzheimer's Dementia, Dysphagia, Failure to Thrive, and significant in-house weight loss. Interventions included but were not limited to supervising and assisting the resident at mealtime as needed. The CCP for Activities of Daily Living (ADLs) dated 2/9/2028 and last updated on 1/21/2023 documented the resident had a self-care deficit as evidenced by the decrease in dressing, grooming, feeding, bathing, toileting, and personal hygiene tasks. Interventions included to provide assistance of one [staff member] at mealtimes. The CCP for Dysphagia dated 6/2/2022 and last updated on 2/7/2023 documented Impaired Swallow/Rehabilitation as evidenced by decreased oral preparatory stage, oral Dysphagia, and Drooling related to Alzheimer's/Dementia. Interventions included but were not limited to Aspiration Precautions, educate staff and family on precautions/limitations; and to monitor intake. The Dietary Progress Note dated 12/30/2022 documented the resident required extensive assistance with feeding and was to be fed while sitting upright as the resident was on Aspiration Precautions. As per the Speech Language Pathology (SLP) evaluation, the resident had a diagnosis of Dysphagia and had impaired mastication. The resident was holding food in the mouth or cheeks or had residual food in the mouth after meals. The Social work progress note dated 1/30/3023 documented a care plan meeting was held with the resident's family and with the care plan team. The resident's changes of poor appetite and resident's condition were discussed. The Speech Language Pathologist note dated 2/7/2023 documented the resident had unclear speech and holds food in their mouth or cheeks or had residual food in their mouth after meals. The Resident Nursing Instructions (instructions provided to the Certified Nursing Assistants (CNA) regarding resident care needs) as of 5/19/2020 documented to provide extensive assistance of one staff member with eating; the resident is on aspiration precautions and is to be kept upright during meals. During an observation on 2/10/2023 at 8:56 AM Resident #10 was observed slouching in their bed. There was an open breakfast tray on the over-the-bed table that was within the resident's reach. The food tray consisted of pureed food on a plate, an open juice carton, an open milk carton, a sandwich, and a peeled banana. The resident was attempting to eat the pureed food with their finger. The head of the bed was elevated, and the resident was observed sliding down while attempting to reach for their meal. The meal ticket dated 2/10/2023 was placed on the resident's breakfast tray and documented soft sandwich OK and Banana OK. The meal ticket did not indicate the resident was on Aspiration Precautions. There were no staff members present in the vicinity to monitor the resident. The assigned CNA #5 was interviewed on 2/10/2023 at 9:00 AM. CNA #5 stated that Resident #10 was not on any precautions related to eating. CNA #5 stated that normally Resident #10 eats in the dining room because they need assistance with eating. CNA #5 stated that today they did not get the chance to get Resident #10 out of bed for the resident to eat breakfast in the dining room because they (CNA #5) were assigned to residents who were due for dialysis. CNA #5 stated they had to get the dialysis residents ready before attending to Resident #10. Registered Nurse (RN) #4, Nurse Manager, was interviewed on 2/10/2023 at 9:10 AM while RN #4 was in Resident #10's room. RN #4 stated that while eating breakfast Resident #10 was not sitting in an upright position. RN #4 stated the resident should have been sitting upright during meals; however, they (RN #4) were told by CNA #5 that when in bed, the resident slides themselves down. RN #4 stated that residents who have a Physician's order for Aspiration Precautions should be eating in an area where they (residents) could be monitored. RN #4 stated they were not aware of the facility policy regarding Aspiration Precautions as they were newly hired by the facility in January 2023. RN #4 stated that as per the MDS assessment, Resident #10 required extensive assistance of one person with feeding. RN #4 reviewed Resident #10's meal ticket and confirmed that the meal ticket did not include the resident on Aspiration Precautions. During a second observation on 2/10/2022 at 9:22 AM Resident #10 was observed in bed with a breakfast meal tray in front of the resident. The resident was eating the pureed meal with her finger. The resident was observed sliding, and slouching down in bed, and there was no staff in the vicinity. During a subsequent observation on 2/10/2023 at 9:40 AM Resident #10 was observed in their bed with a plate containing half a sandwich. The resident was observed picking up the sandwich and eating. The resident was observed not sitting upright while eating and there was no staff observed in the vicinity. The Speech Language Pathologist updated the Resident Care Instructions on 2/10/2023 at 10 AM (after the observations) to include under the notes section: the resident feeds self at times, assist with meal completion. and use standard aspiration precautions. Nurse Practitioner (NP) #1 was interviewed on 2/13/2023 at 12:00 PM and stated residents who are placed on Aspiration Precautions need to be monitored to make sure no choking episodes occur. NP #1 stated staff should be monitoring Resident #10 as the resident is on Aspiration Precautions and has cognitive and behavioral issues. Speech Language Pathologist (SLP) #1 was interviewed on 2/13/2023 at 12:30 PM. SLP #1 stated that Resident #10 has a diagnosis of late-stage Dementia. The resident cannot be understood and can not understand and all their (Resident #10) needs must be met by others. SLP #1 stated Resident #10 likes to feed themselves, likes bread with butter, and is not able to handle challenging consistency; therefore, was placed on a puree diet. SLP #1 stated primarily the resident has oral Dysphagia and was safe to eat alone in their room; however, the staff needs to check in on Resident #10. SLP #1 stated that the Aspiration Precautions for Resident #10 meant that the resident should be sitting upright, the meal is placed in the resident's hand, and at the end of the meal the staff needs to make sure there is no food left in the resident's mouth. SLP #1 stated if staff sees or hears Resident #10 coughing or having a problem with swallowing, they should let the nurse know. RN #5, Charge nurse, was interviewed on 2/13/2023 at 12:45 PM and stated Resident #10 should be monitored during meals due to Aspiration Precautions. RN #5 stated that Resident #10 does not allow anyone to feed them and is able to feed themselves; however, staff needs to ensure that the resident is sitting upright during mealtime. The Regional Dietician was interviewed on 2/13/2023 at 1:30 PM and stated that Aspiration Precaution is not indicated on the meal ticket and nursing staff is responsible for ensuring precautions are followed for residents who have a physician's order for Aspiration Precautions. The Electronic Medical Record (EMR) identifies residents on Aspiration Precautions with a green circle and letter A. The Regional Dietician stated that residents who are on Aspiration precautions should have their heads elevated when eating and should be supervised appropriately. The Director of Nursing Services (DNS) was interviewed on 2/13/2022 at 3 PM and stated they expected staff to know which residents are on Aspiration Precautions. The DNS stated they expected the staff to intermittently reposition and check the residents on Aspiration Precautions when the residents are eating their meals in their room. The DNS stated the residents who are on Aspiration Precautions are encouraged to eat in the dining room as those residents are at risk for aspiration. 28670 2) Resident #140 was admitted with diagnoses that include Dysphagia (difficulty swallowing) following Cerebral Vascular Accident (CVA) and Aphasia (difficulty with speech). A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 7 which indicated the resident had severe cognitive impairment. The resident required extensive assistance of one staff member for eating. The MDS documented the resident holds food in their mouth and receives a therapeutic mechanically altered diet. A Physician's order dated 2/10/2023 documented the resident was to be on Aspiration Precaution. A Comprehensive Care Plan (CCP) for Dysphagia dated 11/4/2022 documented the resident has actual Impaired Swallowing ability as evidenced by decreased oral preparatory stage, and throat clearing related to the CVA. Interventions included to observe for signs and symptoms of coughing, choking, aspiration or chewing difficulties and to allow the resident ample time to eat and masticate food properly. A Nutrition CCP dated 11/4/2022 documented the resident is at risk for malnutrition related to the need for a therapeutic and mechanically altered diet, altered nutritional laboratory results, and severe cognitive impairment. Interventions included to assist the resident with feeding and fluids as needed. During an observation on 2/15/2023 at 8:40 AM Resident #140 was observed asleep in bed. The resident was in a semi-sitting position propped up with 2 pillows. The resident's breakfast tray was observed in front of the resident on the overbed table within the resident's reach. The opened breakfast tray included oatmeal, scrambled eggs, whole milk, and coffee. The items on the tray appeared untouched and the overbed light was turned off. There were no staff members in the resident's room or in close proximity to monitor the resident and encourage the resident to eat. Registered Dietitian (RD) #2 was interviewed on 2/15/23 at 11:33 AM. RD #2 stated that the resident was supposed to be fed by staff because the resident was at risk for aspiration and was on aspiration precautions. RD #2 stated that if the resident was eating meals in their room the resident was to be in an upright position and assisted by staff with feeding. Certified Nursing Assistant (CNA) #6, who was assigned to the resident, was interviewed on 2/15/2023 at 1:19 PM. CNA #6 stated when a resident is on aspiration precautions the resident wears a green wrist band. Resident #140 requires extensive assistance for feeding but at times the resident requires total assistance for feeding, mostly in the morning for breakfast. CNA #6 stated that because Resident #140 is on aspiration precautions, a staff member must be close by to monitor the resident for aspiration and choking. CNA #6 stated on 2/15/2023 the resident was added to their (CNA #6) assignment and that they (CNA #6) were assigned to two residents who had their dialysis appointment at 9:00 AM. CNA #6 stated usually they (CNA #6) would be feeding Resident #140 at 9:00 AM; however, they (CNA #6) had to get the two residents ready for dialysis and were unable to feed Resident #140. The Director of Nursing Services (DNS) was interviewed on 2/15/2023 at 2:18 PM. The DNS stated that if the resident was able to get out of bed, that they would be placed in the dining room for their meals, however, the resident likes to sleep late in the mornings. The DNS stated that each resident would be assisted with feeding based on the resident's assessed needs. The DNS stated that the staff should be intermittently supervising the resident during meals and the most help the resident required was extensive assistance of one staff member for feeding. The DNS stated that a staff member should be in close proximately of the resident during meals. 10NYCRR 415.12(h)(2)

Based on observation, interviews, and record review during a COVID-19 Focused Infection Control Survey conducted on 1/19/2021 the facility failed to maintain an Infection Control Program to prevent the development and transmission of COVID-19. This was evident for one of nine resident rooms observed during meal delivery. Specifically, a Certified Nurse Assistant (CNA #1) did not perform proper hand hygiene between delivering food trays to residents who were placed on transmission-based precautions. The findings are: The CDC Infection Control guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel (HCP) During the Coronavirus Disease 2019 (COVID-19) Pandemic updated 12/14/2020 documents HCP should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing (Personal Protective Equipment) PPE, including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process. The New York State Department of Health (NYSDOH) Revised Health Advisory entitled COVID-19 Cases in Nursing Homes and Adult Care Facilities, dated 3/13/20 and updated 7/10/2020, documented that if there are confirmed cases of COVID-19 in a Nursing Home, all residents on affected units should be placed on droplet and contact precautions, regardless of the presence of symptoms and regardless of COVID-19 status. HCP and other direct care providers should wear gown, gloves, eye protection (goggles or a face shield), and N95 respirators (or equivalent) if the facility has a respiratory program with fit tested staff and N95s. Otherwise, HCP and other direct care providers should wear gown, gloves, eye protection, and facemasks. Facilities may implement extended use of eye protection and facemasks/N95s when moving from resident to resident (i.e. do not change between residents) unless other medical conditions which necessitate droplet precautions are present. However, gloves and gowns must be changed, and hand hygiene must be performed. The facility's Hand Hygiene Policy dated February 2020 documented hand hygiene shall be practiced before and after each resident contact. The facility's COVID-19 Infection Control Policy and Procedure, last updated on 1/7/2021, documented frequent hand washing must be done. Hand washing must be done immediately when coming into contact with any surface in the resident's room and/or any surface that may be contaminated. Perform hand hygiene for a minimum of 20 seconds. On 1/19/2021 from 12:25 PM through 12:38 PM, CNA #1 was observed delivering meal trays to Resident #1 and #2 who resided in the same room. CNA #1 was not wearing gloves when she delivered a meal tray to Resident #1. CNA #1 was then observed moving items on Resident #1's bedside table and repositioning the table. CNA #1 exited the resident's room without washing or sanitizing her hands, removed a meal tray from the meal cart in the hallway, and delivered that tray to Resident #2. CNA #1 then returned to Resident #1 to open packages on the meal tray without washing or sanitizing her hands. CNA #1 then exited the room without washing or sanitizing her hands. Registered Nurse (RN) #1 was interviewed on 1/19/2021 at 12:41 PM and stated staff have been instructed to wash their hands after touching surfaces or items in a resident's room, after providing care, between residents when delivering meal trays, and before exiting resident rooms. CNA #1 was interviewed on 1/19/2021 at 1:39 PM and stated the staff are supposed to sanitize or wash hands if they touch items or surfaces in a resident's room, after patient care, after delivering meal trays, and before leaving the resident's room. CNA #1 was unable to state why she did not wash or sanitize her hands however, stated she should have. CNA #1 stated she received education and training on when to wash her hands. Director of Nursing (DNS) and the Infection Preventionist (IP) were interviewed concurrently on 1/19/2021 at 2:31 PM and stated CNA #1 should have sanitized her hands after touching objects on the bedside table and moving the table, between delivering meal trays to Resident #1 and Resident #2, and prior to exiting residents' room. State tag: 415.19(b)(4)

Based on observation, record review and staff interview during the recertification survey the facility did not ensure that the Comprehensive Care Plan (CCP) was reviewed and revised by an interdisciplinary team to meet the needs of each resident. This was identified for one (Resident #46) of four residents reviewed for Infection. Specifically, Resident #46 had a left arm midline catheter for Antibiotic Therapy related to a Bacterial infection. The CCP lacked documented evidence of goals and interventions for the use and monitoring of the left arm midline catheter. The finding is: Resident #46 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented the resident had short and long memory problems and was severely impaired for daily decision making. The MDS documented in Section O that the resident received Intravenous (IV) medications. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A CCP dated 11/3/2020 documented the resident presently had an infection of the blood stream. The interventions included administer the medications as ordered, maintain infection control practices through proper handwashing, monitor for signs and symptoms of side effects of Antibiotic Therapy, monitor Laboratory results as ordered and monitor vitals as ordered. The CCP lacked documented evidence of the use and monitoring of a midline catheter. The Registered Nurse (RN) Manager was interviewed on 11/9/2020 at 12:53 PM. The RN stated that a CCP for [MEDICAL CONDITION] was in place; however, the Unit RN did not update the CCP with goals and interventions to reflect the use of a midline catheter. The RN stated that the CCP for [MEDICAL CONDITION] should have been updated to reflect the use of the midline catheter. The Director of Nursing Services (DNS) was interviewed on 11/9/20 at 12:57 PM. The DNS stated the MDS team initiates the CCPs, however, the RN's on the unit is responsible for updating the CCP. The DNS stated that the CCP for [MEDICAL CONDITION] should have been updated with goals and interventions to reflect the use and monitoring of the midline catheter. 415.11(c)(2)(i-iii)

Based on observation, record review, and interviews during the Recertification Survey the facility did not ensure that pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) were provided to meet the needs of each resident. This was identified for 1 (Resident #189) of 6 residents observed during medication administration. Specifically, during the medication administration observation for Resident #189, the Registered Nurse (RN) medication nurse prepared to administer the 9 AM dose of twice a day [MEDICATION NAME] (a narcotic) to the resident; however, the [MEDICATION NAME] blister pack did not match the physician's orders [REDACTED]. The finding is: The facility's policy dated 1/2020 titled Medication Administration documented to assure the 6 rights of medication administration (right patient, right medication, right dose, right time, right route, and right documentation) and to compare the Medication Administration Record [REDACTED] Resident #189 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. The MDS documented that the resident frequently had pain and received pain medications. A physician's orders [REDACTED]. A physician's orders [REDACTED]. Review of the October 2020 Medication Administration Record [REDACTED]. On 11/4/2020 at 8:41 AM the medication administration for Resident #189 was observed. The RN medication nurse prepared to provide the standing 9 AM dose of twice a day [MEDICATION NAME], 50 mg. However, the [MEDICATION NAME] blister pack dated 10/20/2020 did not match the current physician's orders [REDACTED]. There were 3 tablets left in the blister pack. The Narcotic Control Record (narcotic log sheet) was reviewed with the RN medication nurse present at 8:42 AM. The Narcotic Control Record for [MEDICATION NAME], 50 mg, documented 3 tablets remaining, consistent with the blister pack; however, the frequency of the medication (i.e. twice a day or PRN) was not documented on the log sheet. On 11/4/2020 at 8:45 AM the RN checked the narcotic box in the medication room and was unable to find blister packs with labels that matched the standing twice a day [MEDICATION NAME] order and the three times a week [MEDICATION NAME] order. The RN Unit Manager was interviewed on 11/4/2020 at 9:25 AM. She stated the hand-written prescriptions were faxed and sent to the pharmacy as soon as the orders were entered (10/26/2020 and 10/31/2020). She stated the blister packs for the new orders have not been received yet and the facility would have to follow up with the pharmacy. A Pharmacist at the medication provider was interviewed on 11/4/2020 at 11:15 AM. She stated that entering the orders in the electronic medical system is not enough and that a prescription is also required. She stated the pharmacy has not received the prescription for the standing order of [MEDICATION NAME] dated 10/26/20. She stated the prescription for the three times a week [MEDICATION NAME], dated 10/31/20, was just received today (11/4/20) at 9:39 AM. She further stated the pharmacy needs the prescription to send the blister pack and the facility should be aware of that. The Director of Nursing Services (DNS) was interviewed on 11/4/2020 at 12:20 PM. She stated the nurses should have ensured that the label matched the order. She stated she would expect the pharmacy to call the facility if a prescription was needed and that the pharmacy did not contact the facility. The DNS was re-interviewed on 11/9/2020 at 9:30 AM. She reviewed the facility policy titled Providing Pharmacy Services dated 10/1/18. She stated the policy did not address the process of sending prescriptions and follow-up between the pharmacy and the nursing staff. The Nurse Practitioner (NP) was interviewed on 11/09/2020 at 10:11 AM. She stated that she wrote out paper prescriptions for the [MEDICATION NAME] orders to be faxed to the pharmacy by the nurse. She stated she did not have explanation as to why the prescriptions were not received by the pharmacy. 415.18(a)

Based on observations, staff interviews and record review during an abbreviated survey (Complaint # NY 828) the facility did not ensure that the physician was promptly consulted and notified when there was a significant change in a resident's laboratory result for one (Resident #1) of three residents reviewed for Quality of Care. Specifically, Resident #1 reported having a black tarry stool (dark red or black in color), he was assessed by a Nurse Practitioner (NP) who ordered the stat (immediately) blood work. The appropriate clinician (physician/NP) was not notified of the 2.6 drop-in Hemoglobin (Hgb) timely after the result was reported by the lab. The findings were: The policy titled laboratory procedures dated 6/2019 documented that all diagnostic interventions will be provided as ordered by the physician. The nurse receiving the order for a stat lab will call the lab and inform the supervisor. The nurse will notify the physician timely after receiving the results of the stat lab work and document the date/time and order changes in the progress note. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was diagnosed with [REDACTED]. The Minimum Data Set (MDS-an assessment tool) dated 8/30/19 documented the resident's cognitive status as intact. The Comprehensive Care Plan titled [MEDICAL CONDITION] dated 8/27/19 documented the resident had decreased hemoglobin (Hgb) and Hematocrit (Hct) levels. Interventions included to administer medications as ordered, monitor labs as ordered, observe for signs and symptoms of [MEDICAL CONDITION] such as fatigue, pallor and decrease activity tolerance. The Complete Blood Count (CBC) result dated 9/2/19 documented Hgb 9.9 gram/dl (low). The NPN dated 9/10/19 at 8:48 PM by the Registered Nurse Supervisor (RNS) #1 documented a clarification note for 9/4/19 at 5:06 PM, received a call from the resident's family with a complaint of having dark stool. The RNS interviewed resident and he stated that it has been ongoing for 2 days. The caregivers were unaware of the resident having dark stools as reported by the resident and the family. The Nurse Practitioner (NP) was made aware and ordered blood work with a stat order. The PO dated 9/4/19 at 5:02 PM documented CBC stat, stool sample for occult blood. The NP note dated 9/5/19 at 3:18 AM documented the resident was seen on 9/4/19 . The patient was on contact precaution for [DIAGNOSES REDACTED]. The resident verbalized having black stools for 4 days. Ordered stool for occult blood, CBC for three days and now. The blood work for CBC was collected on 9/4/19 at 9:52 PM. The lab result dated 9/5/19 at 12:56 AM documented Hgb level of 7.3gm/dl. The laboratory report for CBC from the laboratory provider documented RNS #2 was called on 9/5/19 at 1:43 AM of the result. The medical record lacked documented evidence that a physician (MD) or an NP was notified of the abnormal blood work results until the NP came to assess the resident at 10:30 AM (approximately 9 hours later) when the resident complaint of abdominal pain. The 8:00 AM-4:00 PM RNS #1 was interviewed on 9/16/19 at 4:50 PM and stated, on 9/4/19 the resident and his family notified the RNS of the resident was having black stools for 2 days. She called NP #2 who ordered for occult blood and CBC stat. The 9/5/19 lab result came back with the Hgb level of 7.3 (low). RNS #1 stated that no one from 11 PM-7 AM shift notified the MD of the blood work results that was why the 7 AM-3 PM shift nurse had to report the abnormal blood work results to the NP for Resident #1. NP #2 was interviewed on 9/17/19 at 10:27 AM and stated she saw Resident #1 on 9/4/19 at approximately 6:30 PM for a complaint of black stools. The resident was stable. She ordered a stat CBC. She discussed her plan with the MD. The nurses were expected to call the MD for the lab results. She did not receive a call from the facility regarding Resident #1's abnormal Hgb level on 9/5/19. The 11:00 PM-7:00 AM RNS #2 was interviewed on 9/17/19 at 1:23 PM and stated he did not receive any result of CBC for Resident #1 on 9/5/19. The result would show late on the dashboard at times on the computer as compared to time documented on the lab result. RNS #2 did not call the lab to obtain results of the stat blood work for Resident #1. A subsequent interview on 9/18/19 at 4:15 PM RNS #2 stated that if the lab called and informed him of an abnormal lab, he would acknowledge the call, but he would wait for the lab to fax the results or for the lab result to appear on the computer system and then call the physician. He did not know that he had to call the lab for Resident #1's stat lab results. The Primary MD was interviewed on 9/17/19 at 2:06 PM and stated NP #2 saw Resident #1 on 9/4/19, the patient had black stool, he was medically stable. The CBC and stool for occult blood were ordered immediately. The next morning NP #1 called PMD that the resident's blood work showed a drop in Hgb level. The MD did not receive any calls about the stat lab result from the facility until reported by the NP at 10 AM. The MD expected the staff to call her as soon as the results came. The 11:00 PM-7:00 AM RN #1 was interviewed on 9/17/19 at 2:30 PM and stated she worked on 9/4/19. At night she normally reviewed all the lab results between 12-1 AM and before the end of her shift. She stated there was a problem with the time the labs were posted in the computer system and the time documented on the lab sheets. She would receive the lab result 5-6 hours later than the time documented on the lab sheets. RN #1 stated she did not receive a result for Resident #1 on 9/5/19 during her shift and she did not call the lab to follow up. She stated she was bothered about the delay in receiving the result and she informed the RNs and RNS about the concern and she thought they address the issue but until now she was still getting the results late. The DON was interviewed on 9/17/19 at 3:00 PM and stated the lab was expected to call the facility with the results. A subsequent interview with DON on 9/24/19 at 11:23 AM she stated stat lab had a turn-around of 6 hours from time the specimen was collected to the to time the facility gets the result. The nurse on duty or the RNS was expected to notify the MD of the abnormal result and document the same in the resident's medical record. There was no documentation in the medical record indicating that the MD was made aware. The nurses were also expected to call the lab if the result were not available within 6 hours. The Laboratory Administrator was interviewed on 9/17/19 at 3:18 PM and stated the lab had informed the facility RN via phone at 1:43 AM on 9/5/19 of the abnormal result of CBC. The lab result was in the electronic medical record with a timestamp of 12:56 AM. The Lab Admin stated there were episodes that there was a lag in uploading the result to the electronic medical record. The lab was not responsible for the delay in uploading the lab results. 415.3(2)(ii)(b)

Based on interviews and record review during an abbreviated survey (Complaint #NY 350), the facility did not ensure that each resident received necessary care and services to maintain the highest practicable physical, mental and psychological wellbeing in accordance with the professional standards of practice for one (Resident #1) of three residents reviewed for quality of care. Specifically, Resident #1 had a [DIAGNOSES REDACTED]. The physician ordered the blood work multiple times from (MONTH) (YEAR) through (MONTH) (YEAR) to ascertain the resident's hemoglobin level. There was no follow up by nursing and the physician. The blood work was not completed until 7/10/18 with the hemoglobin level of 5.0 gm/dl (low). The findings were: The facility's policy titled Laboratory Procedures revised 2/2018 documented the Physician (MD)/Nurse Practitioner (NP) will order lab work as needed. The orders will be entered into the electronic medical record by the Physician/NP and saved. The nurse picking up the order will write all blood specimens to be obtained in the lab book. All lab work ordered for the future is to be documented in the unit lab calendar by the nurse picking up the order. The 11-7 nurse will be responsible to review the unit lab calendar daily and transfer all lab work due that day/date to the laboratory book. It is the responsibility of the unit manager to identify lab work not obtained and to re-enter the request in the lab book. The nurse will call the lab if a specimen needs to be collected on weekends/Holidays. The nurse will notify the physician if a resident refuses the lab to be drawn and document same in progress notes. Resident #1 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-an assessment tool) dated 7/21/18 documented the resident's cognitive status as moderately impaired. The physician's orders [REDACTED]. The laboratory result dated 2/28/18 documented a hemoglobin level of 10.7 gm/dl. The PO dated 4/26/18, 6/21/18, and 7/10/18 documented orders for CBC for follow-up due to [MEDICAL CONDITION]. The laboratory results dated [DATE] documented the tube drawn on this patient for CBC had clotted, please reorder test. Approximately after 3 and a half months later, dated 8/12/18 the RN documented, the blood work result was reviewed by the MD on rounds. The result was not signed by the MD. The Medical Progress Note (MPN) dated 5/24/18 and 6/21/18 documented the MD would order CBC to follow up on [MEDICAL CONDITION]. The laboratory result dated 6/22/18 documented, the quantity (of the blood sample) was not sufficient, please re-order. This notice was faxed to the facility. Approximately after one and a half months later, dated 8/12/18 the RN documented that the result was reviewed by MD on rounds. The result was not signed by the MD. The medical record lacked documented evidence that the CBC was ordered on [DATE]. The CBC was not reordered on [DATE] and 6/22/18 after the blood sample clotted and was insufficient. The MPN dated 6/28/18 documented the patient was examined with no distress and labs were reviewed. CBC was not done. The MD documented for CBC to be done in the morning. The medical record lacked documented evidence that the CBC was ordered on [DATE]. The Nursing Progress Note (NPN) dated 7/10/18 documented the MD ordered CMP, CBC, lipids profile in 3 months from 7/10/18. The laboratory result dated 7/11/18 documented a hemoglobin level of 5.4 gm/dl. The NPN dated 7/11/18 documented the CBC result was reviewed by the MD, Hgb 5.4 gm/dl, remarkable. The MPN dated 7/11/18 documented, the resident's hemoglobin was 5.4 gm/dl. The last CBC was done on 2/28/18 with a hemoglobin level of 10.7. There were no reports of hematemesis (blood in vomitus) or melena (blood in stool). The resident with severe [MEDICAL CONDITION] and dynamically appears stable. She refused to go to the hospital. The NPN and PO dated 7/11/18 documented stat (immediate) CBC, Ferritin, Iron, and Folate levels and [MEDICATION NAME] (iron supplement) for nutritional deficiency were ordered. The laboratory results dated [DATE] documented the Hgb level of 5g/dl. The MPN dated 7/12/18 documented the hemoglobin level 5 gm/dl, spoke to a family member and explained the importance of transferring the resident to the hospital for transfusion. The NPN dated 7/12/18 documented the resident was transferred to the hospital and admitted with severe [MEDICAL CONDITION]. The hospital history and physical dated 7/13/18 documented the resident's hemoglobin level was 5.0 gm/dl, critical. She was diagnosed with [REDACTED]. The MPN dated 7/29/18 documented, the resident was admitted to the hospital on [DATE] due to severe [MEDICAL CONDITIONS] and received 3 units of packed cell (blood) [MEDICAL CONDITION] along with intravenous iron during her hospital stay. The Primary Medical Doctor (PMD) was interviewed on 4/8/19 at 10:41 AM and stated he was the assigned PMD for Resident #1 after the hospitalization . The staff was expected to automatically repeat the lab if the collected specimen was clotted or insufficient. The nurse should have notified the physician and received orders to repeat the lab. Resident #1 had chronic [MEDICAL CONDITION] and had a 3-4 points drop in the hemoglobin level. Due to the drop-in hemoglobin level Resident #1 was hospitalized and received a blood transfusion. The Director of Nursing (DON) was interviewed on 8/30/19 at 11:00 AM and stated that when the laboratory results were received from the lab, the nurses would refer the results to the physician. The MD was expected to review and sign off on the results. During the incident with Resident #1, the facility was printing the lab results and was placing them in the MD book for signature. The DON was unable to state why the resident's labs were not reviewed timely by the physician or the specimen not collected after the lab's notification of the insufficient and clotted blood samples. The Medical Director (MD) was interviewed on 9/3/19 2:36 PM and stated Resident #1was referred to him for a [MEDICATION NAME] consult. In (MONTH) (YEAR), he reviewed Resident #1's medical record after the facility staff called him regarding the resident's low hemoglobin levels. The hemoglobin level dropped from 10.7 to 5.0 g/dl. The MD stated he asked the staff why the blood was not drawn prior to 7/11/18, the staff said the resident was agitated and was fighting with the lab technician. There was no documentation of any refusals or notification to the physician of the refusals. On 7/11/18, the resident looked anemic. She was transferred out to the hospital on [DATE] where she received a blood transfusion and intravenous iron. 415.12

Based on observation, staff interviews and record review during an abbreviated and partial extended survey (Complaint # NY 118) the facility failed to implement its system for a prompt response to ventilator alarms for one (Resident #1) of three ventilator-dependent residents reviewed for respiratory care. Specifically, the facility staff did not monitor, and/or did not respond to the functional components of the alarm system. Additionally, the Nurse Call System that was designed to alert staff of the ventilator alarms was not consistently functioning as intended. The facility did not have a system in place for preventative maintenance of the Integrated Nurse Call System. Resident #1 triggered the ventilator alarm for at least nine minutes, to which multiple staff present in the hallway and in the respiratory therapy office did not respond. Subsequently, the resident was found on the floor, unresponsive with no pulse or respiration, Cardio [MEDICAL CONDITION] Resuscitation (CPR) was initiated, the resident was pronounced dead at the hospital. This resulted in actual harm to Resident #1 and potential for serious harm for 38 ventilator-dependent residents that is Immediate Jeopardy. The findings were: The undated facility's policy titled Nurse Call System revised ,[DATE] documented that the facility uses the Nurse call System to monitor ventilator, pulse-oximetry, and general resident calls. At the nursing station, the master console will tone and indicate the nature of each call. All ventilators will be connected to the patient station inside each resident's room. When the ventilator alarm rings, there will be a flashing red/green light outside the room and at the zone lights. Corresponding urgent tones ring at the ventilator, duty stations, and consoles. Ventilator alarms should be addressed promptly. All staff is responsible for responding to ventilator alarms. At the nursing station master console and respiratory console (in the Respiratory Therapy (RT) office); staff will be able to visualize each type of call, alarm, and room number. The facility lacked documented evidence of a policy related to the preventative maintenance of the Nurse Call System that included the ventilator alarm. Resident #1 was a [AGE] year-old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-an assessment tool) dated [DATE] documented severely impaired cognition for the resident. The resident required extensive assistance of 2 persons for bed mobility and transfer. The resident had no impairment to both upper and lower extremities and had no history of falls. The resident was receiving oxygen therapy, suctioning, [MEDICAL CONDITION] care and was utilizing mechanical ventilation. The Medical Orders for Life-Sustaining Treatment (MOLST) dated [DATE] documented a Cardio [MEDICAL CONDITION] Resuscitation (CPR) order for the resident. The physician's orders [REDACTED]. On [DATE] an order for [REDACTED]. The Comprehensive Care Plan (CCP) titled Respiratory Ventilator Dependent and Suctioning dated [DATE], documented the resident was on a mechanical ventilator secondary to inability to maintain adequate oxygen saturation and the resident had a [DIAGNOSES REDACTED]. Evaluate for gurgling respirations and increased secretions and inform MD as indicated. The work order/invoice from the vendor company for the Nurse Call System documented that the company was called by the facility staff on [DATE] and [DATE] related to issues with staff/duty stations (Nurse Call System consoles) on the 2nd floor (the ventilator unit). On [DATE] another work order from the vendor company for the duty station tone issue documented, that the facility staff tried to fix the console on another floor. Damaged devices were noted due to improperly replacing the devices. The Ventilator/Respiratory Care Flow Sheet dated [DATE] documented that the resident's ventilator was checked at 4 PM and the resident was suctioned. The Respiratory Therapist Note (RTN) dated [DATE] at 4:32 PM documented the resident was weaned between 10 AM-4 PM and was returned to AC mode (on ventilator) as scheduled. The RTN dated [DATE] at 10:21 PM by RT #2 documented the RT was called around 7:19 PM into the resident's room and found the resident unresponsive in bed with no (oxygen) saturation and vital signs. The RT started ventilation via Ambu bag at 100% oxygen and the nurse began CPR. Med STAT (a code to call for assistance for immediate resuscitative efforts) was called, the nursing team responded. 911 was called. The resident was transferred to the hospital. The Nurse's Progress Notes (NPN) dated [DATE] at 10:23 PM by the Registered Nurse Supervisor (RNS #1) documented the RNS responded to a Med STAT to the resident's room at 7:17 PM, the MOLST was verified. On arrival, the resident was found in bed, ventilator attached to midline trachea. The resident was unresponsive to all stimuli with no pulse. The Registered Nurse (RN) and the RT were at the bedside, active CPR was in progress with Automated External Defibrillator (AED) in place. 911 was called. The resident left the facility at 7:50 PM accompanied by the EMT to the hospital. At 10:37 PM the hospital informed the RNS that the resident expired. The Nurse Progress Note (NPN) dated [DATE] at 10:39 PM by RN #1 documented the resident was alert and oriented x3 at 3 PM. The resident was on [MEDICAL CONDITION] (trach) to a ventilator and not in any respiratory distress. All due medications were given at around 5 PM. All care was given. At around 7:17 PM the RN was called by a CNA to check the resident. Upon arrival to the room, the resident was found in bed unresponsive to all stimuli; blood pressure and pulse unappreciated (not present). The resident was a full code. Med STAT was called. The RTs and the RNs were at the bedside. The CPR started, AED in place. 911was called. Facility video surveillance was reviewed with the Administrator and the Director of Nursing (DON). Camera 1 (2nd floor C wing hallway) dated [DATE]: -6:59 PM to 7:08 PM displayed a ventilator alarm light above the resident's room door. During this time at least 5 staff members including a Registered Nurse (RN #1), the Certified Nursing Assistant (CNA #2), CNA #3, RT #3 and RT#4 were in the vicinity and did not respond to the ventilator alarm. -7:08: PM CNA (#1) went into the resident's room, she immediately came out and went to the respiratory therapist office. RT #1 and #2 were seen coming out of the RT office going to Resident #1's room followed by RN #2. -7:13 PM RNS #1 came to the unit. -7:25 PM 911 arrived on the unit. 7:41 PM the resident left the unit Camera #6 (2nd floor C wing nursing station) dated [DATE]: -6:,[DATE]:08 PM displayed C wing nursing station (the ventilator unit). No staff was observed at the nursing station by the Nurse Call System (console). On [DATE], the vendor company responded to an emergency service call and found that there were problems with the console on the 4th floor. The console malfunctioned, and it affected the operation of the 2nd-floor ventilator consoles. The custom tones (audibility) on the second floor stopped working. The facility staff power cycled the consoles (refreshed) and it started working normally. The issue was not resolved, and the facility was informed to monitor the system and to contact the vendor company if the issue reoccurs. On [DATE] at 3:18 PM the 2nd floor was observed. Resident #1's room was observed to be approximately 20 feet from the RT office and 28 feet from the nurse's station. The facility submitted a photograph of the ventilator log for Resident #1 on [DATE]. As per the Administrator and the RT Director, the time on the log was 25 minutes behind the actual time. The ventilator log dated [DATE] documented the alarms as follow: At 7:00 PM (actual time): low pressure alarm(circuit disconnect [MEDICAL CONDITION] ventilator) and high respiratory rate alarm. At 7:05 PM and 7:09 PM: low base alarm (occlusion on the ventilator system). At 7:13 PM: check circuit alarm (disconnect from any part of ventilator tubing-bigger than a leak). The facility's investigation dated [DATE] concluded that based on a review of the video recordings of [DATE] the ventilator alarms and call bell alarms were activated from 6:59 PM to 7:08 PM. The staff that was within the vicinity did not respond to the alarms timely. During the investigation, it was identified that the Integrated Nurse Call System was not consistently functioning. Staff interviews revealed that on [DATE] the resident was observed on the floor in the room unresponsive without pulse and respiration. The Administrator was interviewed during the video surveillance review on [DATE] at 1:00 PM. He stated there was a delay in responding to the STAT call due to issue with phone audio. The Administrator also stated that the alarm system in the RT office was not sounding. The Director of Respiratory Therapy placed a work order because the console (integrated nurse call system) in the RT's office had no sound (not audible). The Administrator stated that he was not sure if the console at the nursing station was checked for sound issues. The administrator further stated that as per the vendor company when the annunciator (console) was overloaded (jammed or displayed error message) it would freeze or not ring or beep until the alarm system was reset. The 3:00 PM - 11:00 PM CNA #1 was interviewed on [DATE] at 6:13 PM and stated that on [DATE] at 6:30 PM she left the resident sitting in a wheelchair with [MEDICAL CONDITION] to the ventilator. At 7 PM CNA #1 was in the hallway walking towards Resident #1's room for her break when she saw the white (call/ventilaor light) and the red and green light (ventilator alarm light) on top of Resident #1's room door. She also heard the ventilator alarm when she was in the hallway but it was not that loud. It was the only alarm ringing at that time. CNA #1 went into Resident #1's room. Resident #1 was on the floor laying on her right side on the ventilator tubing. The ventilator alarm was flashing. There was also an audible alarm from the ventilator in the room, but the alarm was not as loud as it usually was. Resident #1 did not respond when CNA #1 touched her. CNA #1 went to the RTs' office to get an RT. There were more than 5 RTs in the room when she opened the office door. RT #2 responded to her call. RT #2 turned the resident to her back. CNA #1 stated the [MEDICAL CONDITION] was intact, but the ventilator tube was not attached to the trach. The RT Director was interviewed on [DATE] at 8:59 AM and stated that the ventilator log time was 25 minutes behind the real time. At 7:00 PM (6:35 PM documented time on the ventilator log). A low-pressure alarm indicated a circuit disconnect between [MEDICAL CONDITION] and the ventilator. At the same time, high respiratory rate (RR) alarm was also documented on the ventilator alarm log which indicated that the resident was breathing fast violating the respiratory rate parameters. A low base pressure alarm indicated occlusion on the ventilator circuit which could be a physical occlusion. The ventilator had a local audible sound and it also alarmed at the console in the RT office. The RTs could possibly hear the ventilator alarms from Resident #1's room even with the office door closed. The RTs did not hear the alarm from the console in the RT office. There was no problem on the console that the RT director was aware of. He checked the volume of the ventilator the following day and it was at its highest volume. The console in the RT office was also working and there were no issues with the volume of the console. The 3:00 PM-11:00 PM RN #1 was interviewed on [DATE] at 12:44 PM and she stated that on [DATE] at 7:15 PM RN #2 called her to check on Resident #1. When she went to Resident #1's room, she noticed that the call/ventilator light was on. She could not recall if the ventilator was alarming locally. Resident #1 was on the floor and 2 RTs were Ambu bagging the resident. Resident #1 was unresponsive. The vital signs were not present. RN #1 told the RTs to transfer the resident to the bed for CPR. The room space was crowded that is why the CPR needed to be done in bed. RN #2 called the Med STAT and brought the crash cart. RN #1 initiated the CPR and other staff responded. The CPR continued until 911 came. RN #1 stated between ,[DATE] PM she was giving medications and was on the opposite side of the unit. On the second floor, everything is always alarming, however, she did not hear any alarms coming from Resident #1's room. RN #1 stated she did not hear an alarm or saw a call/ventilator light at 6:58 PM when she was in the hallway. All alarms including the console were working. The 7:00 AM-7:00 PM RT #1 was interviewed on [DATE] at 12:14 PM and stated that on [DATE] she worked until 9 PM. RT #1 did not see Resident#1's room number displaying on the console throughout her shift in the RT's office. RT #1 did not hear any alarms from the console when she was in the office from 6:45 PM to 7:10 PM. At 7:10 PM when she was giving report to RT #3, a CNA (name not recalled) opened the RT's office door and said Resident #1 was on the floor and she needed help. At the same time, RT #2 who also was in the office stated she was going out to respond to an alarm. RT #1 did not know what alarm RT #2 had heard. RT #2 went with the CNA. RT #1 stopped her report and went to Resident #1's room. Resident #1 was on the floor on her back. The resident'[MEDICAL CONDITION] in place and the ventilator was connected to the resident. RT #2 who had responded first, denied that the resident'[MEDICAL CONDITION] disconnected from the ventilator. RT #1, RT #2 and RN #2 lifted the resident to the bed. RT #1 checked, the resident was pulseless. CPR was initiated. When 911 came, facility staff had been doing the CPR for 15 minutes. The 3:00 PM -11:00 PM RN #2 was interviewed on [DATE] at 2:44 PM and stated that on [DATE] he was assigned to the second-floor A-wing. At 7:15 PM he was giving medications when he saw CNA #1 waving her hand to get his attention. He responded to Resident #1's room and saw Resident #1 lying on the floor, in between the bed and wheelchair in a supine position. RT #2 was fixing the trach. RN #2 did not know if the resident was disconnected and he did not ask RT #2. The resident had no pulse and no blood pressure. The resident's pupils were dilated. RN #2 confirmed that the resident was a full code. He went outside to page the Med STAT. The 2 RTs and CNA #1 were in the room. When RN #2 came back, Resident #1 was in the bed. The CPR was already initiated. 911 was called by RNS #1. RN #2 stated that he was focused on giving medications. He did not know if there were any alarms sounding. No one was sitting to monitor the console on the nursing stations. The 7:00 PM-7:00 AM RT #3 was interviewed on [DATE] at 2:14 PM and stated that on [DATE] she came to the unit at 7:03 PM and went through the hallway (same hallway where the resident's room is located) to the RT office. As she walked by, she heard an alarm going on and off, but she did not know specifically which room was alarming. RT #3 did not see the flashing alarm light. She wanted to check the monitor in the RT office. Once she was in the RT's office the alarm stopped. RT #3 checked the console and there were no alarms displayed. RT #3 heard the CNA asking the RTs for help. RT #1 and #2 responded. At that time there were no alarm sounds or visual alarms displaying on the console in the RT office. RT #3 also did not hear the ventilator alarm in the RTs office from the resident's room. The following day,[DATE], RT #3 noticed the nursing station console on the C wing (the resident's wing) showed low battery. RT #3 could not recall if she reported it to anyone. The 7:00 PM-7:00 AM RT #2 was interviewed on [DATE] at 3:07 PM and stated that there were always alarms going off on the ventilator unit. On [DATE] she did not hear any alarms from Resident#1's room while she was in the hallway. During the shift report she looked at the console in the RT's office and saw (the resident's room #) appear with a ventilator alarm sign. While she was putting her lab coat on to go to check the alarm, CNA #1 came to get one of the RTs. CNA #1 told her to come quick. RT #2 went to the resident's room and saw the resident laying on the floor on top of the ventilator tubing. The ventilator was attached to [MEDICAL CONDITION] was alarming. Resident #1 did not respond to verbal stimuli. RT #2 instructed CNA #1 to call the nurse. RT #1 and one of the nurses responded. The vent would alarm if occluded. The ventilator alarm was audible in the resident's room. The 3:00 PM-11:00 PM CNA #2 was interviewed on [DATE] at 5:06 PM. She stated she was not assigned to Resident #1 on [DATE]. The alarms were always going off on the unit. She was not sure if Resident #1's alarm was sounding. When CNA #2 came out of another room, she did not see the call/ventilator light on Resident #1's room door. There was an alarm sounding. She did not know what room the alarm was sounding from. She did not notice flashing alarm light on the room door for the resident. The 3:00 PM- 11:00 PM CNA #3 was interviewed on [DATE] at 5:34 PM and stated on [DATE] she worked on the 2nd floor provding 1:1 monitoring for another resident. She stated she was not familiar with Resident #1. While going for her break at approximately 7 PM she walked past the nurse's station and Resident #1's room. She was not paying attention. She did not hear any alarms or see any lights on for the resident. Several attempts were made to contact RNS #1 with no response. The DON and Administrator were interviewed concurrently on [DATE] at 5:48 PM, the Administrator stated on [DATE] the DON reviewed the camera after she got a report from staff of a possible delay in response to the ventilator alarms. The facility found that Resident #1's call/ventilator light was on and the staff did not respond to light for at least 9 minutes. The staff was expected to respond to the alarm promptly. The ventilation system worked as designed. The Nurse Call System was not annunciating ventilator or call bell alarms in the RT office console on [DATE]. The RT consultant had reset the system (guided by the vendor company over the phone) and it worked. The vendor company came on [DATE] after the RT Consultant had reset the system. They identified some error codes which they fixed and left with the system in working condition. The DON stated based on the facility investigation she concluded that the staff did not respond timely to a ventilator alarm. 415.12(k)(6)

Based on interviews and record review during an abbreviated survey (Complaint # NY 862 and # NY 048), the facility did not ensure that two of eight residents reviewed for pressure ulcers received necessary assessments and/or care to prevent development of new pressure ulcers and deterioration of the pressure ulcers (Resident #1 and Resident #4). Specifically, Resident #1 was at moderate risk for developing pressure ulcer; developed a stage 2 pressure ulcer (partial thickness skin loss) to the sacral area and stage 3 (full thickness skin loss) to bilateral heels 18 days after admission to the facility. The resident's wounds were not promptly identified, reported, assessed and monitored, and treatments were not implemented as per the physician's orders [REDACTED]. Additionally, Resident #4 had a Stage 4 pressure ulcer (full thickness skin and tissue loss) to the sacral area. The ulcer was followed by the Wound Care Physician who recommended hospitalization for debridement of the wound on two occasions and the recommendation was not addressed by the Primary Medical Doctor (PMD). This resulted in actual harm to Resident #1 that is not Immediate Jeopardy. The findings were: The Facility's Policy titled Pressure Ulcer Risk Assessment, undated, documented pressure ulcer risk assessments will be conducted by licensed or Registered Nurse (RN) on admission/readmission, then quarterly. Assessments may also be conducted after a change of condition or after any newly identified pressure ulcer. The Facility's Policy titled Pressure Injury Prevention and Management, undated, documented: -The licensed nurses will conduct a full body skin assessment on all residents upon admission/readmission. and after a newly identified pressure injury. -The findings will be documented in the medical record. -The interdisciplinary team should develop a relevant care plan with appropriate interventions. -The RN Unit manager or designee, will review all relevant documentation regarding skin assessments, pressure injury risks, progression towards healing and compliance at least weekly and document in medical record. -The Attending Physician will be notified for the presence of new pressure ulcer/injury. The Facility's Policy titled Pressure Ulcer Prevention Guideline, undated, documented: -The facility will implement evidence-based interventions for all residents who are assessed at risk or who have a pressure ulcer present. -Individualized interventions will address specific factors identified in the resident's risk assessment, skin assessment, and any pressure ulcer assessment. -Interventions will be implemented in accordance with physician orders. -The interventions will be documented in the care plan and communicated to all relevant staff. Compliance with interventions will be documented in treatment and Medication Administration Record [REDACTED]. - Effectiveness of interventions will be monitored through ongoing assessment of resident and/or wound. 1) Resident #1 (R#1) was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-an assessment tool) dated [DATE] documented severely impaired in cognition for the resident. The resident required extensive assistance of two persons for bed mobility, transfer and toilet use. The resident did not walk and used a wheelchair for a mobility device. The resident was always incontinent of bowel and bladder, was at risk for pressure ulcer, had no unhealed pressure ulcers and utilized a pressure reducing device in the chair and bed. The Nursing Admission Skin Assessment, dated [DATE], documented the resident had no pressure ulcer. The Braden Scale assessment tool, dated [DATE], documented the resident was at moderate risk for developing pressure ulcers. The Comprehensive Care Plan (CCP) titled Activities of Daily Living (ADL) Functional/Rehab Potential dated [DATE] documented self-care deficit. Interventions included provide ,[DATE]-person assistance for toileting, out of bed to wheelchair with ROHO cushion (a pressure relieving device). The Resident Nursing Instructions (Certified Nursing Assistant (CNA) care plan) dated [DATE] documented turning and positioning every 2 hours and skin check every shift. The CCP titled Skin Integrity, dated [DATE], documented the resident was at risk for skin breakdown secondary to bladder and bowel incontinence, impaired cognitive function and liver and [MEDICAL CONDITION]. Interventions included to check and change briefs every ,[DATE] hours and as needed, gel cushion in wheelchair, monitor/report skin for redness, [MEDICAL CONDITION], openings, rashes, bruising, blisters, excoriation; use pressure reducing mattress, provide incontinent care with each diaper change and protective, preventative skin care. The physician's orders [REDACTED]. The orders were renewed on [DATE]. The medical record lacked documented evidence that the stage 2 pressure ulcer to the sacral area and stage 3 pressure ulcers to bilateral heels were identified prior to [DATE] when noted in physician's orders [REDACTED]. A pressure ulcer risk assessment was not conducted after newly identifying pressure ulcers as per the facility's policy and procedure. The Treatment Administration Record (TAR), dated [DATE] to [DATE], lacked documented evidence that skin integrity was checked on 38 occasions over all shifts. The TAR also lacked documented evidence that the prescribed treatments were administered to bilateral heels stage 3 pressure ulcers on 37 out of 52 occasions and the sacral stage two pressure ulcer on 13 out of 40 occasions. The Weekly Wound Tracking Form, dated [DATE] to [DATE], lacked documented evidence that the resident's pressure ulcers to sacrum and bilateral heels were monitored weekly as per facility's policy and procedures. The Wound Physician notes, dated [DATE] at 10:21 PM, documented the resident had an unstageable pressure ulcer to sacrum measuring 5 x 2.5 x 0.5 cm, 100% yellow slough (dead tissue on the wound bed), with scant drainage. The Wound Physician recommended treatment daily and as needed and follow up weekly and as needed. The CCP titled Skin Integrity, dated [DATE], documented the resident had pressure ulcer on the sacrum. Interventions included to apply local treatment as ordered by the MD, supreme alternating mattress and weekly wound rounds. The CCP lacked documented evidence for interventions related to the bilateral heel pressure ulcers. The Wound Physician notes, dated [DATE] at 9:20 PM, documented unstageable pressure ulcer to sacrum with recommendation for hospitalization and debridement of sacral wound. The Nursing Progress Note (NPN), dated [DATE], documented the resident was seen by the vascular surgeon to evaluate for debridement. The resident to be scheduled for debridement in operating room next week for sacral wound. The Facility Medical Director's (FMD) note, dated [DATE], documented the resident developed stage 4 pressure ulcer to sacrum and there was necrotic (non-living) tissue at the base. The debridement was cancelled, and the resident was placed on comfort care as per family wishes and expired on [DATE]. The Registered Nurse Supervisor (RNS) #1 was interviewed on [DATE] at 1:31 PM and stated she assessed the wounds on [DATE]. The sacral wound was a stage 2 pressure ulcer; the right and left heel wounds were assessed as stage 3 pressure ulcers; these were new pressure ulcers for the resident. RNS #1 stated she wrote the treatment orders according to the facility protocol however, she did not write a note on [DATE] related to the wounds because she forgot. RNS #1 could not recall if she notified the MD or the wound care nurse regarding the resident's wounds. RNS #1 stated that she did not initiate a care plan or modify any intervention related to her assessment of the wounds. The 3:00PM -11:00 PM RN/RN Charge Nurse (RNCN) was interviewed on [DATE] at 2:37 PM and stated he did the resident's treatment from ,[DATE]-[DATE]. He did the treatment most of the time and he missed some treatment administrations for Resident #1 because he was busy. RNCN stated the missing signatures in the TAR indicated the treatment was not done. RNCN stated Resident #1 had a Stage 2 on the sacrum and treated with calcium alginate. The stage 3 wounds to right and left heel were dry. He did not assess the wounds and did not measure the wounds; he just signed the TAR. The wound MD would usually write a note and documented the condition of wounds. RNCN stated he was not informed about the policy on how to report a skin breakdown. Resident #1's wound started on [DATE] and was not seen by the wound care MD until [DATE] for sacral ulcer and it was diagnosed as unstageable. There was no care plan initiated regarding the ulcer of sacrum and bilateral heels until [DATE]. The 7:00 AM - 3:00 PM Licensed Practical Nurse (LPN) #1 was interviewed on [DATE] at 3:24 PM and stated that she worked on [DATE]-[DATE] and did the residents wound treatment. LPN #1 stated Resident #1 had open wounds on the heels and the dressing was wet. There was a lot of drainage on the heels, the right heel was worse than the left heel. The wound on the sacrum was open, pinkish, red with some slough. LPN #1 stated she did not document how the wound appeared because the wound care nurse would usually document it. LPN #1 stated she did not notice if the wounds worsened however, the heel ulcers were bad. The Nurse Practitioner (NP) was interviewed on [DATE] at 10:49 AM and stated that she evaluated Resident #1 on [DATE], [DATE], [DATE] and [DATE] for swelling in the legs. She was not informed of the sacral wound until [DATE] when the RNCN called her to evaluate the wound on the sacrum. She was not asked to check the skin on bilateral heels. The RN Unit Manager (RNUM) was interviewed on [DATE] at 11:47 AM and stated she first aware of the pressure ulcers a day or two prior to [DATE] when the CNA #1 asked her to look at the resident's sacral wound because it was getting worse. The RNUM called the Wound Care Nurse (WCN). The WCN said she was not notified of the wound prior to that date. The RNUM stated she did not do a full skin assessment at that time and focused only on sacral area. RNUM stated after reviewing the order, she saw there was an order for [REDACTED]. There was no care plan related to the sacral wound. RNUM stated the WCN was supposed to do the weekly documentation and update the care plan. RNUM initiated the care plan on [DATE] for the sacral wound. RNUM stated she did not inform the WCN about the pressure ulcers on the heels. The 7:00 AM - 3:00 PM CNA #1 was interviewed on [DATE] at 12:50 PM and she stated she was assigned to Resident #1 on and off in July. On [DATE] she saw redness on the sacrum and she reported it to LPN #5 who looked at it. There was no treatment on the area when she saw it. The resident had a dressing on her bilateral heels, booties, regular mattress and was on turning and positioning. CNA #1 stated she did not notice any drainage on the heel. A protective dressing was placed on the sacrum. CNA #1 noticed the wound in the sacrum was bigger and she informed the RNUM. There was an odor on the wound. The WCN from [DATE] until [DATE] was interviewed, via phone, on [DATE] at 11:30 AM. The WCN stated she was not notified of Resident #1's pressure sores. The RNS should have updated the care plan upon assessment of the wounds and the WCN would then update the CCP during wound rounds. The Wound Care Consultant (WCC) was interviewed on [DATE] at 9:33 AM and stated he did the weekly wound care rounds with the WCN for wounds that were referred to him. He initially saw Resident #1 on [DATE]. The WCC was asked only to evaluate Resident #1's sacral area. Resident #1 had an unstageable wound to the sacrum measuring 5 x 2.5 x 0.5 cm. The WCC stated he saw Resident #1 again on [DATE] and he recommended hospitalization and debridement of sacral wound. WCC stated there was no sign of infection at that time however, the wound was necrotic and needed debridement. Primary Medical Doctor (PMD) #1 was interviewed on [DATE] at 2:22 PM and stated he was the PMD for Resident #1 from [DATE]-[DATE] and on [DATE] he completed the monthly assessment for PMD #2. PMD #1 saw Resident #1 with RNS #1 on [DATE] however, he did not document his findings. He instructed the staff to put booties on the resident and to refer her to the wound care team who would supervise the wound. PMD #1 stated when he saw the sacral and heel ulcers they were in the beginning stages with only abrasions and superficial redness on the heels which was considered a stage 2. PMD #1 thought the resident was referred to the wound care team. PMD #1 did his monthly assessment on [DATE] and he did not review any skin sheets because no skin sheets were completed at that time. PMD #1 stated as far as he knew, the wound treatment was in place and was done. PMD #2/Medical Director (FMD) was interviewed on [DATE] at 3:23 PM and he stated he took over the resident's care after the 15th of July. The FMD stated he was not informed about the wound until August. There was a breakdown of communication. The FMD stated that if there was any breakdown of skin, the PMD needed to evaluate it and recommend a wound care consult if needed. The FMD saw Resident #1's sacral wound on [DATE] which was unstageable. The FMD stated that any resident with stage 2 ulcers would be followed by wound care team. The Director of Nursing (DON) was interviewed on [DATE] at 11:30 AM and stated that the facility did not have a specific wound treatment protocol. The treatments were individualized. When a new wound was identified, the nurses were to call the physician for the treatment orders. 2) Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS) assessment dated [DATE], the resident had severely impaired cognition, required extensive assistance with two-persons for bed mobility, and had total dependence on two-persons for transfer and toilet use, was totally incontinent of bladder, used a wheelchair as mobility device and did not walk. The MDS also identified that Resident #4 was at risk for developing pressure ulcer(s). Resident had documented pressure ulcers including (1) Stage 3, (1) Stage 4 and (1) unstageable with slough/eschar that were present on admission. The most severe tissue type was eschar. The Braden scale assessment dated [DATE] documented the resident was at very high risk for development of pressure ulcers. The CCP titled Skin Integrity: Presence of Skin Breakdown to Sacrum dated [DATE] documented Resident #4 had a stage 4 pressure ulcer to sacrum, Stage 3 to right ischium and Unstageable pressure ulcer to left ear, and all were present on admission. The interventions included to apply local treatment as ordered by MD, assess for signs of infection and weekly ulcer assessment and documentation by wound care team. The Wound physician progress notes [REDACTED]. The Medical Progress Note (MPN) dated [DATE] documented vent dependent, overall prognosis poor. The WPPN dated [DATE] documented sacrum stage 4 ulcer with 50% necrotic (dead) tissue. No change in size. Suggested hospitalization for surgical debridement of wounds and continued care. The WPPN dated [DATE] documented sacrum stage 4 with 60% necrotic tissue. No change in treatment and again suggested hospitalization for surgical debridement of wounds and continued care. The Medical Progress Note dated [DATE] documented the resident with multiple comorbidities and multiple pressure ulcers. Continue same care. The medical record lacked documented evidence that the Wound Care Physician's (WCP) suggestion for hospitalization for surgical debridement of wounds twice was addressed by the PMD. The Wound Care Nurse (WCN) was interviewed on [DATE] at11:09 AM and stated she Resident #4 was admitted with a very large wound on the sacrum. Her wound was treated locally and was not improving. The WCP recommended debridement but the PMD did not agree with it. The WCP was interviewed on [DATE] at 9:31 AM and he stated he had seen Resident #4 weekly and he recommended debridement of the wounds. The wounds had slough and needed debridement. The debridement never happened. He made his recommendations and spoke to the WCN and it was up to the facility to act on them. His communication with the PMD was through nursing and everyone was aware of his recommendations. The facility did not have a policy related to debridement, so he recommended hospitalization for debridement. The WCP stated the facility had no consent and no instrument for debridement. The DON #1 was interviewed on [DATE] at 3:15 PM and she stated she assumed the position on [DATE]. DON #1 stated if WCP felt that a debridement needed to be done, he would recommend it and the PMD would be informed. The PMD would agree or disagree based on comorbidities and discussion with family. The PMD however needed to document the reasons for not following the recommendations. A subsequent interview with DON on [DATE] 11:59 AM she stated there was no specific policy on debridement. The facility had bedside debridement kits available and a bedside debridement could be done. The PMD was interviewed on [DATE] at 11:29 AM, he stated the WCP recommended hospitalization and debridement however, Resident #4 was too sick so he could not medically clear her for debridement. The PMD stated Resident #4 could not safely go through surgery and anesthesia. In this situation the WCP needed to perform a bedside treatment and chemical debridement. The PMD stated he could not recall if he spoke to the WCP, he just spoke to the nurses. The PMD stated he read the WCP's recommendation and, most of the time, he would just speak to the staff and would not document in the medical record. The PMD stated the WCP did not want to do debridement at bedside. The PMD stated that there was no policy against bedside debridement, only how deeply they could debride. The PMD stated he did not know why the WCP did not do the debridement at the bedside all along. The Facility Medical Director (FMD) was interviewed on [DATE] at 3:23 PM and stated that the WCP recommended hospitalization for debridement if he thought the debridement could not possibly be done at the bedside. The PMD was expected to write a note as to why he was not following the WCP's recommendation. 415.12 (c)(2)

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 prevent elopement of residents and to monitor and supervise residents with a history of elopement or wandering behavior. The Medical Director also failed to coordinate the medical care of a resident with a known history of psychiatric illness. This failure resulted in Resident#1's elopement from the facility. This resulted in no known actual harm with the potential for serious harm that is Immediate Jeopardy for Resident #1 and 31 residents identified by the facility as at risk for elopement. Cross References: F 323 - Accidents & Supervision F 490 - Administration F 520 - Quality Assessment & Assurance Complaint Number: NY 178 The findings are: An interview was conducted with the Psychiatrist on 5/24/13 at 1:50 PM. The Psychiatrist stated that he was aware of an initial consultation ordered for Resident #1 on 1/11/13 but was waiting for family availability to be present; the resident was not seen until 4/7/13 and has not been seen again. The Psychiatrist stated that the resident "cannot make any decisions for herself. She's (Resident #1) quite disorganized in thought. She has very limited understanding. You cannot instruct her (Resident #1) what to do." An interview was conducted with the Director of Nursing (DON) on 5/28/13 at 2:06 PM. The DON stated that, prior to 5/4/13, Resident #1 did not get off the secure unit since March 2013. She was not aware that Resident #1 had eloped on 5/4/13 until after 9:00 AM and does not know when the resident was physically assessed but should have been physically assessed immediately after being returned to the unit. All residents should be assessed for elopement quarterly at a minimum. The DON also stated that, other than the issue of the security guard inattentiveness at the front desk, there were no other concerns identified regarding Resident #1's elopement. There is a "gray area" at the change of shift and there is no one staff specifically responsible for observing a resident; "Just because you (staff) come on shift doesn't mean you have an assignment." An interview was conducted with the Attending Physician (AP) on 5/28/13 at 5:24 PM, the AP stated that Resident #1 has ongoing psychiatric issues but she does not know to what extent. She is not aware of whether or not the resident has ever been seen by Psychiatry but Resident #1 "should have a comprehensive psychiatric follow-up due to this incident (elopement)." The AP further stated, "Staff need to be much more stringent in providing supervision with her (Resident #1)." An interview was conducted with the Medical Director (MD) on 5/29/13 at 10:38 AM, the MD stated that he does not draft policies but approves them. He has had multiple discussions with Administration regarding Resident #1's elopement behavior but does not recall any specifics. The MD further stated that he is not aware of any changes in policy in relation to Resident #1's elopement. 415.15 (a)

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 at risk for unsafe wandering and/or elopement. The Administration failed to perform an investigation to determine the root cause of the 5/4/13 incident with Resident #1 in order prevent further instances of unsafe wandering and failed to identify system failures related to residents who are at risk for unsafe wandering and/or elopement. This has the potential to affect the health and safety of 31 residents who have been assessed as at risk for elopement. This resulted in no known actual harm with the potential for serious harm that is Immediate Jeopardy. Complaint Number: NY 178 Cross References: F 323 - Accidents & Supervision F 501 - Medical Director F 520 - Quality Assessment & Assurance The findings are: An interview was conducted with the Risk Manager (RM) on 5/28/13 at 12:22 PM. The RM stated that she knows Resident #1 was found a few times in different parts of the facility but incident investigations were not done. The RM stated that an occurrence such as a resident getting off the secure unit "should be discussed in morning meeting the next day to formulate a plan." The RM could not say whether or not this was ever done with regard to Resident #1. An interview was conducted with the In-Service Coordinator (ISC) on 5/28/13 at 1:33 PM. The ISC stated that each day during morning report any incident involving a resident is discussed with all department heads. Resident #1 was discussed after the 5/4/13 elopement but the ISC does not recall ever discussing Resident #1's behaviors prior to this elopement. The ISC stated that she does not know whether or not security guards were re-inserviced on elopement prevention after Resident #1's elopement on 5/4/13. The ISC further stated that all other staff were not re-inserviced on elopement prevention because the annual in-service on elopement prevention is not due until June 2013. An interview was conducted with the Director of Nursing (DON) on 5/28/13 at 2:06 PM. The DON stated that, prior to 5/4/13, Resident #1 did not get off the secure unit since March 2013. She was not aware that Resident #1 had eloped on 5/4/13 until after 9:00 AM and does not know when the resident was physically assessed but should have been physically assessed immediately after being returned to the unit. All residents should be assessed for elopement quarterly at a minimum. The DON stated that, other than the issue of the security guard inattentiveness at the front desk, there were no other concerns identified regarding Resident #1's elopement.There is a "gray area" at the change of shift and there is no one staff specifically responsible for observing a resident; "Just because you (staff) come on shift doesn't mean you have an assignment." An interview was conducted with the Attending Physician (AP) on 5/28/13 at 5:24 PM. The AP stated that Resident #1 has ongoing psychiatric issues but she does not know to what extent. The AP stated that she is not aware of whether or not the resident has ever been seen by Psychiatry but Resident #1 "should have a comprehensive psychiatric follow-up due to this incident (elopement)." The AP further stated, "Staff need to be much more stringent in providing supervision with her (Resident #1)." An interview was conducted with the Medical Director (MD) on 5/29/13 at 10:38 AM. The MD stated that he does not draft policies but approves them. The MD has had multiple discussions with Administration regarding Resident #1's elopement behavior but does not recall any specifics.He is not aware of any changes in policy in relation to Resident #1's elopement. An interview was conducted with the Administrator on 5/29/13 at 11:07 AM. The Administrator stated that she was immediately advised by the RNS of Resident #1's elopement on 5/4/13. The Administrator advised the RNS to place the resident on a one to one supervision; this was not done. An investigation was started and it was concluded that the Security Guard failed to stop the resident from exiting the building. Pass-code key pads were explored for securing the elevators but have not yet been fully installed. The Administrator further stated that she is not aware of any other concerns with Regard to Resident #1's elopement. 415.26

Based on record review and staff interviews conducted 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 at risk for elopement/wandering. Specifically, the QAA Committee failed to investigate in order to determine the root cause of Resident #1's unsafe wandering/elopement from the secure unit. Subsequently, the resident was able to exit the building through the front lobby door. The QAA Committee failed to conduct quality assessment and assurance to ensure the development and implementation of policies and procedures for the prevention of elopement, and the monitoring and supervision of residents with a known history of elopement/wandering. The QAA Committee also failed to identify system failures related to residents who are at risk for elopement/wandering. This resulted in no known actual harm with the potential for serious harm that is Immediate Jeopardy for 31 residents identified by the facility as at risk for elopement. Cross References: F 323 - Accidents & Supervision F 490 - Administration F 501 - Medical Director Complaint Number: NY 178 The findings are: An interview was conducted with the Risk Manager (RM) on 5/28/13 at 12:22 PM. The RM stated that she knows Resident #1 was found a few times in different areas of the facility but incident investigations were not done. An occurrence such as a resident getting off the secure unit "should be discussed in morning meeting the next day to formulate a plan." The RM could not say whether or not this was ever done with regard to Resident #1. An interview was conducted with the In-Service Coordinator (ISC) on 5/28/13 at 1:33 PM. The ISC stated that each day during morning report any incident involving a resident is discussed with all department heads. Resident #1 was discussed after the 5/4/13 elopement but the ISC does not recall ever discussing Resident #1's behaviors prior to this elopement. The ISC stated that she does not know whether or not security guards were re-inserviced on elopement prevention after Resident #1's elopement on 5/4/13. The ISC further stated that all other staff were not re-inserviced on elopement prevention because the annual in-service on elopement prevention is not due until June 2013. An interview was conducted with the Director of Nursing (DON) on 5/28/13 at 2:06 PM. The DON stated that, prior to 5/4/13, Resident #1 did not get off the secure unit since March 2013. The DON stated that she was not aware that Resident #1 had eloped on 5/4/13 until after 9:00 AM and does not know when the resident was physically assessed but should have been physically assessed immediately after being returned to the unit. All residents should be assessed for elopement quarterly at a minimum. The DON stated that, other than the issue of the security guard inattentiveness at the front desk, there were no other concerns identified regarding Resident #1's elopement. She further stated that there is a "gray area" at the change of shift and there is no one staff specifically responsible for observing a resident; "Just because you (staff) come on shift doesn't mean you have an assignment." An interview was conducted with the Attending Physician (AP) on 5/28/13 at 5:24 PM. The AP stated that Resident #1 has ongoing psychiatric issues but she does not know to what extent. The AP stated that she is not aware of whether or not the resident has ever been seen by Psychiatry but Resident #1 "should have a comprehensive psychiatric follow-up due to this incident (elopement)." The AP further stated, "Staff need to be much more stringent in providing supervision with her (Resident #1)." An interview was conducted with the Medical Director (MD) on 5/29/13 at 10:38 AM. The MD stated that he does not draft policies but approves them. He has had multiple discussions with Administration regarding Resident #1's elopement behavior but does not recall any specifics.The MD further stated that he is not aware of any changes in policy in relation to Resident #1's elopement. An interview was conducted with the Administrator on 5/29/13 at 11:07 AM. The Administrator stated that she was immediately advised by the RNS of Resident #1's elopement on 5/4/13. The Administrator advised the RNS to place the resident on a one to one supervision, which was not done. An investigation was started and it was concluded that the Security Guard failed to stop the resident from exiting the building. Pass-code key pads were explored for securing the elevators but have not yet been fully installed. The Administrator further stated that she is not aware of any other concerns with Regard to Resident #1 ' s elopement. 415.27(a-c)

Based on observation, staff interviews and record review during an abbreviated and partial extended survey the facility failed to ensure a safe environment, providing adequate supervision and monitoring to protect the health and safety of each resident. Specifically, one (Resident #1) of eight residents reviewed with a history of unsafe wandering was admitted to the facility and assessed to be an elopement risk. The resident was placed on a secure unit, from which she was able to leave 10 times without staff awareness from 1/20/13 to 4/9/13. The resident was found at other areas of the facility including the basement and front door. No investigations, assessments or changes to the resident's plan of care were made. Fifteen minute visual monitoring was started and the resident was again found off the unit. On 5/4/13 the resident left the secure unit unnoticed by staff, bypassed the security guard and exited the front lobby door. The resident was found outside walking across the center of the road by two off-duty staff members. This resulted in no known actual harm with the potential for serious harm that is Immediate Jeopardy and Substandard Quality of Care for 31 residents identified by the facility as at risk for elopement on unit 2 South. Complaint Number: NY 178 The findings are: The Policy and Procedure on Elopement/Missing Resident dated 12/09 documented that once a resident is located the resident will be assessed by the Nursing Supervisor or designee for any signs and symptoms of injury and/or new physical/mental findings; the primary physician will be notified for hospital evaluation. The Policy and Procedure on Prevention of Elopement and Wandering Protocol dated 12/10 documented that, on admission, all residents will be assessed by a nurse to determine his or her risk for harm due to wandering off the unit and/or elopement from the facility. These assessments are completed quarterly or in an event of a significant change in status. The Policy and Procedure on Reception and Security Desk Responsibilities dated 12/12 documented that the reception area/desks will be manned at all times without exception. The receptionist/security guard may not leave without a replacement to ensure 24 hour coverage. If a break is needed, the RN (Registered Nurse) Supervisor must be notified and will assign a replacement person. Resident #1 is [AGE] years old and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (an assessment tool) dated 4/14/13 documented that the resident's cognition is moderately impaired. The Hospital Psychiatric Consultation dated 12/11/12 documented that the resident has a chronic psychiatric disorder. The Physician order [REDACTED]. The medical record lacked documented evidence that the resident was seen by Psychiatry before 4/7/13. The Elopement Risk Assessment (ERA) dated 1/11/13 documented that the resident was assessed to be at risk for elopement. The ERA was updated on 1/18/13 to include the resident's verbalizations of wanting to go home and not accepting residency. The Nursing Progress Notes (NPN) dated 1/12/13 documented that the resident ambulates around the hallway without asking for assistance. The supervisor is aware; obtained order for wander guard but resident refused. Keep on 30 minutes monitoring. The Care Plan Activity Report (CPAR) for Mobility, Ambulation and Transfers dated 1/13/13 documented that the resident may ambulate on unit without assistive device with supervision. The CPAR for Abuse/Neglect dated 1/14/13 documented that the resident is at risk for abuse/neglect secondary to Schizophrenia. Interventions included maintaining a safe environment at all times. The CPAR for Elopement dated 1/14/13 documented that the resident is at risk for elopement as evidenced by resident is ambulatory/impaired cognition; leaving unit without notifying staff. Interventions included observing for signs of elopement and address accordingly; 30 minute visual monitoring. The resident refuses a wander guard. The Social Services Progress Notes dated 1/17/13 documented that the resident ambulates ad-lib and wanders around the unit. The resident has a psychiatric history and will be monitored for increase in behaviors. The CPAR for Wandering dated 1/18/13 documented that the resident is at high risk for wandering. Interventions included obtaining a psychiatric consult as ordered. The NPN from 1/20/13 to 4/9/13 documented that the resident had been found on other units, at the front lobby door and in the basement on the following dates: 1/20/13, 2/19/13, 2/20/13, 3/2/13, 3/14/13, 3/25/13 (three times), 4/4/13 and 4/9/13. The CPAR for Elopement documented one intervention between 1/20/13 to 4/9/13. On 2/25/13 the CPAR documented an intervention for family to assist staff in counseling resident at least weekly reinforcing appropriate behavior. The Initial Psychiatry Evaluation dated 4/7/13 documented that the resident had disorganized behavior at home and episodes of wandering into the neighborhood. The resident is disorganized in thought process, has significant cognitive dysfunction and is not capable of making a decision. The NPN dated 4/9/13 documented that the resident was trying to leave through the front door, redirected back to the unit; maintained on every 30 minute monitoring. The NPN dated 4/10/13 documented that the resident was placed on 15 minute monitoring due to attempted elopement yesterday. The NPN dated 4/13/13 documented that staff received a call from another unit stating that the resident is on the first floor by the elevator and was stopped by the security guard. The resident was brought back to the unit and counseled about leaving the floor. The Visual Observation Monitoring Sheet dated 5/4/13 documented that the resident was visually observed in her room at 7:00 AM, 7:15 AM and 7:30 AM. The NPN dated 5/4/13 documented that, at around 7:30 AM, the resident was brought back to the unit by one of the 11-7 CNAs (Certified Nursing Assistant) who stated that the resident was attempting to cross the street. Resident alert, in no distress. Wander guard placed at right ankle. 15 minute monitoring continues. The Occurrence Report dated 5/4/13 at 7:30 AM documented that the resident was brought back to the unit after a CNA found the resident attempting to cross the street in front of the building. Checked resident; no distress; no injuries. Wander guard placed on right ankle. Continue with 15 minute monitoring. The doctor was notified at 9:50 AM. The undated Investigation documented that the resident was on a secure unit and her plan of care was followed as she was observed every 15 minutes. The security guard breached the facility policy and failed to stop the resident from exiting the facility. The corrective plan of action included the termination of the security guard on duty and in-servicing of all other security guards. The restructuring of nursing assistants to provide hallway supervision and the installation of a key pad device to operate elevators are being explored. On 5/23/13 at 9:50 AM the Security Guard was observed with his head down at the front desk of the south building preoccupied with his cell phone. A resident was passing the desk, unsteadily attempting to stand. The Security Guard did not look up to observe the resident. An interview was conducted with the 7:00 AM to 3:00 PM Licensed Practical Nurse (LPN #1) on 5/23/13 at 12:44 PM. LPN #1 stated that, on 5/4/13, the 2 South unit was short-staffed and she was the only nurse when she came on duty. Resident #1 should have been visually checked every 15 minutes because the resident has been found off the unit many times before; however, LPN #1 was not able to make CNA assignments until after 7:30 AM., when the resident was returned to the unit by CNA #6, who said that she found the resident outside in the middle of the road. LPN #1 called the nursing supervisor, who did not come to see the resident for over an hour. CNAs do not usually receive their assignments until after verbal report is given to them and, depending upon what is going on each morning, assignments may not be made for a half hour. LPN #1 stated that, at the change of shift, CNAs from both the previous shift and oncoming shift are together on the unit but LPN #1 is not sure who would be actually responsible for the visual monitoring of a resident. An interview was conducted with a 7:00 AM to 3:00 PM CNA #1 on 5/23/13 at 12:53 PM. CNA #1 stated that she knows the resident because Resident #1 seems to escape a lot. On 5/4/13 CNA #1 did not see the resident until after the resident was brought in from outside. CNA #1 stated that she doesn ' t usually have to start checking on residents until after 7:30 AM. She thinks the 11:00 PM to 7:00 AM shift is supposed to do the visual monitoring before then. On 5/23/13 at 1:38 PM while on tour with the Risk Manager the front desk of the south building was observed to be unoccupied. There were no staff members in the vicinity and the Risk Manager did not have an explanation as to the whereabouts of the Security Guard. An interview was conducted with the Registered Nurse Unit Manager (RNUM) on 5/23/13 at 1:57 PM. The RNUM stated that she was not on duty at the time of the resident's elopement but Resident #1 was an elopement risk from the time of her admission in January 2013. The resident has always refused a wander guard despite many efforts to disguise and place a wander guard on the resident. After being able to leave the unit many times, the resident was started on 15 minute visual checks and other than the 5/4/13 elopement, the RNUM does not think the resident ever got off the unit again since March 2013. The RNUM stated that any resident who is at risk for elopement is automatically on 30 minute visual monitoring but there are particular residents who have 15 minute monitoring. The 11:00 PM to 7:00 AM CNAs would be responsible for the last visual check of a resident at 7:00 AM and the oncoming 7:00 AM to 3:00 PM shift would take responsibility starting at 7:15 AM. The RNUM is not aware of any problems with visual monitoring. An interview was conducted with the assigned 7:00 AM to 3:00 PM CNA #2 on 5/23/13 at 2:11 PM. CNA #2 stated that when she came on duty on 5/4/13, she was not yet assigned to Resident #1 because no assignments are given until after the nurse is able to give CNAs morning report. CNA #2 stated that morning report usually happens by 7:30 AM but it was much later on 5/4/13 because there was not enough staff on the unit. CNA #2 stated that, at 7:00 AM on 5/4/13, she made rounds and saw the resident in bed and a few minutes later in the dining room. CNA #2 stated that she was not visually monitoring the resident because assignments were not yet made and the 7:00 AM to 3:00 PM CNAs would not be responsible to begin monitoring until after 7:30 AM anyway. CNA #2 stated that she has never actually seen the resident get off the unit "but somehow she's able to do it a lot." An interview was conducted with the 11:00 PM to 7:00 AM Registered Nurse (RN) on 5/23/13 at 2:31 PM. The RN stated that he last recalls seeing Resident #1 in bed around 5:15 AM when he administered a nebulizer treatment and blood sugar finger stick to the resident. The RN stated that he was sitting at the nursing desk for a long time after 7:00 AM finalizing paperwork but he did not ever see the resident pass by the desk. The resident has been found in different areas of the building and presumably has been able to get off the unit because she does not have a wander guard. The RN stated that the resident has been on 15 minute checks for the past month but, prior to this, there were no specific monitoring instructions for the resident. At the start of his shift, CNA assignments to monitor a resident do not begin until 11:30 PM and end at 7:00 AM. The RN was unable to state who is responsible for monitoring a resident between 11:00 PM and 11:30 PM that is on 15 minute visual checks. An interview was conducted with the Security Guard after being observed with his head down behind the desk on 5/23/13 at 3:42 PM. The Security Guard stated that he is supposed to be watching for any resident or visitor who comes into or goes out of the facility. He does not get official breaks but leaves the desk from time to time for a few minutes without getting a replacement. An interview was conducted with the assigned 11:00 PM to 7:00 AM CNA #3 on 5/24/13 at 10:19 AM. CNA #3 stated that he last saw Resident #1 around 6:45 AM when he went in to the bedroom to assist another resident; Resident #1 was in bed. CNA #3 drew the curtain to assist the other resident and does not know when or if Resident #1 passed by. CNA #3 stated that the 7:00 AM to 3:00 PM nursing shift should start doing visual checks at 7:00 AM and the last time CNA #3 is required to visually check a resident is at 6:45 AM. CNA #3 stated that most times there is no CNA assigned at the start of the 7:00 AM to 3:00 PM shift, so CNA #3 will initial the visual monitoring sheet for the 7:00 AM check; Resident #1 needs to be initialed twice because she is on 15 minute checks. CNA #3 stated that he initialed the resident's 15 minute check for 7:15 AM on 5/4/13. An interview was conducted with an 11:00 PM to 7:00 AM CNA #4 on 5/24/13 at 10:39 AM. CNA #4 stated that she was sitting in her car about 7:11 AM and saw Resident #1 crossing the street. CNA #4 did not know Resident #1 but presumed it was a resident and jumped out of her car at the same time as CNA #6 did the same. Both CNAs escorted the resident back into the building and CNA #6 brought the resident to her unit. CNA #4 stated that she does not work on the resident's unit but has been assigned to visually monitor residents on visual checks.The 11:00 PM to 7:00 AM staff has to sign for residents at 7:00 AM and then the next shift takes over. However, when CNA #4 begins her shift at 11:00 PM she does not have to start visual checks until 11:30 PM. CNA #4 stated that "there's a gap during that time (11:00 PM to 11:30 PM) and everyone is responsible for the residents." An interview was conducted with a 7:00 AM to 3:00 PM CNA #5 on 5/24/13 at 11:21 AM. CNA #5 stated that she floats to different units and when she comes on duty, she usually does not have an assignment for the first half hour. She knows Resident #1 but did not see the resident on the morning of 5/4/13 when she worked on unit 2 South. Resident #1 is known to a lot of staff "because she gets found everywhere except her unit." An interview was conducted with an 11:00 PM to 7:00 AM CNA #6 on 5/24/13 at 11:46 AM. CNA #6 stated that she was waiting for her car to warm up and saw Resident #1 in the middle of the street; CNA #6 ran to get the resident. Another CNA #4 came running for the resident as well. CNA #6 stated that she does not work on the resident's unit but knows Resident #1 because "she ends up on 1 South all the time." CNA #6 brought the resident back to her unit and informed LPN #1 where she found the resident. CNA #6 stated that, when she brought the resident back into the building, the Security Guard at the desk was asking CNA #6 questions, asking if Resident #1 was a resident. She (CNA #6) ignored the Security Guard "because they're useless." CNA #6 stated that, when she starts her shift at 11:00 PM, she would not have to begin monitoring residents until 11:30 PM, "so when I leave I only sign for resident at 7:00 AM. I don't know what happens after that but they (7:00 AM to 3:00 PM staff) probably don't start monitoring until 7:30 AM." An interview was conducted the Licensed Master Social Worker (LMSW) on 5/24/13 at 12:47 PM. The LMSW stated that a SCREEN (an assessment tool for possible mental illness) is done by the hospital before a resident is admitted to the facility and not done again at the facility. The LMSW stated that, if a resident has a mental illness, social work is not necessarily involved unless the mental illness manifests into a behavior. The particular resident would be followed by Psychiatry, but "I don't know off hand if she (Resident #1) has ever been seen by a psychiatrist." The LMSW stated that her part in Resident #1's plan of care for elopement has been to reach out to the family in order to have the family reinforce the facility's policy on elopement and not leaving the unit. The LMSW was unable to answer any further questions about the resident ' s ability to follow instructions and, when asked whether or not reinforcement of policy was an effective intervention, the LMSW stated, " Sometimes. " During a subsequent interview with the RNUM on 5/24/13 at 1:11 PM, the RNUM stated that Resident #1 was assessed on admission to be at risk for elopement and should have been reassessed at least quarterly. The resident was not assessed again because "I've been behind." If a resident comes into the facility on psychiatric medication, the resident must be seen by the psychiatrist. The RNUM stated that she was not aware that Resident #1 was not seen by Psychiatry until 4/7/13. An interview was conducted with the Psychiatrist on 5/24/13 at 1:50 PM. The Psychiatrist stated that he was aware of an initial consultation ordered for Resident #1 on 1/11/13 but was waiting for family availability to be present; the resident was not seen until 4/7/13 and has not been seen again. The Psychiatrist stated that the resident "cannot make any decisions for herself. She's (Resident #1) quite disorganized in thought. She has very limited understanding. You cannot instruct her (Resident #1) what to do." An interview was conducted with the 7:00 AM to 3:00 PM Registered Nurse Supervisor (RNS) on 5/28/13 at 11:11 AM. The RNS stated that LPN #1 called her around 7:30 AM on 5/4/13 and said Resident #1 was just brought back to the unit after being found outside in the road. The RNS did not know how or when the resident had left the facility. The RNS stated, "We were short on staff, so I kept doing staffing and said I would be up (to assess the resident) when I'm done." The RNS stated that she went to assess the resident between 8:45 AM and 9:00 AM; there were no injuries. The RNS stated that she thinks the resident was on 30 minute checks but is not sure. She further stated that she is not aware of any previous attempts by Resident #1 to get off the unit or elope from the facility. An interview was conducted with the Director of Rehabilitation (DR) on 5/28/13 at 11:51 AM. The DR stated that Resident #1 is physically independent without an assistive device but needs constant supervision cognitively. An interview was conducted with the Director of Maintenance (DM) on 5/28/13 at 12:02 PM. The DM stated that the second and third floor exits and elevators are wander guard alarmed. The facility is going to begin work on installing pass-code keypads on the elevators but this has not yet been done. The DM further stated that "mechanically, it is harder and harder to keep residents in the building. We (staff) have to do a better job at watching them. It comes down to that." An interview was conducted with the Risk Manager (RM) on 5/28/13 at 12:22 PM. The RM stated that she knows Resident #1 was found a few times in different parts of the facility but incident investigations were not done. The RM stated that an occurrence such as a resident getting off the secure unit "should be discussed in morning meeting the next day to formulate a plan." The RM could not say whether or not this was ever done with regard to Resident #1. An interview was conducted with the In-Service Coordinator (ISC) on 5/28/13 at 1:33 PM. The ISC stated that each day during morning report any incident involving a resident is discussed with all department heads. Resident #1 was discussed after the 5/4/13 elopement but the ISC does not recall ever discussing Resident #1's behaviors prior to this elopement. The ISC stated that she does not know whether or not security guards were re-inserviced on elopement prevention after Resident #1's elopement on 5/4/13. The ISC further stated that all other staff were not re-inserviced on elopement prevention because the annual in-service on elopement prevention is not due until June 2013. An interview was conducted with the Director of Nursing (DON) on 5/28/13 at 2:06 PM. The DON stated that, prior to 5/4/13, Resident #1 did not get off the secure unit since March 2013. She was not aware that Resident #1 had eloped on 5/4/13 until after 9:00 AM and does not know when the resident was physically assessed but should have been physically assessed immediately after being returned to the unit. All residents should be assessed for elopement quarterly at a minimum. The DON also stated that, other than the issue of the security guard inattentiveness at the front desk, there were no other concerns identified regarding Resident #1's elopement. There is a "gray area" at the change of shift and there is no one staff specifically responsible for observing a resident; "Just because you (staff) come on shift doesn't mean you have an assignment." An interview was conducted with the Attending Physician (AP) on 5/28/13 at 5:24 PM. The AP stated that Resident #1 has ongoing psychiatric issues but she does not know to what extent. The AP stated that she is not aware of whether or not the resident has ever been seen by Psychiatry but Resident #1 "should have a comprehensive psychiatric follow-up due to this incident (elopement)." "Staff need to be much more stringent in providing supervision with her (Resident #1)." An interview was conducted with the Medical Director (MD) on 5/29/13 at 10:38 AM. The MD stated that he does not draft policies but approves them. The MD has had multiple discussions with Administration regarding Resident #1's elopement behavior but does not recall any specifics.He is not aware of any changes in policy in relation to Resident #1's elopement. An interview was conducted with the Administrator on 5/29/13 at 11:07 AM. The Administrator stated that she was immediately advised by the RNS of Resident #1's elopement on 5/4/13. The Administrator advised the RNS to place the resident on a one to one supervision; this was not done. An investigation was started and it was concluded that the Security Guard failed to stop the resident from exiting the building. Pass-code key pads were explored for securing the elevators but have not yet been fully installed. The Administrator further stated that she is not aware of any other concerns with regard to Resident #1's elopement. 415.12 (h) (1) (2)

Based on record review and staff and family interviews during the Post Survey Revisit (PSR) #1, the facility did not ensure that one of eighteen residents reviewed for timely and accurate assessments received timely medical services to address a change in condition. The facility did not follow their directed Plan of Correction (POC), which included a complete and thorough Registered Nurse (RN) assessment for vomiting; including to assess for the last bowel movement, check for impaction, bowel sounds, and assessment of amount. Specifically, Resident # 4, with [DIAGNOSES REDACTED]. The facility did not have a complete Registered Nurse (RN) assessment, did not notify the Physician timely, and did not send the resident for further assessment in a timely manner. The resident expired nine hours after the vomiting episode occurred. This resulted in actual harm that is not immediate jeopardy. The finding is: Resident #4, who was a [AGE] years old male, had [DIAGNOSES REDACTED]. The most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had both short and long term memory impairment and had severely impaired daily decision making skills. The resident required total assistance of two people for bed mobility. The resident required extensive assistance of one person for eating. The most recent physician's orders [REDACTED]. The LPS was originally ordered [DATE] and both Glucerna and 2 Cal HN were originally ordered [DATE]. Review of the Medication Administration Record [REDACTED]. The resident received 2 Cal HN on [DATE] at 9 AM and 5 PM. A Licensed Practical Nurse (LPN #1) nurse's note dated [DATE] at 5:10 AM documented that Resident # 4 had one episode of emesis, chocolate supplement consistency. No complaint of nausea after first incident. Vital signs were Blood Pressure ,[DATE], Pulse Rate 80, Oxygen Saturation rate was 92% on room air. Respiratory rate was 18 respirations per minute and the resident's temperature was 98.0 degrees orally. The nurse documented to continue to monitor. A note written [DATE] at 5:53 AM by a Respiratory Therapist #1 documented that at 5:45 AM the Respiratory Therapist was called to assess the resident due to vomiting coffee brown secretions. The resident was placed on 3 Liters of Oxygen via Nasal Cannula and the SpO2 was 93%. The Respiratory Therapist documented that the resident will continue to be monitored. A RN Supervisors nurse's note (RN #1) dated [DATE] at 1:06 PM documented that the resident was alert and responsive to stimuli. The resident refused breakfast and lunch. No further vomitus was noted. The Physician was notified and the Physician ordered [MEDICATION NAME] 300 mg x 1 now and [MEDICATION NAME] 150 mg by mouth BID. The resident's vital signs were as follows: Blood Pressure ,[DATE], Temperature 97.4 degrees, Pulse Rate 134, Respiratory Rate 16 respirations per minute, and SPO2 98%. The nurse documented that the resident would continue to be monitored. There was no documented evidence of a comprehensive Gastro-intestinal assessment or an abdominal assessment. Additionally, there was no documented evidence that the resident's pulse rate was further monitored and/or reported to the physician. A physician's orders [REDACTED]. The MAR indicated [REDACTED]. A Respiratory Therapist #2 note dated [DATE] at 3:14 PM documented that they responded to a STAT call at 2:45 PM. The resident (#4) was unresponsive, vomiting coffee brown colored secretions. The resident was suctioned orally for large amount of blood. No vital signs were present. The resident was a Do Not Resuscitate (DNR). The resident expired at 3 PM. A RN Supervisors nurse's note (RN # 1) dated [DATE] at 3:35 PM documented that at 2:45 PM the resident was noted with respiratory distress. At 2:46 PM a STAT was called. Oxygen was given via an Ambubag. The nurse was able to obtain a thready pulse. The BP was unable to be obtained. The Physician was notified. At 2:50 PM 911 was called. At 2:55 PM the nurse was unable to obtain the resident's pulse, BP, or respirations. 911 was cancelled. The physician was notified. Family information was given to the Physician. A RN Supervisor nurse's (RN #1) note dated [DATE] at 5:50 PM documented an addendum to the previous note. At 8:00 AM the resident was alert and oriented x 3. The resident was noted resting in bed in no distress. The resident was monitored during the shift. At 1:00 PM the resident was resting in bed stating that he feels all right. Despite refusing all meals. No distress was noted. Resident stating to the nurse that he does not want to go to the hospital. The resident's wife visited the husband and was asked by wife did he want to go to the hospital. The resident reiterated that he did not want to go to the hospital. Monitoring continued. Approximately 2:45 PM, called to room, the resident was noted with a moderate amount of blood coming out of his nostrils and mouth, then STAT proceeding began. The resident was a DNR. A RN Supervisor nurse's (RN #1) note dated [DATE] at 6:55 PM documented an addendum that the resident was pronounced (deceased ) by 2 Registered Nurses (RN) at 2:55 PM. A RN nurse's (RN #2) note dated [DATE] at 12:47 AM, written by the 11 PM-7 AM RN Supervisor, documented a late entry. At 5:45 AM (on [DATE]) the RN Supervisor was called by the nurse in charge that the resident had vomited. When the resident was checked the resident was observed in bed on a high Fowlers position, alert and oriented x 3. No distress was noted. The resident was noted with dark yellow emesis on the sheet, small in amount. The resident's BP was ,[DATE], Pulse was 89, respiratory rate was 18 and O2 saturation rate was 94%. No further emesis was noted. The resident was endorsed (to the following shift). There is no documented evidence of a comprehensive GI or abdominal assessment conducted on this resident. Review of the facility's investigation revealed the following statements: 1) A statement from the 11 PM-7 AM shift LPN #1. The LPN documented "Sometime past 5:00 AM resident vomited medium amount on the right side of bed and had spit out remaining vomit in mouth, vomit on sheet found in sprinkled form, color of vomit dark yellow-brown chocolate. .....vitals BP ,[DATE], P (pulse)= 89, R (respirations)= 18 per/min, O2= 94 saturation." 2) A statement by the 11 PM-7 AM charge nurse. The charge nurse documented "[DATE] around 5:45 AM resident was on distress on 4N called by (nurse in charge). The resident was vomited with coffee brown secretions. Resident was placed on nasal cannula 2 L. spo(?) ,[DATE]%, RR ,[DATE], resident was alert and oriented". 3) A statement by the 11 PM-7 AM RN Supervisor #2. The supervisor documented "....At around 5:45 AM, charge nurse called and informed me that the resident vomited. I immediately went to 4 North to check and observed the resident. He's in bed on a high Fowler's position. Resident was alert. oriented X 3. No distress noted. Noted with dark, yellow-colored emesis (scattered) on the sheet, small in amount. I asked the resident. how is he doing?, he answered, "I'm doing fine". Vital signs: BP ,[DATE], P 89, R 18, O2 Sat 94%. No further emesis was observed until end of shift and it was endorsed to the morning shift (,[DATE])". 4) A statement from the 7 AM-3 PM shift LPN #2. The LPN was documenting a statement for the incident that occurred on [DATE]. The LPN wrote "...I later checked on him (Resident #4) before lunchtime. resident appears pale in complexion and looked uncomfortable as if in pain. vital signs taken again BP (up symbol) (which indicates elevation in the blood pressure reading) HR (up symbol) (which indicates elevation in the heart rate)(elevated BP and Heart Rate are indicators of bleeding). charge nurse notified, MD called.....". 5) A statement from the Attending Physician. The statement documented "On [DATE] around 1 PM I received a call from a nurse who reported that the resident had vomiting with "chocolate like material" earlier that day at 5:45 AM. ...Due to the fact that resident was reported to be stable with normal BP and pulses I decided to treat him in-patient and ordered po [MEDICATION NAME]." The conclusion to the facility investigation was documented as "Whereas the resident was stable--as evidenced by normal vital signs and level of consciousness with no GI complaints present with the exception of him vomiting a small amount of chocolate colored material which is believed that he vomited the chocolate supplement found at his bedside. The resident showed no distress, showed no signs of bleeding at that time. Later that day the resident became unstable and vomited blood. He was in the process of being transferred out 911 when he expired. It is believed that the nurses followed the correct path with this resident. Under normal situations a call would not be made to the physician for vomiting one time of supplement. As per Gastrointestinal Care Path (interact) the nurses acted appropriately." An interview was held on [DATE] at 1:30 PM with the RN Supervisor (RN#1) that wrote the [DATE] nurse's notes at 1:06 PM, 3:35 PM, 5:50 PM and 6:55 PM. The RN stated that she was informed by the 11 PM-7 AM shift RN Supervisor that the resident had vomited once on the 11 PM-7 AM shift. The RN stated that she was not aware if the physician was called by the 11 PM -7 AM RN Supervisor. The RN stated that she checked on the resident during the 7 AM - 3 PM shift and that the resident had not eaten his breakfast or lunch. The RN stated that she called the physician around 1:00 PM because the resident was not eating and to report that the resident had vomited earlier that day, a coffee brown emesis, in the early AM . The RN stated that the physician ordered [MEDICATION NAME]. The RN stated that the vomitus was reported to her as coffee brown colored, not coffee ground. The RN stated that the resident's wife visits daily and that the resident's wife did not want the resident sent out to the hospital due to the flu epidemic. An interview was held with the Physician on [DATE] at 1:57 PM. The Physician stated that he was contacted for the first time on [DATE] at approximately noon or 1 PM. The Physician stated that the RN reported that the resident had not eaten his breakfast and lunch and that the resident had vomited earlier in the AM. The Physician stated that the RN reported to him that the resident was stable and in no distress. The Physician stated that he ordered [MEDICATION NAME] for the resident and to observe him closely. The Physician stated that he starts his day at approximately 5:30 AM and that the first time the facility called him about the resident was close to noon. The Physician stated that the resident had a massive bleed here at the facility. The Physician stated that usually he receives calls for minor problems, including low [MEDICATION NAME] levels, and that no messages were left on his voicemail regarding the resident's earlier vomiting. The physician stated that the nursing staff probably should have reported the coffee brown emesis, that the staff probably did not think it was a problem. The Physician further stated that this was abnormal for the resident and that this was the first vomiting episode that the resident had. An interview was held with the Director of Nursing Services (DNS) on [DATE] at 2:15 PM. The DNS stated that the night supervisor reported a yellowish color of vomit and that a can of chocolate supplement was found next to the resident's bed. The DNS stated that the facility started an investigation into the resident's death because the resident's death was unexpected and that the Medical Examiner was not called. The resident had vomited bright red blood. The DNS stated that the Physician was called later in the day, around 1:00 PM and was informed at that time about the resident's earlier vomiting episode. The physician ordered [MEDICATION NAME] for the resident. The DNS stated that the resident's vomit was coffee brown color and that a can of supplement was seen at the resident's bedside. The DNS stated that the vomit was not described as coffee ground. The DNS further stated that she would not expect the nurse to call the physician for one vomiting episode. The DNS stated that if the emesis was coffee ground she would expect the nurse to call the physician but not if the emesis was coffee brown. The RN Supervisor (RN#2) from the 11 PM - 7 AM shift who documented the [DATE] nurse's note at 12:47 AM, was not available for interview. The 7 PM - 7 AM Respiratory Therapist #1 who documented the [DATE] note at 5:53 AM, was not available for interview. The deceased Resident #4' s wife was interviewed on [DATE] at 3:40 PM by phone and stated she was present in the facility on [DATE] at approximately 1:00 PM. She stated at that time, she visited her husband and observed dark, coffee brown colored emesis on the curtains. When she inquired- it was reported to her that he had vomited earlier that morning. She stated that the facility should have called her with this condition because he had a history of [REDACTED]. "Had they called me when he vomited, I would have been near my husband earlier that day". She asked staff what he drank, they reported- vanilla shake (contrary to what was documented in the record). She does not recall observing any shakes near her husband's bedside that day. She stated that a nursing assistant spoke to her and advised her to send her husband to the hospital because he did not look good. She was unable to recall the name of the nurse assistant. She reported that neither the doctors nor the nurses discussed hospitalization with her (contrary to what was documented in the medical record). The wife reported that her husband had [MEDICAL CONDITION] and was unable to make decisions for himself and nodded "no" to everything and could not understand why the facility would ask her husband about hospitalization . She observed her husband having abdominal pain that afternoon and could not understand why the facility failed to transfer her husband to the hospital prior to his death. An interview was held on [DATE] at 3:54 PM concurrently with the facility Administrator, DNS and Consultant. The DNS stated that the facility had started an investigation into the resident ' s death and that statements were obtained from the staff involved in the resident ' s care surrounding the resident ' s death. The DNS stated that the RN Supervisor followed the Care Path for GI Symptoms. The resident was stable the whole day. A can of chocolate supplement was found at the resident ' s bedside when the resident vomited in the early AM. The resident ' s vital signs were stable at the time of the resident ' s vomiting. The DNS stated that coffee colored emesis is not the same as coffee ground emesis and that the care pathway does not include calling the physician if one episode of vomiting is observed. Review of the facility ' s investigation revealed that no statements were obtained from either of the Respiratory Therapists involved in caring for the resident on [DATE], nor the Certified Nursing Assistants caring for the resident. Additionally, there was no statement from the nurse who had last administered the supplements to the resident. Review of the Care Path for GI symptoms documented that if nausea and/or vomiting occur take the resident ' s vital signs. If the Vital signs criteria is met then call the physician. If the vital sign criteria are not met then further nursing evaluation, including but not limited to: evaluating the abdomen for tenderness or distention, absent or hyperactive bowel sounds, jaundice, blood in stool or vomitus, should be performed. Review of the nurse's notes from the first time the resident vomited at 5:10 AM on [DATE] until the time the resident expired at 2:55 PM revealed no documented evidence that the resident ' s abdomen was comprehensively assessed for pain, tenderness, or bowel sounds, nor that the resident ' s bowel records were reviewed. There was no documented RN assessment by the 11 PM - 7 AM RN Supervisor who was informed that the resident had vomited on [DATE] at 5:10 AM. There was an incomplete assessment documented on the following day at [DATE] at 12:47 AM. There was no documented evidence that a comprehensive assessment was performed by the 7 AM - 3 PM RN Supervisor of the resident ' s abdomen for bowel sounds, tenderness or pain. Additionally, there is no documented evidence that the physician was made aware of the resident's Pulse Rate of 134 as documented in the 1:06 PM RN note. A copy of the twenty-four hour reports for [DATE] and [DATE] were requested. Neither the [DATE] or [DATE] twenty four hour report was provided to the survey team. The Directed Plan of Correction , in which the facility asserts they will be 100% in full compliance by [DATE], documented that a complete and thorough RN assessment would be completed for nausea/vomiting /profuse diarrhea. The Directed POC, Section VI. B 5., documented that an assessment of the resident's last bowel movement, checking for impaction and listening to the resident's bowel sounds were to be performed. There is no documented evidence that the 11 PM - 7 AM or the 7 AM - 3 PM RN Supervisors assessed the resident thoroughly. Additionally, the Directed POC, Section VIII -Notification of Change in condition, Part B. documented the Physician should be notified by the RN with an assessment of the resident's condition. 415.12

Based on electronic record review, staff interviews and observations during the recertification survey, the facility did not ensure that the necessary and timely care and services were provided to promote the highest practicable, physical, mental, and psychosocial well being. This was evident for 4 out of sample residents reviewed for timely hospital discharge. Specifically, 1) Resident #489 had abnormal Chest X-rays, EKG and Respiratory instability without documentation supporting not being transferred to the hospital. 2) Resident #488 with abnormal blood work and Rectal Bleeding had no documentation supporting the benefit of not being transferred to the hospital. 3) Resident # 443, admitted to the facility for Short Term Rehabilitation and had a progressive, continuous decline in the resident's general condition without documented evidence that all services were provided as ordered by the Physician. In addition, diagnostic interventions were not carried out, to ensure that the resident would reach optimal improvement and avoid the decline. 4) Resident #386 a [MEDICAL TREATMENT] resident with abnormal blood work had no documentation supporting the benefit of not being transferred to the hospital. 5) Resident #281 with abnormal blood work had no documentation supporting the benefit of not being transferred to the hospital for blood transfusion. Additionally, for one of 3 residents reviewed for Urinary Incontinence in a total sample of 42 residents, This resulted in actual harm for Residents #489, Resident #488 and Resident #443, and no actual harm with potential for more than minimal harm for Residents #386 and #28, that is not immediate jeopardy. The findings include but are not limited to: 1) Resident #489 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had no advance directives implemented. The Electronic Medical Admission assessment dated [DATE] documented that the resident was alert and oriented x (times) 3 (to person, place, and time). Blood Pressure (BP) was 130/85, Heart Rate (HR) 80 and Respirations 16. The residents lungs were noted to be clear. Electronic Progress Notes (EPN's) dated 10/27/12 through 11/2/12 were reviewed. On 10/27/12 at 11:36 PM, a EPN documented that the resident's Oxygen (O2) Saturation sats (measurement of the percentage of hemoglobin binding sites in the bloodstream occupied by oxygen) on 5 liters of oxygen /LPM was between 88%-90% (normal range is equal to or greater than 92%). The resident was placed on a simple mask at 8 liters. The Physician was made aware and [MEDICATION NAME] (diuretic) 80 milligrams (mg) Intramuscularly (IM) was ordered along with a Chest X-ray. Chest X-ray report dated 10/28/12 documented that the resident had no infiltrates with a [DIAGNOSES REDACTED]. EPN dated 10/31/12 at 11:11 AM documented that the resident was noted with O2 sat of 88-91%. The resident was attended to by the Respiratory Therapist (RT) and a non rebreather mask was applied. The resident was coughing with congestion. The residents BP was 80/50 and heart rate was 145. The Medical Director was notified, and a telephone order was given to administer Intravenous (IV) fluids and a STAT (immediate) Chest X-ray was ordered . RT EPN dated 10/31/12 at 11:47 AM documented that the resident was seen at the bedside. "Unable to obtain O2 sat secondary to cold extremities and low blood pressure." On non rebreathing mask @ 10 LPM via concentrator, O2 sat fluctuating from 89-94%, HR 115-120's, lungs clear and diminished. Chest X-ray report dated 10/31/12 documented "slightly worsened [MEDICAL CONDITIONS] from the prior study of 10/28/12. Underlying right lung base infiltrate cannot be excluded." EKG dated 10/31/12 documented [MEDICAL CONDITION] Fibrillation with Rapid Ventricular Response- Premature Ventricular Contractions-changes may also partly be due to rhythm-Non Specific ST Segment -T Wave Abnormality early transition The RT EPN dated 10/31/12 at 11:47 AM documented that the resident was seen at the bedside. "Unable to obtain O2 saturation secondary to cold extremities and low blood pressure." On non rebreathing mask @ 10/LPM via concentrator. Physician note dated 10/31/12 at 7:50 PM documented that the resident was seen due to complaints of shortness of breath at rest. BP was 90/60 HR 98. Bilateral rales were noted over lungs The Physician documented to transfer the resident to the hospital ER in a few hours if no improvement was noted. Medical EPN at 3:00 PM on 11/1/12 documented that nursing requested the resident to be evaluated due to low pulse ox of 91% on 10 LPM. Resident stated that he felt lethargic BP 92/66. A Follow-up Chest X-ray report dated 11/01/12 documented [MEDICAL CONDITION] increased since study dated 10/31/12. PN dated 11/1/12 at 10:43 PM documented that the resident was maintained on O2 at 10/LPM via venti mask @50%. The resident's BP was 105/70, HR was 120-130. PT PN dated 11/2/12 documented that the resident was found in respiratory distress at 9:15 AM. O2 sat was 87% on 50% venti mask. The resident's HR was 95-126, respirations were 8 and labored. PN dated 11/2/12 at 9:50 AM documented that the resident was transferred to the hospital for respiratory distress. EPN documented that the resident was pronounced dead at 11:00 PM on 11/2/12. There was no documentation in the EMR that the benefits of keeping the resident in the facility instead of transferring to the hospital had been discussed with the resident and or family. On 11/19/12 at 9:45 AM the Director of Nursing Services (DNS) was interviewed. The DNS stated that before a resident is transferred to the hospital the Registered Nurse (RN) Supervisor is involved. The RN Supervisor will assess the resident, call the attending, and then call the DNS. The DNS is then responsible to call the Medical Director before a resident is transferred to the hospital. On 11/19/12 at 11:05 AM the Administrator was interviewed. The Administrator stated that he was aware that the Medical Director and DNS were to be notified before a resident was transferred to the hospital. The Administrator further stated that he was aware of the Medical Director overriding physician's orders [REDACTED]. The Administrator also stated that the goal is to provide as many services in the facility as possible. On 11/19/12 at 12:10 PM the 3:00 PM-11:00 PM Registered Nurse (RN) Supervisor was interviewed. The RN stated that before a resident is transferred to the hospital except in emergency situations the attending physician and DNS must be first notified. On 11/19/12 at 2:00 PM the Medical Director was interviewed. The Medical Director stated that hospitals are not friendly. Residents are likely to develop Pressure Ulcers, lose weight and develop [MEDICAL CONDITION]. The Medical Director further explained that the facility has geared up with greater capacity, to care for residents in the facility. The facility is providing an alternative venue to the emergency room . The Medical Director further stated that he did not feel there was any delay in transferring the resident to the hospital. 2) Resident #488 is [AGE] years old and had [DIAGNOSES REDACTED]. MDS dated [DATE] documented that the residents cognition was severely impaired. The resident was receiving [MEDICATION NAME] (anticoagulant) 3.5 mg daily for [DIAGNOSES REDACTED]. [MEDICATION NAME] Time (PT) is a blood test to monitor the response to anticoagulant therapy. In a resident receiving anticoagulants PT is usually maintained between one and a half and two times the normal control value. International Normalized Ratio (INR) used to adjust a residents drug dosage to get the PT into the desired range that is right for the resident. Current lab data documented the following: 10/1/12 PT 26.9 range (9.8 -11.9) INR 2.6 range (1.0-2.0) 10/8/12 PT 27.1 range (9.8 -11.9) INR 2.6 range (1.0-2.0) On 10/8/12 10:35 PM according to the Electronic Medical Record (EMR) a stat (immediate) Complete Blood Count (CBC) was ordered at 10:35 PM and phoned into the lab. EPNs (Electronic Progress Notes) dated 9/24/12 through 10/10/12 were reviewed for this resident. The EPN dated 10/9/12 at 1:14 AM documented that the day shift (10/8/12) reported that the resident was bleeding a large amount of blood from the rectum. At 9:00 PM this evening 10/8/12, the Certified Nursing Assistant (CNA) noted a large amount of rectal blood while the resident was being changed. The attending physician was notified, the nursing supervisor was made aware, and then the Medical Director was notified by the supervisor. The BP was 65/45, Heart Rate (HR) was 118. The Medical Director ordered Vitamin K (used for blood clotting) 10 mg IM, IV fluids were started and a stat (immediate) Complete Blood Count (CBC) was ordered. At 11:15 PM the BP was 80/45, HR 65. At 11:40 PM the resident was noted to have another episode of large rectal bleeding. According to the EPN a follow up call was placed to the lab for the stat CBC. EPN dated 10/9/12 6:47 AM, documented that the resident was noted with a small amount of bleeding from rectal area . The Physician was made aware. There were no new orders at this time. According to the Laboratory (lab) report, the CBC was first drawn on 10/9/12 as part of the routine blood collection and the specimen was received at the lab at 12:04 PM. This was a 14 hours after the CBC had been ordered. According to the lab report the CBC results were reported to the 3:00 PM-11:00 PM RN supervisor on 10/9/12 at 7:26 PM. The results were Hemoglobin (Hgb) 5.9 (reference range 11.8-16.4) and Hematocrit (Hct) 19 (reference range 37-47). The EPN dated 10/10/12 and written at 4:55 AM documented that the attending physician had been notified of the Hgb 5.9 and Hct 19 at 9:00 PM on 10/9/12. At that time the attending physician ordered to transfer the resident to the hospital for 3 units of blood. The RN supervisor was made aware of the attending physician's orders [REDACTED]. The nursing supervisor notified the DNS of the impending transfer. The next EPN for this resident was documented on 10/10/12 at 3:24 PM. The EPN documented that the resident was scheduled tomorrow 10/11/12 for transfer to the hospital for 3 units of blood. EPN dated 10/11/12 at 9:29 AM documented that the resident was transferred to the hospital for blood transfusion. The EPN further documented that the resident was admitted to the hospital with [REDACTED]. EPN dated 10/19/12 documented readmission to the facility. Two Hospital Consultation Reports dated 10/11/12 documented the reason for consults as Fever and Gastrointestinal (GI) Bleeding. The GI consult documented that the resident had been transferred from the nursing home after she was found to be profoundly Anemic with Hgb of 4. 4 and Hct of 13.6. On 11/19/12 at 12:00 PM the facility Laboratory staff was interviewed. During the interview with the lab, they stated that the CBC had not been ordered as a STAT on 10/8/12. On 11/19/12 at 2:00 PM the Medical Director was interviewed. The Medical Director stated that it was more beneficial to the resident to schedule in advance for blood [MEDICAL CONDITION] rather than admitting them through the emergency room (ER). This way the resident receives the blood transfusion and is then sent right back to the facility. The Medical Director also stated that there was no necessity to transfer the resident any sooner to the hospital. On 11/20/12 at 11:30 AM the attending physician was interviewed. The physician stated that he had spoken with the Medical Director regarding the residents transfer to the hospital on [DATE]. The physician stated that the Medical Director spoke with him about the Medical Director scheduling a blood transfusion prior to the transfer of the resident. The physician stated that he was ok waiting for the arrangements for the transfusion to be made prior to the transfer. 3) Resident # 443 was admitted to the facility for Short Term Rehabilitation from an acute care hospital on [DATE] with a [DIAGNOSES REDACTED]. The Admission MDS assessment dated [DATE] documented that the resident had a Basic Interview for Mental Status (BIMS) Score of 15, cognitively intact. The MDS documented that the resident indicated no Mood Symptoms on interview. In addition, the MDS documented that there were no indicators of [MEDICAL CONDITION] and no presence of Behavior Symptoms. The MDS documented that the resident was able to participate in all Activities of Daily with staff assistance. The MDS further documented that the resident was continent of bowl and bladder. There were no other health conditions documented on the MDS. The MDS also documented that the resident expected to return to the community. EPN dated 9/10/12 through 9/19/12 documented that the resident was exhibiting increased confusion with a decrease in appetite. The EPN dated 9/19//12 documented that the resident was depressed and not eating. A Urinalysis (UA) with Culture and Sensitivity (C&S) and Blood Analysis for a Complete Blood Count (CBC) and a Complete Metabolic Profile (CMP) was ordered by the Physician on 9/17/12. There were no laboratory results documented for the UA/C&S in the medical record. During an interview with the a laboratory staff member on 11/19/12 at 10:00 AM, the laboratory staff member stated that the specimen for UA/C&S had not been sent to the lab for analysis. A physician's orders [REDACTED]. On 9/22/12 the physician's orders [REDACTED]. The physician's orders [REDACTED]. The physician's orders [REDACTED]. The Neurology Consult had not been completed as of 11/20/12. There was no documented evidence in the medical record that the Neurologist's office had been notified of the consultation order. A physician's orders [REDACTED]. The resident was also placed on [MEDICATION NAME] (blood thinner) 90 mg subcutaneously every twelve hours for [MEDICAL CONDITION]. On 9/19/12 a physician's orders [REDACTED]. The Psychiatry Consultant examined the resident on 9/21/12, made a recommendation for anti depressive medication to address the resident ' s depressive symptoms and the Neurology Consult. Lab Results dated 9/22/12 documented that the resident had a Red Blood Cell (RBC) Count of 3.88 (Normal (N) 4.20-5.40), Hemoglobin (HGB) of 10.5 ((N 11.8-16.1) and a Hematocrit (HCT) of 32 (N 37-47). A physician's orders [REDACTED]. This was also confirmed with the laboratory on 11/19/12 at 10:00 AM. The Physician ordered on [DATE] a Neurology Consult. This consult had not been completed. A physician's orders [REDACTED]. The results dated 9/27/12 documented the RBC as 3.52 (N 4.20-5.40), HGB as 10.1 (N 11.8-16-1) and HCT of 30 (N 37-47). The Physician ordered on [DATE] Stool for Occult Blood times 3 for [DIAGNOSES REDACTED]. An EPN dated 9/26/12 through 10/2/12 documented that the resident continued to be confused, refusing meals and refusing supplements. On 9/27/12, the EPN documented at 10:56 PM that the resident was weak but arousable. A Dietary EPN dated 9/28/12 at 2:56 PM documented that the resident ' s intake remained extremely poor, was refusing the supplement and had a low [MEDICATION NAME] level. On 9/29/12 the Physician ordered a Psychiatric Evaluation for Depression. This was not completed. The Nursing EPN on 10/2/12 documented the resident with a Sacral Pressure Ulcer, Stage II and a Stage 1 of the left Heel. A Medical EPN dated 10/2/12 documented the resident as lethargic and depressed. laboratory results dated [DATE] documented the resident with RBC of 2.59 (Normal reference range of 4.20-5.40) HGB of 7.9 (11.8-16.1) and HCT of 22 (N 37-47). In addition, the Blood Urea Nitrogen (BUN) was documented at 75 (N 7-23) and Creatinine was 1.63 (N .70-1.50). The Medical EPN documented by the Nurse Practitioner on 10/5/12, documented that the resident had a BUN of 72, CBC of 7.9 (HGB of 7.9 (Normal reference range of 11.8-16.1)) and was arousable. IV fluids were continued and a [DIAGNOSES REDACTED]. On 10/6/12 at 7:00 AM the labs were reviewed by the Attending Physician. The physician documented [DIAGNOSES REDACTED]. A family consent was obtained for placement of a Gastrostomy Tube (GT-tube inserted into the stomach for nourishment). On 10/6/12 at 6:59 AM the Physician ordered to transfer to the emergency room (ER). The Nursing EPN documented at 7:00 AM the Physician ordered the transfer to the ER. The Nursing P/N dated 10/6/12 at 9:54 AM documented that the resident was transferred to the hospital ER at 9:00 AM. The Nursing P/N documented at 3:00 PM the resident was admitted to the hospital with [REDACTED]. The Hospital Urology Consultation dated 10/10/12 documented that the resident had large Blood with 50 White Cells present in the urine on admission. [DIAGNOSES REDACTED]. The discharge Patient Review Instrument dated 10/26/12 documented that the resident was admitted to the hospital with [REDACTED]. Resident observations were made on 11/19/12 and 11/20/12. The resident was in bed, eyes closed. The resident was unable to be interviewed. The Attending Physician was interviewed on 11/20/12 at 1:15 PM. The Physician stated that, although the orders for the U/A with C&S should have been completed, it would have not changed the outcome. The Resident had an acute [MEDICAL CONDITION] with very poor appetite. The Physician stated that it would be difficult to determine what the total cause of the decline had been, however, the fact that the resident had become depressed and had a poor intake was definitely a part of it. In addition, the Physician stated that they were waiting for an approval for a GT from the family. The Physician also stated that the resident should have been seen by the Neurologist. The Physician stated that it was asked for several times and was unaware why it had not been completed. The Director of Nursing Services (DNS) was interviewed on 11/20/12 at 1:00 PM. The DNS stated that the Neurologist comes to the facility to see any residents that have a consultation request. The DNS was unable to determine if the Neurologist had been notified or if a Consultation Request had been made out for the resident. The DNS stated that they were waiting for the family to make a determination regarding the need for a feeding tube before they would transfer the resident to the hospital. An interview was conducted with the resident's Social Worker (SW) on 11/20/12 at 1:30 PM. The SW stated that the family had one meeting with the facility staff regarding the resident's poor appetite. The SW stated that options for Comfort Care or for " No hospitalization s " were not discussed with the family. 415.12

Based on record review and staff interviews during the abbreviated and partial extended survey the facility failed to provide a quality assessment and assurance program that functions to develop and implement appropriate plans of actions to readily identify issues with the potential to cause serious harm to the health and safety of residents at risk for falls. Specifically, the QAA Committee failed to conduct quality assurance and assessment to ensure the development and implementation of policies and procedures for fall prevention and the monitoring and supervision of residents at risk for falls. The QAA Committee also failed to perform assessment to determine the root cause and prevent further instances of resident falls and failed to identify system failures related to residents who are at risk for falls. One (Resident #1) of ten residents reviewed with a history of falling fell on three occasions within one week and no interventions were implemented to prevent the possibility of future falls. Resident #1 sustained a head injury after the second fall and required staple closure at the hospital. Upon return to the facility, no new interventions were implemented and Resident #1 fell again almost nine hours later. This resulted in actual harm to Resident #1 and the potential for serious harm that is Immediate Jeopardy for 37 residents identified by the facility as being at risk for falls. Refer also to F 323 - Accidents and Supervision, F 490 - Administration and F 501 - Medical Director. Complaint ID Number: NY 571 The findings are: The Accident/Incident Policy dated 10/1/08 documented that all resident occurrences, whether accidents or incidents, will be documented and investigated to ascertain cause and have a plan developed to prevent reoccurrence. The Incident/Accident Reports for April 2012 documented 44 resident falls, 6 of which resulted in injuries. The Incident/Accident Reports for May 2012 documented 43 resident falls, 5 of which resulted in injuries. The Accident/Incident Investigation Form (AIIF) dated 6/2/12 documented that Resident #1 was alert and oriented times three and required limited assistance of one person for bed mobility, extensive assistance of one person for transfers and locomotion. Resident #1 was found kneeling on the floor on the left side of his bed on 5/29/12. The AIIF concluded that "it was determined that the plan of care was constantly followed." The AIIF dated 6/7/12 documented that, on 6/4/12, Resident #1 was observed on the floor in a sitting position inside his room with an open area to the back of his head. The doctor ordered a transfer to the hospital, where a CT scan of the head was negative. The resident was seen 15 minutes prior to the accident. The AIIF concluded that there was no evidence of abuse, neglect or mistreatment and the environment was safe and clutter-free. The AIIF dated 6/5/12 documented that, on 6/5/12 at 6:55 AM, Resident #1 was observed sitting on the floor next to his bed with no visible injuries. The resident was seen 5 minutes prior to the accident. At approximately 9:30 AM the resident was evaluated by the Physician Assistant in the facility due to increased confusion. The resident was transferred to the hospital for evaluation and admitted with [MEDICAL CONDITION]. The AIIF concluded that there was no evidence of abuse, neglect or mistreatment. An interview was conducted with the Director of Nursing (DON) on 6/7/12 at 1:06 PM. The DON stated that the facility does not keep a list of residents that are at risk for falls and does not have a policy on fall prevention or monitoring a resident. The DON stated that, after Resident #1 was found on the floor on 5/29/12, a psychiatric consult was ordered by the Attending Physician but, since Resident #1 was not on [MEDICAL CONDITION] medications, the consult never occurred. The DON further stated that Resident #1 should have been monitored every 30 minutes after the fall on 6/4/12 but there was no other monitoring in place before this. On 6/7/12 at 2:09 PM the DON presented the surveyor with the Resident Roster and stated she highlighted 37 residents who might be at risk for falls. The DON also presented the surveyor with the 30 Minute Frequent Check Forms for Resident #1 dated 6/4/12 and 6/5/12, stating, "There was no other monitoring than this." An interview was conducted with the Physician Assistant (PA) on 6/8/12 at 11:18 AM. The PA stated that he was called to see Resident #1 on 6/4/12 at 9:00 AM was told by LPN #3 that the resident was agitated. The PA stated that Resident #1 "was flailing around the bed and was very agitated. I ordered an [MEDICATION NAME] injection but it had only a moderate improvement and his (Resident #1's) oxygen saturation was very low." Resident #1 was having trouble breathing and the PA sent him out to the hospital around 9:30 AM. The PA stated that he was aware that Resident #1 had fallen on 6/4/12 and had been sent back to the facility from the hospital with staples to the back of his head. However, the PA stated, "I was never told that he had fallen the morning I examined him. I was only told that he was agitated." The PA stated that Resident #1 had been found on the floor on 5/29/12 without injury. The PA stated that "it should be protocol to monitor any resident after a fall every 30 minutes for at least 7 days. He (Resident #1) should have been monitored every 30 minutes from the first fall (5/29/12)." An interview was conducted with the Attending Physician (AP) on 6/11/12 at 10:53 AM. The AP stated that Resident #1 "was falling due to his inability to estimate his own capacity." The AP stated that Resident #1 had "poor judgment and times of confusion" and the AP ordered 30 minute monitoring of Resident #1, "so that at least someone was watching him in order to guide him to safety." The AP stated that Resident #1 should have been monitored every 30 minutes from his first fall on 5/29/12. The AP further stated that he "ordered a Psych consult because of his (Resident #1's) judgment but I don't know why he was not seen." An interview was conducted with the Assistant Director of Nursing (ADON) on 6/11/12 at 1:51 PM. The ADON stated that there is a policy on incidents and accidents but there is no specific policy on falls or fall prevention. The ADON stated, "When an incident happens, we would review it (the incident) to put something in place." An interview was conducted with the In-Service Director (ISD) on 6/11/12 at 2:14 PM. The ISD stated that there is no policy on falls or fall prevention but staff is taught regarding "prompt reporting after an incident." The ISD stated that "resident monitoring would be following a resident's plan of care. The nurse would initiate a form (30 minute form) from a doctor's order and place the form on a clipboard or in a black binder for the aides." The ISD stated that the aides should visually check a resident before signing the form. An interview was conducted with the Administrator on 6/12/12 at 9:50 AM. The Administrator stated that there is daily morning report with all departments to discuss anything that has occurred with regard to residents and a safety committee meets once a week to review accidents and incidents. The Administrator stated that he reviews all Incident/Accident Reports before signing off on them. The Administrator stated that he was not aware of residents not being monitored as ordered. The Administrator stated that the DON had been terminated from employment with the facility. An interview was conducted with the Medical Director (MD) on 6/12/12 at 11:07 AM. The MD stated that his role is "to ensure a plan is created after a resident falls" but was unaware of Resident #1 having any falls. When asked if the facility has a policy on falls and fall prevention, the MD stated, "Off the top of my head, I could not tell you, but the RN (Registered Nurse) should call the doctor after each fall and the doctor would give initial orders." 415.27 (a-c)

Based on record review and staff interviews during an abbreviated and partial extended survey it was determined that the administration of the facility failed to ensure that there was a system in place for fall prevention and supervision of residents at risk for falls to assure that each resident reached and maintained the highest practicable level of physical and psychosocial wellbeing. Specifically, Resident #1 experienced multiple falls and was not provided the necessary supervision to protect his health and safety. Resident #1 fell three times within a week, the second of which resulted in a head injury. The facility failed to communicate the resident's supervision needs and revise the plan of care. Resident #1 fell a third time almost nine hours later and is hospitalized to date. The facility also failed to have policies and procedures in place related to fall prevention. This resulted in actual harm to Resident #1 and the potential for serious harm that is Immediate Jeopardy for 37 residents identified by the facility as being at risk for falls. Refer also to F 323 - Accidents and Supervision, F 501 - Medical Director and F 520 - Quality Assessment and Assurance. Complaint ID Number: NY 571 The findings are: An interview was conducted with the Director of Nursing (DON) on 6/7/12 at 1:06 PM. The DON stated that the facility does not keep a list of residents that are at risk for falls and does not have a policy on fall prevention or monitoring a resident. The DON stated that, after Resident #1 was found on the floor on 5/29/12, a psychiatric consult was ordered by the Attending Physician but, since Resident #1 was not on [MEDICAL CONDITION] medications, the consult never occurred. The DON further stated that Resident #1 should have been monitored every 30 minutes after the fall on 6/4/12 but there was no other monitoring in place before this. On 6/7/12 at 2:09 PM the DON presented the surveyor with the Resident Roster and stated she highlighted 37 residents who might be at risk for falls. The DON also presented the surveyor with the 30 Minute Frequent Check Forms for Resident #1 dated 6/4/12 and 6/5/12, stating, "There was no other monitoring than this." An interview was conducted with the Attending Physician (AP) on 6/11/12 at 10:53 AM. The AP stated that Resident #1 "was falling due to his inability to estimate his own capacity." The AP stated that Resident #1 had "poor judgment and times of confusion" and the AP ordered 30 minute monitoring of Resident #1, "so that at least someone was watching him in order to guide him to safety." The AP stated that Resident #1 should have been monitored every 30 minutes from his first fall on 5/29/12. The AP further stated that he "ordered a Psych consult because of his (Resident #1's) judgment but I don't know why he was not seen." An interview was conducted with the Assistant Director of Nursing (ADON) on 6/11/12 at 1:51 PM. The ADON stated that there is a policy on incidents and accidents but there is no specific policy on falls or fall prevention. The ADON stated, "When an incident happens, we would review it (the incident) to put something in place." An interview was conducted with the In-Service Director (ISD) on 6/11/12 at 2:14 PM. The ISD stated that there is no policy on falls or fall prevention but staff is taught regarding "prompt reporting after an incident." The ISD stated that "resident monitoring would be following a resident's plan of care. The nurse would initiate a form (30 minute form) from a doctor's order and place the form on a clipboard or in a black binder for the aides." The ISD stated that the aides should visually check a resident before signing the form. An interview was conducted with the Administrator on 6/12/12 at 9:50 AM. The Administrator stated that there is daily morning report with all departments to discuss anything that has occurred with regard to residents and a safety committee meets once a week to review accidents and incidents. The Administrator stated that he was not aware of residents not being monitored as ordered. The Administrator stated that the DON had been terminated from employment with the facility. The Administrator stated that he reviews all Incident/Accident Reports before signing off on them. The Incident/Accident Reports for April 2012 documented 44 resident falls, 6 of which resulted in injuries. The Incident/Accident Reports for May 2012 documented 43 resident falls, 5 of which resulted in injuries. An interview was conducted with the Medical Director (MD) on 6/12/12 at 11:07 AM. The MD stated that his role is "to ensure a plan is created after a resident falls" but was unaware of Resident #1 having any falls. When asked if the facility has a policy on falls and fall prevention, the MD stated, "Off the top of my head, I could not tell you, but the RN (Registered Nurse) should call the doctor after each fall and the doctor would give initial orders." 415.26

Based on observation, record review and staff interviews during an abbreviated and partial extended survey it was determined that the facility failed to ensure that each resident assessed and identified as at risk for falls was provided adequate supervision and monitoring to protect the health and safety of the residents. The facility failed to ensure that residents who have fallen or are at risk for falls were provided with supervision and monitoring. Specifically, the facility failed to monitor a resident (Resident #1 of 10 residents reviewed with a history of falls), who fell on three occasions within one week. The second fall resulted in a head injury, which was treated with staple closure at the hospital. Upon return from the hospital on the evening of 6/4/12, the facility failed to revise the plan of care to prevent further falls or injuries. Thirty minute checks were ordered by the physician and the order was not carried out to the plan of care. The following morning of 6/5/12, Resident #1 fell a third time and was transferred to the hospital for agitation where Resident #1 was admitted to the ICU (Intensive Care Unit). This resulted in actual harm to Resident #1 and the potential for serious harm that is Immediate Jeopardy and Substandard Quality of Care for 37 residents identified by the facility as being at risk for falls. Complaint ID Number: NY 571 The findings are: Resident #1 is [AGE] years old and was admitted to the facility on [DATE] for short-term rehabilitation, was discharged home and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documented that Resident #1 was cognitively intact. The Accident/Incident Policy dated 10/1/08 documented that all resident occurrences, whether accidents or incidents, will be documented and investigated to ascertain cause and have a plan developed to prevent reoccurrence. The Fall Risk assessment dated [DATE] documented that Resident #1 was at risk for falls. The Admission Nursing assessment dated [DATE] documented that Resident #1 required one person physical assist for transfers and locomotion. The Care Plan Activity Report (Comprehensive Care Plan) (CPAR) dated 5/4/12 documented that Resident #1 was at risk for falls. The CPAR and Resident CNA Accountability lacked documented evidence of interventions for the supervision and monitoring of Resident #1. The CPAR dated 5/4/12 documented Resident #1's self-care deficit for mobility, ambulation and transfers. Interventions included providing one person assist with transfers and out of bed to wheelchair for mobility. The CPAR and Resident CNA Accountability lacked documented evidence of interventions for ambulation. The Physical Therapy Progress Report dated 5/17/12 documented that Resident #1 could ambulate 20 feet with a Rolling Walker and CGA (contact guard assist). The Incident/Accident Report (I/A) dated 5/29/12 at 12:45 AM documented that Resident #1, confused at times, was observed kneeling on the floor at the left side of his bed. There were no injuries noted. Measures taken to prevent recurrence were bed alarm to alert staff when resident is out of bed and 30 minute monitoring. Although these measures were listed, they were not implemented by staff. The Nursing Progress Notes (NPN) dated 5/29/12 at 4:05 AM documented that Resident #1 was observed kneeling on the floor at the left side of his bed; when asked what happened, the resident said you don't have to worry, I did not fall, I was just praying, don't take me to the hospital. The resident was assisted back to bed, body assessment done and no visible injury noted. The physician's orders [REDACTED]. The physician's orders [REDACTED]." The medical record lacked documented evidence of 30 minute monitoring from 5/29/12 to 6/4/12. The NPN dated 6/4/12 at 2:40 PM documented that Resident #1 was found on the floor in sitting position, bleeding from open area to back of head. Pressure applied, bleeding stopped. MD (medical doctor) notified. Order transfer to the hospital for eval; possible CT scan of head. The I/A dated 6/4/12 at 2:10 PM documented that Resident #1 was found on the floor in room, alarm sounding, sitting position, open areas to back of head, bleeding; pressure applied, bleeding stopped. The resident was transferred to the hospital for evaluation. The I/A's section, "Nursing Measures taken to prevent recurrence," was blank. The section, "M.D.'s Measures to prevent recurrence," dated 6/7/12 documented 30 minute monitoring/safety protocols. The Hospital Discharge Instructions dated 6/4/12 documented that Resident #1 had a head injury with staple removal required in 7 to 10 days. The NPN dated 6/4/12 at 9:51 PM documented that Resident #1 returned to the unit, status [REDACTED]. Pressure dressing to occipital area noted ...ordered Q (every) 30 minutes monitoring x 7 days. The physician's orders [REDACTED]." The NPN dated 6/5/12 at 7:43 AM documented that Resident #1 was "found on the floor at 5:45 AM confused...Resident did not hit head. No visible injury noted. Will continue to monitor." The I/A dated 6/5/12 at 6:55 AM documented that Resident #1 was observed sitting on the floor next to his bed unable to give an account of what had happened due to confusion. Body check done; no visible injury noted. The I/A's section, "Nursing Measures taken to prevent recurrence," was blank. The section, "M.D.'s report ...and Measures to prevent recurrence," dated 6/7/12 documented safety protocols maintained/no acute injury noted; resident transferred to the hospital. The Medical Progress Note dated 6/5/12 at 9:31 AM (written by the Physician Assistant) documented that Resident #1 was evaluated for complaint of agitation and confusion. Resident noted to be severely agitated and confused. Resident unresponsive to verbal questions and states incoherent words. Ativan ordered stat for resident with mild decrease in agitation symptoms. Resident currently on 5 liters of oxygen but pulse ox at 88%. Decision to transfer resident made. The NPN dated 6/5/12 at 10:58 AM documented that, at the start of tour, Resident #1 was observed to be very agitated and restless, incoherent and confused. Resident is s/p (status [REDACTED]. Order obtained to transfer resident to ER (emergency room ) for evaluation and treatment secondary to change in mental status. The NPN dated 6/5/12 at 10:16 PM documented that Resident #1 was admitted to the ICU (intensive care unit) with [DIAGNOSES REDACTED]. The 30 Minute Frequent Check Form dated 6/4/12 for the 3 to 11 nursing shift documented that Resident #1 was in his room awake and calm from 10:00 PM to 11:00 PM (signed by CNA #4). The section for the 11 to 7 nursing shift from 11:00 PM to 11:30 PM was blank. The sections from 11:30 PM to 4:30 AM documented that Resident #1 was in bed (signed by LPN #1). The sections from 4:30 AM to 5:30 AM documented that Resident #1 was in bed, agitated/standing. There was no documented evidence of frequent checks from 5:30 AM to 7:00 AM. The 30 Minute Frequent Check Form dated 6/5/12 documented that Resident #1 was in his bedroom sleeping, restless from 9:30 AM to 10:30 AM and sitting, restless from 10:30 AM to 11:00 AM (signed by CNA #1). The I/A's for April 2012 documented 44 resident falls, 6 of which resulted in injuries. The I/A's for May 2012 documented 43 resident falls, 5 of which resulted in injuries. An interview was conducted with the Director of Nursing (DON) on 6/7/12 at 1:06 PM. The DON stated that the facility does not keep a list of residents that are at risk for falls and does not have a policy on fall prevention or monitoring a resident. The DON stated that, after Resident #1 was found on the floor on 5/29/12, a psychiatric consult was ordered by the Attending Physician but, since Resident #1 was not on psychotropic medications, the consult never occurred. The DON further stated that Resident #1 should have been monitored every 30 minutes after the fall on 6/4/12 but there was no other monitoring in place before this. An interview was conducted with the Director of Social Work (DSW) on 6/7/12 at 1:29 PM. The DSW stated that Resident #1 had been in the facility for short-term rehab in April 2012, was discharged home for about one week when he fell and Resident #1's sister realized she could not care for him. Resident #1 went to the hospital and, then, was readmitted to the facility for long-term care on 5/3/12. An interview was conducted with the Social Worker (SW) on 6/7/12 at 1:46 PM. The SW stated that Resident #1 could express himself but was not a good historian. The SW stated that Resident #1 was "alert with periods of confusion but definitely not fully alert and oriented." An interview was conducted with the 7:00 AM to 3:00 PM Registered Nurse Supervisor (RNS#1) on 6/7/12 at 1:55 PM. RNS #1 stated that, on 6/4/12 at 1:45 PM, RNS #1 responded to a page and Resident #1 was on the floor in his room with an open laceration to the back of his head. RNS #1 notified the doctor and sent Resident #1 to the hospital. RNS #1 stated that Resident #1 had not lost consciousness but "was his normal self with on and off confusion." RNS #1 further stated that he "knew him (Resident #1) but don't know what was in place for him (Resident #1's plan of care). I knew he was not completely alert, though." An interview was conducted with the charge 11:00 PM to 7:00 AM Licensed Practical Nurse (LPN #1) on 6/7/12 at 2:01 PM. LPN #1 stated that, on 6/5/12, she began working on the unit at 12 Midnight. LPN #1 stated that Resident #1 had been sleeping and slept until 5:00 AM. LPN #1 stated that she did not receive any special instructions regarding the care of Resident #1 but LPN #1 did know that Resident #1 had returned from the hospital on the previous nursing shift. LPN #1 reported that Resident #1 was known to walk around and did so without assistance. LPN #1 reported that Resident #1 was confused but stated that Resident #1 did not require monitoring. On 6/7/12 at 2:09 PM the DON presented the surveyor with the Resident Roster and stated she highlighted 37 residents who might be at risk for falls. The DON also presented the surveyor with the 30 Minute Frequent Check Forms for Resident #1 dated 6/4/12 and 6/5/12, stating, "There was no other monitoring than this." An interview was conducted with the assigned 7:00 AM to 3:00 PM Certified Nursing Assistant (CNA #1) on 6/7/12 at 2:11 PM. CNA #1 stated that, on 6/4/12, she had seen Resident #1 walking alone in the hallway about 10 minutes before he fell . CNA #1 stated that Resident #1 would often be at the doorway or outside his room and CNA #1 never had to help him to walk. CNA #1 stated the Resident #1 would put himself in and out of bed and CNA #1 did not think that Resident #1 had any alarms. CNA #1 further stated that Resident #1 was not on the monitoring schedule for residents. CNA #1 acknowledged her signature on the 30 Minute Frequent Check Form dated 6/5/12 from 9:30 AM to 11:00 AM but CNA #1 did not recall seeing Resident #1 during those times. CNA #1 could not offer an explanation regarding her signature on the form 4 times. An interview was conducted with the charge 7:00 AM to 3:00 PM Licensed Practical Nurse (LPN #2) on 6/7/12 at 2:19 PM. LPN #2 stated that, on 6/4/12, LPN #2 found Resident #1 sitting on the floor, bleeding to the back of his head. LPN #2 paged the supervisor, applied pressure to Resident #1's head and the bleeding subsided. Resident #1 was sent out to the hospital. LPN #2 stated that Resident #1 did not require assistance to ambulate and would walk on the unit by himself. LPN #2 stated that she was not sure if Resident #1 required monitoring before the fall on 6/4/12 and further stated that the CNAs sign the sheets for monitoring. LPN #2 stated that she does not look at the monitoring sheets. An interview was conducted with the 3:00 PM to 11:00 PM RNS #2 on 6/7/12 at 3:08 PM. RNS #2 stated that Resident #1 returned from the hospital on [DATE] between 9:00 PM and 9:30 PM with staples to the back of his head. RNS #2 stated that he did not know if Resident #1 required 30 minute monitoring but "should have been monitored closely. The CNA should be eyeballing the resident from time to time." An interview was conducted with the Physical Therapist (PT) on 6/8/12 at 10:00 AM. The PT stated that Resident #1 was not consistent with ambulation, was unsteady and required hands-on assistance for safety. The PT stated that Resident #1 was a fall risk and should not have been ambulating on the unit at all. The PT stated that, if a resident's therapist feels a resident is safe to ambulate on the unit, the therapist will tell the nurse and the resident will be placed on floor ambulation. The PT stated that Resident #1 "was never consistent so I never put him on floor ambulation. On the unit, he (Resident #1) should have been in a wheelchair for safety." An interview was conducted with the assigned 3:00 PM to 11:00 PM CNA #2 on 6/8/12 at 10:41 AM. CNA #2 stated that, on 6/4/12, Resident #1 came back from the hospital around 9:00 PM. CNA #2 stated that Resident #1 did not want anything, so CNA #2 gave him a urinal and he was laying in bed. CNA #2 stated that she was not told to do anything special for the resident and there were no special instructions on the accountability. CNA #2 stated that she did not see Resident #1 again on 6/4/12 after giving him the urinal. CNA #2 stated that there are residents who she has to "sign a sheet for every half hour but I don't think he (Resident #1) was one of them." CNA #2 stated that she tries "to keep the sheets signed" but, when asked did she actually check on the residents, CNA #2 stated, "I try, but there are times I don't." An interview was conducted with the Physician Assistant (PA) on 6/8/12 at 11:18 AM. The PA stated that he was called to see Resident #1 on 6/4/12 at 9:00 AM was told by LPN #3 that the resident was agitated. The PA stated that Resident #1 "was flailing around the bed and was very agitated. I ordered an Ativan injection but it had only a moderate improvement and his (Resident #1's) oxygen saturation was very low." Resident #1 was having trouble breathing and the PA sent him out to the hospital around 9:30 AM. The PA stated that he was aware that Resident #1 had fallen on 6/4/12 and had been sent back to the facility from the hospital with staples to the back of his head. However, the PA stated, "I was never told that he had fallen the morning I examined him. I was only told that he was agitated." The PA stated that Resident #1 had been found on the floor on 5/29/12 without injury. The PA stated that "it should be protocol to monitor any resident after a fall every 30 minutes for at least 7 days. He (Resident #1) should have been monitored every 30 minutes from the first fall (5/29/12)." A subsequent interview was conducted with LPN #1 on 6/8/12 at 12:40 PM. LPN #1 stated that she did not give report to LPN #3 regarding Resident #1's fall on the morning of 6/5/12. LPN #1 further stated that she signed the 30 Minute Frequent Check Form for Resident #1 from 11:30 PM (6/4/12) to 4:30 AM (6/5/12) but did not see the resident. LPN #1 stated, "I should have seen him (Resident #1) but I just would ask an aide if he's okay and sign it. Probably shouldn't do that but a lot of times if someone hears that a resident's okay, you'll just sign it. There's no real responsibility. Any one can do it." An interview was conducted with the 6/5/12 charge 7:00 AM to 3:00 PM LPN #3 on 6/8/12 at 1:15 PM. LPN #3 stated that she received report from LPN #1 when she came on duty on 6/5/12. LPN #3 stated that she was told that Resident #1 had fallen the day before, was sent to the hospital and came back with staples to his head. LPN #3 stated that she did not know that Resident #1 had fallen during the night shift on 6/5/12. LPN #3 stated that, on the morning of 6/5/12, Resident #1 was growing increasingly agitated and seemed more confused than usual. LPN #3 stated that Resident #1 was always somewhat confused but, on 6/5/12, Resident #1 was not able to converse at all, so LPN #3 had the PA come to see the resident. LPN #3 stated that the PA ordered a STAT (immediate) Ativan injection but this did not have much effect on Resident #1, so the PA ordered the resident be sent out to the hospital. LPN #3 stated that Resident #1 went out to the hospital by ambulance shortly after 9:30 AM. LPN #3 wrote a note in the medical record about an hour later. LPN #3 stated that Resident #1 would often come to the doorway or into the hallway on his own. LPN #3 stated that she did not believe Resident #1 needed assistance to walk and "could basically do his own thing." LPN #3 stated, "I guess any resident might be considered at risk for falls but I don't think he (Resident #1) was actually someone who was at risk." LPN #3 further stated regarding monitoring a resident that "the way I do it is I go to see the resident but some people do it other ways. They may just ask an aide and then sign the 30 minute form." LPN #3 stated that Resident #1 was not on 30 minute monitoring. An interview was conducted with the charge 3:00 PM to 11:00 PM LPN #4 on 6/8/12 at 1:53 PM. LPN #4 stated that Resident #1 came back from the hospital on [DATE] around 9:30 PM and was medicated for pain. LPN #4 stated, "There was nothing specific about him (Resident #1). No change in taking care of him. The supervisor didn't say to do anything different." LPN #4 stated, "We have 30 minute checks but it's not like it's assigned to any one person. He (Resident #1) was not on them (30 minute checks) though." Regarding Resident #1's risk for falls, LPN #4 stated, "He walked around. He ambulated alone. Risk for falls? Not that I'm aware of." An interview was conducted with an 11:00 PM to 7:00 AM CNA #3 on 6/8/12 at 2:10 PM. CNA #3 stated that she worked the night shift from 6/4/12 into 6/5/12 but was not assigned to Resident #1. CNA #3 stated that there is a book at the nurse's desk to sign for residents who are on 30 minute checks. CNA #3 stated that there is no one assigned to check a resident and, "if you have time, you check." An interview was conducted with the 11:00 PM to 7:00 AM RNS #2 on 6/8/12 at 3:09 PM. RNS #2 stated that, when she came on duty on 6/4/12, RNS #1 gave her report that Resident #1 had fallen and returned from the hospital with a laceration to the back of his head. RNS #2 stated that, on 6/5/12 around 6:55 AM, LPN #1 called RNS #2 to say that Resident #1 had been found sitting on the floor. RNS #2 stated that she saw the resident and Resident #1 had no visible injuries. RNS #2 called the doctor and said that the PA would be coming in soon, so the doctor agreed to wait for the PA to see Resident #1. RNS #2 stated that she did not give any further report about the resident to anyone. RNS #2 stated that she knows Resident #1 and, many times, saw the resident outside his room or down the hall during the night. RNS #2 stated that she did not know of any restrictions on Resident #1's ambulation status. RNS #2 stated, "I tell the staff all the time to keep an eye on all the residents. I don't want them to fall on my shift." When asked regarding monitoring Resident #1, RNS #2 stated, "He was like everyone else." An interview was conducted with a 3:00 PM to 11:00 PM CNA #4 on 6/8/12 at 4:20 PM. CNA #4 stated that she had been assigned to Resident #1 but was not working on 6/4/12. CNA #4 was unaware that her signature was on the 30 Minute Frequent Check Form for 6/4/12 and stated, "How could I sign when I wasn't even there." CNA #4 further stated, "I don't think he (Resident #1) was on monitoring. You would look after him when you come in on tour and, then, check every few hours like anyone else." CNA #4 stated that Resident #1 "could get up and walk around if he needed you." An interview was conducted with the assigned 11:00 PM to 7:00 AM CNA #5 on 6/8/12 at 4:54 PM. CNA #5 stated that Resident #1 had come back from the hospital on [DATE] because he had fallen. CNA #5 stated that, on 6/5/12 around 6:00 AM, CNA #5 was doing rounds and saw Resident #1 on the floor in his room. CNA #5 called for LPN #1. CNA #5 stated that Resident #1 was supposed to have an alarm on the bed but CNA #5 did not hear it going off. CNA #5 stated that she doesn't check bed alarms. CNA #5 stated that she did not know of any other instructions to care for Resident #1 and stated, "He walked around on his own. There were no special instructions." An interview was conducted with the Attending Physician (AP) on 6/11/12 at 10:53 AM. The AP stated that Resident #1 "was falling due to his inability to estimate his own capacity." The AP stated that Resident #1 had "poor judgment and times of confusion" and the AP ordered 30 minute monitoring of Resident #1, "so that at least someone was watching him in order to guide him to safety." The AP stated that Resident #1 should have been monitored every 30 minutes from his first fall on 5/29/12. The AP further stated that he "ordered a Psych consult because of his (Resident #1's) judgment but I don't know why he was not seen." An interview was conducted with the Assistant Director of Nursing (ADON) on 6/11/12 at 1:51 PM. The ADON stated that there is a policy on incidents and accidents but there is no specific policy on falls or fall prevention. The ADON stated, "When an incident happens, we would review it (the incident) to put something in place." An interview was conducted with the In-Service Director (ISD) on 6/11/12 at 2:14 PM. The ISD stated that there is no policy on falls or fall prevention but staff are taught regarding "prompt reporting after an incident." The ISD stated that "resident monitoring would be following a resident's plan of care. The nurse would initiate a form (30 minute form) from a doctor's order and place the form on a clipboard or in a black binder for the aides." The ISD stated that the aides should visually check a resident before signing the form. 415.12 (h) (1) (2)

Based on record review and staff interviews during an abbreviated and partial extended survey the Medical Director failed to ensure that the facility was providing appropriate 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 in place for fall prevention and the monitoring and supervision of 37 residents who were assessed to be at risk for falls. The failure to develop, implement and evaluate systems to supervise and monitor residents identified as at risk for falls resulted in actual harm to Resident #1 and the potential for serious harm that is Immediate Jeopardy for 37 residents identified by the facility as being at risk for falls. Refer also to F 323 - Accidents and Supervision, F 490 - Administration and F 520 - Quality Assessment and Assurance. Complaint ID Number: NY 571 The findings are: The Incident/Accident Reports for April 2012 documented 44 resident falls, 6 of which resulted in injuries. The Incident/Accident Reports for May 2012 documented 43 resident falls, 5 of which resulted in injuries. An interview was conducted with the Medical Director (MD) on 6/12/12 at 11:07 AM. The MD stated that his role is "to ensure a plan is created after a resident falls" but was unaware of Resident #1 having any falls. When asked if the facility has a policy on falls and fall prevention, the MD stated, "Off the top of my head, I could not tell you, but the RN (Registered Nurse) should call the doctor after each fall and the doctor would give initial orders." 415.15 (a)

Based on observation, record review and staff interviews during an abbreviated and partial extended survey it was determined that the facility failed to ensure that each resident assessed and identified at risk for elopement/wandering was provided adequate supervision, and monitoring to protect the health and safety of the residents. The facility failed to ensure there was a system in place to safeguard residents at risk for elopement and wandering during a facility outing. The facility's failure to communicate to facility staff that a number of residents on the outing required supervision due to their risk for elopement and wandering resulted in a resident's undetected elopement. Specifically, one (Resident #1) of 6 residents reviewed with a history of wandering and was planned for 30 minutes visual monitoring attended a facility outing and successfully eloped undetected by the facility's staff and was not located until a call was received four days later from a hospital in another county stating that Resident #1 had been found unresponsive and later pronounced dead at the hospital. This resulted in actual harm to Resident #1 that is Immediate Jeopardy, Substandard Quality of Care and potential for serious harm to Residents (#2, #3, #4, #5, and #6)who have been assessed as at -risk for elopement/wandering and are taken out on facility outings. Complaint Number: NY 157 The finding is: 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 Resident #1's cognition as severely impaired. The Wandering Risk Scale dated [DATE] and updated [DATE] documented that Resident #1 was assessed to be at low risk for wandering. The Comprehensive Care Plan dated [DATE] and updated [DATE] documented that Resident #1 was low risk for wandering and utilized a wander guard to left ankle due to ambulatory status and [DIAGNOSES REDACTED]. The Certified Nursing Assistant Assignment/Accountability Record dated [DATE] documented that Resident #1 wore a wander guard to his left ankle and did not include 30 minute monitoring. The Policy and Procedure for Out of Facility Trips dated ,[DATE] documented that the Director of Recreation will determine the necessary staff/resident ratio to properly supervise and monitor the residents, according to the individual needs of the residents and assign the staff accordingly. The Policy and Procedure for Wandering Risk Protocol Scale dated ,[DATE] documented (on admission) all residents will be assessed by a nurse to determine his or her risk for harm due to wandering by utilizing 'Wandering Risk Scale' ...Residents that score in the high risk range or as per discretion by the Licensed Nurse, a wander guard will be placed on those residents." The Policy and Procedure for Prevention of Elopement (PPPE) dated ,[DATE] documented the risk factors for elopement including, but not limited to, a resident who has a history of wandering/elopement. The PPPE further documented "if a resident is assessed to be at risk for elopement ...a wander guard device is put on the resident and the resident is placed on every 30 minutes monitoring ...All staff ...are to be made knowledgeable of residents at risk for elopement and be prepared to intervene." The facility's Investigative Summary dated [DATE] documented that there were 19 residents who went to an inter-generational trip at a local school on [DATE]. Resident #1 was noted missing during a headcount by staff at 12:20 PM. Based on the risk assessments since admission, Resident #1 was not at risk for elopement, low risk for wandering and a wander guard was provided to the resident upon admission as a preventive measure. Adequate staff was provided, the resident's plan of care and facility policy were followed, however, due to the fact that the school cafeteria was full of students, school staff, residents and facility staff when the incident occurred, the resident left the cafeteria unnoticed by the staff. The 30 Minute Frequent Check Sheets from [DATE] to [DATE], documented that Resident #1 was being monitored for his whereabouts every 30 minutes . The Wanderguard/Elopement List dated [DATE] documented Resident #1's wander guard. An undated list of residents (provided by the Director of Recreation) documented 19 residents attending the Thanksgiving Luncheon on [DATE]. Five of the nineteen residents were on the Wanderguard/Elopement List. The Elopement Risk assessment dated [DATE] documented that Resident #1 was not at risk for elopement. The Medical Progress Notes dated [DATE] documented that Resident #1 did not have capacity to make decisions regarding medical care, discharge and finances due to dementia. The physician's orders [REDACTED]. The Nursing Progress Notes (NPN) dated [DATE] at 12:30 PM, documented that the recreation staff who went out with the residents called the unit to inform that Resident #1 was missing from the group. The nursing supervisor was informed. The NPN dated [DATE] documented that, on [DATE] at approximately 12:30 PM, Resident #1 could not be located in the school cafeteria. An immediate search was conducted in the entire school as well as its neighboring areas. The resident's sister, police precinct and hospitals were informed. The Medical Progress Notes dated [DATE] documented that on [DATE], during a recreational trip, Resident #1 "was missed and never found - search is in progress ...history of mild dementia ...Patient was following commands and was never on one to one observation. His elopement score was low. I do not think that patient's health or life is in any immediate danger at this time. Search for patient to be continued." The Fire Department of New York ( FDNY) Prehospital Care Report dated [DATE] at 7:04 AM documented that the resident was found in another county face down on the side walk, pulseless, frozen body, unresponsive, unable to open mouth, unable to be intubated. The resident was taken to the hospital. The Hospital Emergency Physician Record dated [DATE] at 7:15 AM documented that the resident was brought to the emergency room , where intubation was tried but failed because the resident's mouth was unable to be opened due to rigor. The resident was very cold (72 degrees Fahrenheit). Anesthesia and tracheostomy team called. Anesthesia intubated the resident and the resident was placed on external warmer and warm saline infusion. The Office of Chief Medical Examiner Report documented that the resident was found in the street by EMS (Emergency Medical Services). The resident was pronounced dead on [DATE] at 8:55 AM due to cardiac arrest and hypothermia. An interview was conducted with a Recreation Aide (RA #1) on [DATE] at 12:33 PM. RA #1 stated that, on [DATE] at approximately 11:00 AM, a number of residents assembled in the lobby area on unit 1 South. RA #1 stated that although she could not recall the number of residents, a headcount of residents going on the trip was taken and the residents and recreation staff left the facility to walk to a local school for a holiday meal outing . RA #1 stated she escorted Resident #1 in a group of other residents from the facility to the local school. RA #1 recalled Resident #1 being among a headcount at 12:10 PM at the school, but when RA #1 did another headcount at 12:20 PM, Resident #1 could not be found. RA #1 stated that she immediately told RA #2 and started to search inside and outside the school but could not locate the resident. RA #1 stated that she thought Resident #1 had been seated at one of two tables in the front of the school cafeteria but could not be sure as to which table. RA #1 stated that she was not specifically assigned to Resident #1 because no one (staff) has any specific assignments. RA #1 knew of four residents on unit 2 South (Resident #1's unit) that went out on the trip because RA #1 does activities on that unit. RA #1 stated that she did not know whether or not Resident #1 wore a wander guard. She had a list of residents on the trip but the list did not say anything about the residents except their names. RA #1 stated that she always knew Resident #1 and did not know of any residents at risk for wandering on the trip.She also stated that no one told her about wandering and elopement regarding the residents on the outing. An interview was conducted with the [DATE] assigned 7:00 AM to 3:00 PM Certified Nursing Assistant (CNA #1) on [DATE] at 1:17 PM, she floats throughout the facility and was only assigned to Resident #1 on [DATE]. CNA #1 stated that she recalled Resident #1 as being pretty independent, doing everything for himself, but did not talk very much. CNA #1 stated that she had to write down where the resident was every 30 minutes but CNA #1 did not know why she had to do this and whether or not Resident #1 wore a wander guard. An interview was conducted with Resident #1's daily assigned 7:00 AM to 3:00 PM CNA #2 on [DATE] at 1:50 PM. CNA #2 stated that he has been taking care of Resident #1 for the past three months and knew Resident #1 wore a wander guard and CNA #2 had to make sure he knew where the resident was every 30 minutes. Resident #1 could do a lot for himself but needed help to remember to do things. An interview was conducted with RA #2 on [DATE] at 2:04 PM. RA #2 stated that on [DATE], the recreation staff left the facility through the back door of unit 1 South with residents to go for a Thanksgiving lunch at the local school. RA #2 stated that the staff walked with the residents to the school. RA #2 stated that she has been working at the facility for about ten years and RA #2 has an idea of residents' behaviors. RA #2 stated that, based on her knowledge, she tries to keep an eye on residents. RA #2 stated that the recreation staff usually tries to watch out for the residents they know, but there are no specific assignments on trips. RA #2 stated that "sometimes you may have one or two residents from your floor and other times five or six." RA #2 stated that the school cafeteria was chaotic and congested because there were a lot of students from the school mixed in with the residents. RA #2 stated that she did not know if Resident #1 wore a wander guard and did not think any resident was at risk for elopement. RA #2 stated that she was not told of any resident who needed to be watched any differently or about wandering and elopement regarding the residents on the outing.. An interview was conducted with RA #3 on [DATE] at 2:13 PM. RA #3 stated that she really only knows the residents on the 3rd floor of the facility where she works and was not sure if she knew Resident #1. RA #3 stated that when she goes on trips with residents, she is supposed to pay attention to all residents and is not assigned to any one in particular. RA #3 stated that she was not told of any specific behaviors regarding any of the residents on the trip and did not know if any residents might have been at risk for elopement or wandering. An interview was conducted with RA #4 on [DATE] at 2:18 PM. RA #4 stated that she went on the trip with the residents on [DATE] and was helping to push a resident, who was in a wheelchair. RA #4 stated that she had to veer away from the group while walking from the facility to the school because the side walks had cracks over which RA #4 could not push the wheelchair. Once she arrived at the school, RA #4 had to keep an eye on residents. RA#4 further stated that there were many people at the school and it was very hard to do. RA #4 stated that she did not know if any resident on the trip wore a wander guard, but she didn't think so and no one told her about wandering and elopement regarding the residents on the outing. An interview was conducted with RA #5 on [DATE] at 2:34 PM. RA #5 stated that she was not really assigned to anyone on the trip and was just watching over the residents as they walked from the facility to the school. RA #5 was not aware that Resident #1 had escaped because RA #5 had to leave the school and return to the facility to get another resident who had been added to the list. RA #5 stated that when she returned to the school, Resident #1 was gone already. No one told her about wandering and elopement regarding the residents on the outing. An interview was conducted with the Licensed Master Social Worker (LMSW) on [DATE] at 9:55 AM. The LMSW stated that she has assessed Resident #1' s cognition a few times since the resident ' s admission to the facility. Resident #1 was alert and oriented to person and has consistently scored as severely impaired on the BIMS (Brief Interview for Mental Status). The LMSW stated that care planning for a resident with wandering and/or elopement behaviors is done by the nursing department. An interview was conducted with the 7:00 AM to 3:00 PM 2 South unit charge Registered Nurse (RN) on [DATE] at 11:15 AM. The RN stated that Resident #1 had been pacing and wandering the hallway when he first came into the facility. Resident #1 lived at the end of the hall and, due to his independent ambulatory status a wander guard was placed on the resident as a precautionary measure and placed on 30 minute monitoring. Per facility policy, any resident with a wander guard must be monitored. The RN stated that she did assess Resident #1 twice since his admission to the facility and did not take into account the resident's history of wandering upon admission, which would have changed the assessment to make the resident at risk for wandering and elopement. The RN stated that, on [DATE], the recreation department had a list of residents who were being taken on a trip to a local school. The RN stated there was no discussion with or report given to recreation regarding any resident who might be at risk to wander. The RN stated there have been trips such as this one in the past and the RN did not recall having a discussion regarding residents' behaviors prior to the trips. An interview was conducted with the Attending Physician (AP) on [DATE] at 11:45 AM. The AP stated that Resident #1 came to the facility with a history of delirium and severe dementia but the AP was never notified about the resident's pacing. The AP stated that wandering and elopement are pretty close to each other and the AP cannot say with certainty that Resident #1 was not an elopement risk. Regarding the physician's orders [REDACTED].#1 was on 30 minute monitoring. The AP further stated that he is also the Medical Director (MD) for the facility and having conferred with Administration, he has reviewed policies, but has not made changes regarding policies on wander guard, prevention of elopement and out of facility trips. An interview was conducted with the Director of Recreation (DR) on [DATE] at 1:39 PM. The DR stated his staff developed a list of residents who wanted to go on trips and who were the most appropriate residents and residents who have not out in the past. The staff's lists are formulated into one list which must be given final approval by the Director of Nursing. The DR stated that, on the day of any particular trip, the list is given to the charge nurse on each nursing unit and the DR would expect to be made aware of any resident who might need to be more closely monitored. The DR stated that on [DATE], no staff member told him of any resident who was at risk for wandering or elopement. He was not aware of any resident on the [DATE] trip who had a history of [REDACTED]. The DR further stated that he did not attend the outing on [DATE] but believes that he provided the recreation staff with specific assignments to individual residents. The DR stated that these assignments were provided in written form but "I probably threw it out." An interview was conducted with the 3:00 PM to 11:00 PM Registered Nurse Supervisor (RNS) on [DATE] at 2:03 PM. The RNS stated that he assessed Resident #1 for wandering and elopement on the day the resident was admitted to the facility. The RNS stated that, although there was no known history from the hospital regarding wandering, Resident #1 was pacing up and down the hall. Resident #1's ambulatory status was independent and his room was by the exit door, so the RNS felt it was prudent to put a wander guard on Resident #1 because Resident #1 "could easily blend in." The RNS stated that due to the resident's wander guard, Resident #1 was also placed on 30 minute monitoring. Any resident who has a wander guard is placed on 30 minute monitoring "to know their whereabouts in case they try to elope. If a resident had any times of wandering in the facility, then this is still his history and would be on the assessments." The RNS stated that he did not do any of Resident #1's assessments for wandering and elopement since the resident's admission but the history "should have been on the assessment." An interview was conducted with the Director of Nursing (DON) on [DATE] at 12:35 PM. The DON stated that when Resident #1 was found to be missing from the outing, a full search of the neighborhood and police contact was made. Four days later the DON spoke with a hospital in Brooklyn and was made aware that Resident #1 had been found unresponsive on the street by EMS. The DON stated that she went to the hospital where the DON identified Resident #1's body. Resident #1 had died but the hospital would not provide the DON with any further information regarding the resident. The DON stated that she is acting as the In-Service Coordinator. There is no specific guideline to follow when residents go out on a facility trip. The DON stated that the DR should disseminate the Wanderguard/Elopement List to the recreation staff and the recreation staff should know their residents. The DON further stated that Resident #1 was on the Wanderguard/Elopement List on [DATE] and was being monitored every 30 minutes because all residents with wander guards are monitored in this way. The DON did not believe that Resident #1 was at risk for wandering or elopement and referred to the resident's assessments. Upon further inquiry, the DON stated that any resident with a history inclusive of wandering at any time would be at risk for elopement. The DON stated that as a result of the investigation of Resident #1's elopement, the facility concluded that the resident went undetected due to the high activity level at the school. All recreation staff were given disciplinary action for same. The DON was unable to state what the recreation staff should have done. An interview was conducted with the Administrator on [DATE] at 2:14 PM. The Administrator stated that he was advised of Resident #1's elopement at 12:30 PM on [DATE] and took immediate efforts at searching for the resident involving the police and hospitals but was not able to locate the resident. The Administrator stated that, sometime afterwards, he was told by staff that it was chaotic at the school and no staff saw how Resident #1 left the school cafeteria. The Administrator stated that there should be a designated leader to give out assignments to staff when residents are taken out on a trip and a process of going over with the nurse how much supervision is needed before the trip occurs. 415.12(h)(1)(2)