Every finding on record at The Grand Rehabilitation and NRSG at Guilderland

Based on observations, record review, and interviews during a recertification and abbreviated survey (Case #'s NY00363829, NY00364424, and NY00347964), the facility failed to ensure residents were free of any significant medication errors for five (5) (Resident #s 12, 23, 47, 77, and 327) of 10 residents reviewed for medication administration. Specifically, (a.) Resident #47 was not administered 12 days-worth of psychiatric medication from 11/25/2024 to 12/06/2024. Over the 12 days, the resident decompensated psychiatrically, and on 11/29/2024 at 9:00 AM, the resident requested to be sent to the hospital. (b.) Resident #12 was not administered their antibiotics (medication to treat active infections) 10 of 20 times as prescribed. (c.) Resident #23 was not administered antibiotics as prescribed, receiving only four (4) of eight (8) doses prescribed. (d.) Resident #77 was not administered prescribed medication to lower their high potassium level on 12/21/2024 and did not receive the medication until 12/25/2024, after it was noted that Resident #77's potassium level was further elevated. (e.) Resident #327 was not administered antibiotics until two (2) days after the order was prescribed, causing a delay in treatment for an active infection. This resulted in actual harm for Resident #47 which was Immediate Jeopardy and Substandard Quality of Care with the likelihood of risk for harm to the health and safety of Residents #12, #23, #77, and #327. This is evidenced by: The Policy and Procedure titled, Administering Medications, effective 10/1997 and reviewed on 1/2025, documented that Medications should be administered in a safe and timely manner, and as prescribed. The policy Interpretation and Implementation documented the following: Medications must be administered in accordance with the orders, including any required time frame; medications must be administered within one (1) hour of their prescribed time, unless otherwise specified; if a dosage was believed to be inappropriate or excessive for a resident, or an education had identified consequences, the person preparing or administering the medications should contact the resident's Attending Physician or the facility's Medical Director to discuss the concerns. The following information must be checked/verified for each resident prior to administering medications: allergies to medications; vital signs, if necessary; for residents not in their rooms or otherwise unavailable to receive medication on the pass, the Electronic Medication Administration Record may be flagged. After completing the medication pass, the nurse would return to the missed resident to administer the medication; if a drug was withheld, refused, or given at a time other than the scheduled time, the individual administering the medication should document the same in the Electronic Medication Administration Record for that drug and dose. The person withholding, receiving the refusal, or administering medication at a different time would notify the attending/covering physician. The individual administering the medication must sign the resident's Electronic Medication Administration Record as indicated by the software after giving each medication and before administering the next one. As required or indicated for medication, the individual administering the medication would record in the resident's medical record: (a.) the date and time the medication was administered; (b.) the dosage; (c.) the route of administration; (d.) the injection site (if applicable); (e.) any complaints or symptoms for which the drug was administered; (f.) any results achieved and when those results were observed; and (g.) the signature and title of the person administering the drug; topical medication used in treatment must be recorded on the resident's treatment record; and residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, had determined that they have the decision-making capacity to do so safely. Resident #47 Resident #47 was admitted to the facility with diagnoses of schizophrenia (a mental condition characterized by thoughts or experiences that seem out of touch with reality), chronic obstructive pulmonary disease with acute exacerbation (a chronic lung disease that causes progressive and irreversible damage to the airways in the lungs), and type 2 diabetes mellitus (a chronic condition where the body does not use insulin properly or does not produce enough insulin to regulate blood sugar levels). The Minimum Data Set, dated dated dated , 10/01/2024 documented the resident was cognitively intact, could be understood, and understand others. The Care Plan for Resident Displays/Reports the following moods: feeling down, depressed, hopeless, feeling tired or having little interest or pleasure in doing things, revised 12/02/2024, documented the resident had a history of suicidal ideation and their last statement was on 11/25/2024, when they had suicidal ideation, no plan. Interventions included administer psychotropic medications as ordered, assess for suicidal ideation if needed, no cords per statement of suicidal ideation, and psychological services as needed Order Summary Report for order date range 11/01/2024 to 3/07/2025, documented an order dated 11/25/2024 for Clozapine oral tablet, give 375 milligrams by mouth at bedtime for schizophrenia. There was no end date on the order. Record review of manufacturer specification of Clozaril (clozapine), located at https://clozaril.com/important-safety-information/ documented the following: Important Safety Information, Discontinuing Treatment documented to reduce the dose gradually over a period of 1 to 2 weeks if termination of clozapine therapy was planned and there was no evidence of moderate to severe neutropenia (low number of neutrophils (a type of white blood cell) in the bloodstream). For abrupt clozapine discontinuation for a reason unrelated to neutropenia, continuation of the existing ANC (absolute neutrophil count) monitoring was recommended. It documented to monitor all patients carefully for the recurrence of psychotic symptoms. Medication Administration Record dated November 2024 documented, Clozapine 375 milligrams was to start on 11/25/2024 at 9:00 PM and documented: o 11/25/2024 was not given and documented: awaiting pharmacy delivery. o 11/26/2024 was not given and documented: medication was enroute from pharmacy, would administer upon arrival. Physician notified. o 11/27/2024 was documented as given. o 11/28/2024 was not given and documented: the medication was on order and awaiting arrival from the pharmacy. Skilled nursing would follow up. Hospital Discharge Summary dated 11/25/2024, Hospital Course documented the resident was found to have a lung infection and was also seen by psychiatry services. The resident was on one-to-one observation for suicidal ideation. Prior to discharge, the resident was cleared by psychiatry services and was taken off one-to-one observation. Discharge diagnosis/plan included schizophrenia and suicidal ideation. Behavioral Health Services Note dated 11/26/2024 documented the resident recently returned for a hospitalization for medical reasons, but then required additional time on the psychiatric unit for suicidal ideation. The resident currently was reporting feeling more stable, with no thoughts of suicidal ideation. The resident reported continued thoughts of mild depression and confusion. Target symptoms that would be the focus of treatment: depression, psychosis. A nursing note dated 11/29/2024 at 8:36 AM by Registered Nurse #5 documented Resident #47 stated, I want to die. I want to go to the hospital. Registered Nurse #5 informed the provider and social work and assigned a staff member to sit with the resident. 911 was called and the resident was sent to the Emergency Department. The resident was sent to the hospital at 9:00 AM. A nursing note dated 11/29/2024 at 4:07 PM, documented the resident returned from the Emergency Department at 4:05 PM. The Medication Administration Record dated November 2024 documented Clozapine 375 milligrams was given on 11/29/2024 and 11/30/2024 at 9:00 PM. Surveyors were unable to determine how/why Clozapine was documented as given on 11/27/2024, 11/29/2024, and 11/30/2024. There was no documented evidence Clozapine was delivered to the facility in November 2024: Pharmacy report for Clozapine for Resident #47, dispense date range 2/01/2024 to 3/03/2025, did not document Clozapine was dispensed in November 2024. The medication was not dispensed until 12/6/2024. Per the report of what was available in the facility PYXIS (automated medication dispensing system), Clozapine was not stocked in the facility. The Medication Administration Record dated December 2024documented Clozapine 375 milligrams was to be given at bedtime and was scheduled for 9:00 PM. It documented: o 12/01/2024 was not given and documented: enroute from pharmacy. Physician notified. o 12/02/2024 was documented as given. o 12/03/2024 was documented as given. o 12/04/2024 was documented as given. o 12/05/2024 was not given and documented: awaiting pharmacy delivery. There was no documented evidence that Clozapine was delivered to the facility from 12/01/2024 to 12/05/2024. A Physician Progress Note dated 12/06/2024 at 3:38 PM by Nurse Practitioner #2, documented Resident #47 was prescribed Clozapine for schizophrenia. Clozapine level was less than 10. (therapeutic range 350-600 nanograms/milliliter) It documented questionable medication adherence. The medication administration report showed 5 times the resident did not receive medication, unclear why. A nursing note dated 12/06/2024 at 4:01 PM documented the nurse was informed by the pharmacy that the resident's clozapine was waiting for approval, and as soon as it was approved, it would be sent on the next delivery. Provider was made aware. The Medication Administration Record dated December 2024 documented Clozapine 375 milligrams was not given on 12/06/2024 at 9:00 PM. A Medication Administration Note dated 12/06/2024 at 8:51 PM, documented: awaiting pharmacy delivery. The Pharmacy Packing Slip Proof of Delivery documented Clozapine 375 milligrams was delivered to the facility for Resident #47 on 12/06/2024 at 9:49 PM. There was no documentation on the Medication Administration Record dated 12/06/2024 that the clozapine was administered on 12/06/2024 after it was received in the facility at 9:49 PM. The Medication Administration Record dated 12/7/2024 documented Clozapine 375 milligrams was given at 9:00 PM. A nursing note dated 12/08/2024 at 4:24 PM by Registered Nurse #6 documented at 3:35 PM Registered Nurse #6 and the unit nurse entered the resident's room and found Resident #47 flailing their arms around and flipping their body over continuously and putting themselves onto their knees and attempting to stay on the floor. Resident #47 was not speaking normally, oriented to self , and unable to say the name of the facility. Typically, the resident could say the name of the facility. Resident #47 has also known Registered Nurse #6's name for months but could not recall their name. Resident #47 stated they wanted to go to the hospital. Resident #47 has not received their psychiatric medication in a week and the resident was not functioning safely. A nursing note dated 12/08/2024 at 5:19 PM by Registered Nurse #documented they called 911 and report was given to the Emergency Medical Technicians. Resident #47 appeared to understand they were going to the hospital and wanted to go. The Hospital Emergency Documentation documented the resident was seen on 12/8/2024 at 7:36 PM. Chief complaint: The resident was brought in by ambulance from the nursing home for altered mental status. The resident had a history of schizophrenia and has not been given their clozapine for unknown time/unreason. The Emergency Department Course/Medical Decision Making documented resident presents with altered mental status. Differential diagnosis included but not limited to medication side effect, medication withdrawal, urinary tract infection, or metabolic abnormality. Basic labs, urinalysis, and chest x-ray were obtained. Urinalysis was not suggestive of urinary tract infection. Chest x-ray and computed tomography did not show any significant findings. On reevaluation, the resident was arousable and was able to have a conversation. The resident stated they remembered feeling somewhat confused that afternoon but now felt back to normal. The resident was discharged and transported back to the facility by ambulance. The Emergency Department Clinical Summary, Discharge Information, documented the resident discharged on [DATE] at 2:26 AM with diagnosis of confusion. A Physician Progress Note dated 12/09/2024 at 3:39 AM by Nurse Practitioner #6 documented they received a call from the facility for admission medication reconciliation. The resident returned from the hospital after hallucinating. During an interview on 3/2/2025 at 12:12 PM, Nurse Practitioner #2 stated Resident #47 missed several doses of Clozapine and ended up going to the hospital because they were suicidal. Resident #12 Resident #12 was admitted to the facility with diagnoses of severe intellectual disabilities (a developmental delay that limits a person's ability to function in social and practical ways), chronic kidney disease stage 3 (a moderate level of kidney damage that would make it harder for kidneys to filter waste and fluid from the blood), and type 2 diabetes mellitus. The Minimum Data Set (an assessment tool) dated 12/09/2024 documented the resident had severe cognitive impairments, could be understood, and sometimes understand others. A Physician Progress Note dated 1/02/2025 at 12:28 PM documented Resident #12 was diagnosed with a urinary tract infection on 12/19/2024, with enterococcus faecalis bacteria in critically high amounts. It documented they were prescribed an antibiotic, Amoxicillin 500 milligrams by mouth; however, according to nursing staff, the resident had been spitting out the pills and refusing to take them. Based on the resident's behavior, the oral antibiotic was changed to intravenous antibiotic (administered into a vein). The resident was prescribed the antibiotic Ampicillin, 2 grams intravenously every 6 hours for 7 days. A Physician Order dated 1/02/2025 at 11:56 AM documented Resident #12 was to receive Ampicillin Sodium Solution, reconstituted 2 grams, starting 1/02/2025 at 6:00 PM, administered intravenously every 6 hours at 12:00 AM, 6:00 AM, 12:00 PM, and 6:00 PM for 7 days. Registered Nurse Orders Administration Report dated 1/02/2025 6:00 PM dose was not given. The record was blank. There was no documented evidence why the medication was not given. A Physician Order dated 1/03/2025 at 1:10 PM documented Ampicillin Sodium Solution reconstituted 2 grams, intravenously every 6 hours at 12:00 AM, 6:00 AM, 12:00 PM, and 6:00 PM for 7 days. Start date 1/3/2025 at 6:00 PM. A Registered Nurse Orders Administration Report dated January 2025 documented Ampicillin Sodium Solution Reconstituted 2 grams, use intravenously every 6 hours for urinary tract infection for seven (7) days. The medication was scheduled to be given at 12:00 AM, 6:00 AM, 12:00 PM, and 6:00 PM. The resident did not receive 10 out of 20 scheduled doses as follows: o 1/03/2025 12:00 AM, 6:00 AM, and 12:00 PM doses were not given and there were no progress notes. Physician Progress Note dated 1/03/2025, documented the resident missed three (3) doses due to a delay in delivery by the pharmacy and a staff shortage. o 1/04/2025 12:00 AM, 6:00 AM, and 6:00 PM doses were not given and there was no documented evidence why the medication was not given. o 1/05/2025 6:00 PM dose was not given and there was no documented evidence why the medication was not given. o 1/06/2025 6:00 PM dose was not given and there was no documented evidence why the medication was not given. o 1/07/2025 12:00 PM dose was not given and there was no documented evidence why the medication was not given. A Physician Progress Note dated 1/07/2025 at 4:50 PM by Nurse Practitioner #2 documented they were notified that several doses of intravenous Ampicillin had been missed. Ampicillin was ordered to treat enterococcus faecalis urinary tract infection. The intravenous medication was specifically ordered as the resident had been refusing all medications by mouth. This was brought to the physician's attention on 1/02/2025 and as a result, was started on Ampicillin 2 grams intravenously every six (6) hours. Order changed to Levaquin 250 milligrams intravenously once a day at 2:00 PM, for better medication compliance. The Medication Administration Record dated January 2025 documented Levofloxacin (Levaquin) intravenous solution, use 250 milligrams intravenously in the afternoon for urinary tract infection for three (3) days, to start on 1/07/2025 at 2:00 PM. A record review of the Medication Administration Record revealed the resident did not receive the Levaquin on 1/09/2025. There was no documented evidence why the medication was not given. A Physician Progress Note dated 1/10/2025 at 11:50 AM by Nurse Practitioner #2 documented the resident was prescribed intravenous Levaquin for urinary tract infection. The resident did not receive the last dose yesterday afternoon (1/09/2025). Plan: would give the last dose of intravenous Levaquin 250 milligrams now. The provider would follow up to ensure the dose was received. A record review of the Medication Administration Record revealed the resident received the intravenous Levaquin on 1/10/2025. During an interview on 3/02/2025 at 12:12 PM, Nurse Practitioner #2 stated they had to alter orders to account for no staffing. It had been something they had to do since about October 2024. They could not recall other resident names, but they knew missed medication doses for other residents had happened in the past. They stated nurses were documenting medications were not available but were not notifying providers. Providers had to double cover infections with more than one (1) antibiotic because they were unsure if residents had received all the doses. They stated Resident #12 was ordered to have Ampicillin intravenously every six (6) hours to treat urinary tract infection. They did not have enough nurses on the unit to administer the medication as ordered and the resident missed doses of Ampicillin. They had to think of a way to provide medication to the resident and ordered Levaquin intravenously once daily for three (3) days for better medication compliance by nursing staff. They stated that even with the Levaquin being a once daily medication, the resident did not get it for three (3) consecutive days as ordered. They stated the resident missed the third dose and they had to order a one-time dose of Levaquin intravenously. Resident #23 Resident #23 was admitted to the facility with diagnoses of chronic obstructive pulmonary disease (a chronic lung disease that causes progressive and irreversible damage to the airways in the lungs), acute on chronic systolic congestive heart failure (a sudden worsening of symptoms of a pre-existing condition of weakened heart muscles), and type 2 diabetes mellitus. The Minimum Data Set, dated dated dated [DATE] documented the resident was cognitively intact, could be understood, and understand others. A Physician Progress Note dated 2/22/2025 at 6:00 PM by Nurse Practitioner #3 documented they received a call from nursing staff reporting the resident's urinalysis and culture results returned positive for urinary tract infection and was sensitive to Augmentin (antibiotic). The resident was prescribed Augmentin 875 milligrams twice daily. A Physician Order dated 2/22/2025 documented Amoxicillin-potassium clavulanate (Augmentin) tablet 875-125 milligrams, give 1 tablet by mouth every 12 hours for urinary tract infection for seven (7) days. Start date 2/22/2025. The Medication Administration Record dated February 2025 documented Amoxicillin-potassium clavulanate tablet 875-125 milligrams, give one (1) tablet every 12 hours for urinary tract infection for seven (7) days, to start on 2/22/2025 at 6:00 PM. It was scheduled to be given at 6:00 AM and 6:00 PM. The order was discontinued on 2/26/2025 at 8:29 AM, for a total of eight (8) doses to be given. The facility printed a report from the automated medication dispensing system on 2/27/2025 for Resident #23, for date range 2/21/2025 to 2/25/2025, documented Augmentin (four (4) doses) were removed from the automated medication dispensing system on: o 2/22/2025 at 5:43 PM o 2/23/2025 at 7:12 AM o 2/24/2025 at 4:02 PM o 2/25/2025 at 3:34 PM Review of the Medication Administration Record dated February 2025 for Amoxicillin-potassium administration revealed the resident did not receive four (4) doses as follows: o 2/23/2025 6:00 PM documented Augmentin was given. There was no record that it was removed from the automated medication dispensing system. o 2/24/2025 6:00 AM was not given and there was no documented evidence why the medication was not given. o 2/25/2025 6:00 AM documented Augmentin was not given. The medication administration notes documented: did not come from pharmacy and not available in automated medication dispensing system. Supervisor aware. o 2/26/2025 6:00 AM was not given. The medication administration notes documented: not available from pharmacy and none in automated medication dispensing system. Supervisor notified. During an interview on 2/26/2025 at 12:40 PM, Resident #23 stated they missed two or three doses of antibiotics because they were not available. During an interview on 3/02/2025 at 12:12 PM, Nurse Practitioner #2 stated Resident #23 developed pneumonia while being treated for urinary tract infection. They stated the Augmentin that was ordered would have taken care of the urinary tract infection and pneumonia if the nurses had given the medication as ordered. They stated they had to order intravenous antibiotic for Resident # 23's pneumonia because of the missed doses of Augmentin. They stated Resident #47 missed several doses of Clozapine and ended up going to the hospital because they were suicidal. Resident #77 Resident #77 was admitted to the facility with diagnoses of chronic kidney disease (chronic kidney damage that makes it harder for kidneys to filter waste and fluid from the blood), cerebral infarction (a medical condition where the blood flow to the brain is interrupted, leading to the death of brain cells), and chronic obstructive pulmonary disease. The Minimum Data Set, dated dated dated [DATE] documented the resident was cognitively intact. The resident made themselves understood and was able to understand others. A Laboratory Report dated 12/21/2024 documented the results of a basic metabolic panel (helps doctors check the body's fluid balance and levels of electrolytes) that was collected on 12/20/2024. The potassium result was 5.2 (reference range 3.5 - 5.1) and was flagged as being high. An Order Summary Report for 11/01/2024 to 3/31/2025 documented an order dated 12/21/2024 for sodium zirconium cyclosilicate, give one (1) packet by mouth for hyperkalemia (high level of potassium in the blood often caused by kidney disease) for one (1) day. A nursing note dated 12/21/2024 at 10:54 PM by the Registered Nurse #3 documented they received a call from the provider regarding Resident #77 having a potassium level of 5.2. The provider placed a new order for sodium zirconium cyclosilicate. Registered Nurse #3 contacted the pharmacy, and they reported they were not able to get the medication to the facility until the following afternoon. The provider was made aware and confirmed it was okay that the medication was not available until the following afternoon. The Medication Administration Record dated December 2024 did not document sodium zirconium cyclosilicate was given on 12/22/2024, and there was no documented evidence in a Nursing Progress Note that the provider was notified. A Laboratory Report dated 12/24/2024 documented the results of a basic metabolic panel that was collected on 12/23/2024. The potassium result was 5.4 (reference range 3.5 - 5.1) and was flagged as being high. A Physician Progress Note dated 12/24/2024 at 3:45 PM by Physician #2 documented the resident was seen for routine lab review related to chronic illness. It documented resident received one (1) dose of the sodium zirconium cyclosilicate for potassium of 5.2 on 12/21/2024, and on that day the potassium level was 5.4. There was no documented evidence Resident #77 received sodium zirconium cyclosilicate on 12/21/2024, 12/22/2024, or 12/23/2024. An Order Summary Report for order date range 11/01/2024 to 3/31/2025, documented an order dated 12/24/2024 for sodium zirconium cyclosilicate oral packet 10 grams (sodium zirconium cyclosilicate), give one (1) packet by mouth two (2) times a day for hyperkalemia for one (1) day. An Order Note dated 12/25/2024 at 2:16 AM by Registered Nurse documented the order for sodium zirconium cyclosilicate oral packet 10 grams, give one (1) packet two (2) times a day for hyperkalemia was outside of the recommended dose or frequency. The frequency of two (2) times a day exceeded the usual frequency of every two (2) days to daily. It documented the provider was aware. The Medication Administration Record dated December 2024 documented sodium zirconium cyclosilicate oral packet 10 grams was given on 12/25/2024 at 9:00 AM. Resident #327 Resident #327 was admitted to the facility with fracture of upper and lower end of the right fibula (when the smaller bone in the lower leg is broken at both the knee and the ankle regions), atrial fibrillation (a common heart rhythm disorder where the upper chambers of the heartbeat irregularly and rapidly), and dementia (a chronic generative condition characterized by progressive or persistent memory impairment). The Minimum Data Set, dated dated dated [DATE] documented the resident was able to understand and be understood by others. A Physician's Order dated 4/16/2024 documented the resident was to receive Azithromycin (an antibiotic) 500 milligrams intravenously one time a day for pneumonia for two (2) administrations. The Medication Administration Record documented the resident did not receive either dose of the antibiotic. The progress note dated 4/16/2024 documented the nurse was unable to establish intravenous access, the provider was called and did not give any new orders. There was no documentation on the Medication Administration Record or in the progress notes for the missed dose on 4/17/2024. On 4/18/2024, Resident #327 was transferred to the hospital by family request and admitted overnight. The resident was treated for pneumonia and received intravenous antibiotics. During an interview on 3/02/2025 at 1:48 PM, Director of Nursing #1 stated that they were aware there were medications missing from the pharmacy. They had been looking into it. They stated they had not run into any reports of missing medications or medication errors but had just been informed by staff that pharmacy did not send medications. Director of Nursing #1 stated they would expect staff who discovered medications were not in-house to check the automated medication dispensing system to see if there were any available, contact the Medical Doctor to tell them what was available for substitution, document in the Electronic Medical Record that the medication was not available and that the dose was missed, and call the pharmacy to make sure the medication would come on the next run. Missed medications should be reported to the supervisor. Director of Nursing #1 stated they were unaware that there was a medication error form, and that documentation of missed medications should be in the shift-to-shift 24-hour report that was reviewed every day. Director of Nursing #1 stated Nurse Managers were also supposed to check the 24-hour shift to shift report for discrepancies on their units. The Quality Assurance Plan Initiative meeting had occurred one time since they have been a Director of Nursing, and they were having night nurses review carts and medications to ensure that everything was where it needed to be. The pharmacy made three (3) deliveries a day, early in the morning on the overnight shift, in the afternoon on day shift, and on the evening shift around 8:00 PM or 9:00 PM. During an interview on 3/02/2025 2:00 PM, Administrator #1 stated in the past they had reached out to the providers to help figure out issues. They stated they would expect staff to call the pharmacy for missing medication doses and to find out when they could be delivered. Administrator #1 stated they would expect staff to call the Medical Director to see if something else could be given. They stated they would expect staff to monitor the resident and document whatever direction was given by provider. They stated the medication issues in the building just came to light over the last week. The facility completed medication error/missed dose sheets when there was an error or missed medication. Administrator #1 stated they had not received any sheets in January or February 2025 unless they were on the Director of Nursing's desk, and they did not know it. They stated they did not run reports specific to medication issues, but they would expect the nurses would write a progress note that would be on the 24-hour report that gets reviewed daily. They stated they had never heard that there were not enough staff at the facility to get medications passed or resident care done. During an additional interview on 3/02/2025 at 3:11 PM, Administrator #1 stated they had started a house-wide education regarding what was available in the automated medication dispensing system and what to do when something was not available. Supervisors and unit managers had been reeducated on the policy of checking their reports, checking the clinical dashboard for late and/or missing medications. Daily reports would be run regarding medication errors and missed doses and if the providers were notified. Administrator #1 stated they will be checking reports for yellow and red colors (indicated late or missed doses) daily and trying to correct inconsistencies in real time. 10 New York Codes Rules and Regulations 415.12(m)(2) 43805 48744

Based on observation, record review, and interviews during a recertification and abbreviated survey (Case #NY00347964), the facility did not ensure the provision of sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident throughout the facility. Specifically, the facility's minimum staffing levels were not met each day from 2/22/2025 through 3/06/2025 per facility assessment and New York State Nursing Home Minimum Staffing and Direct Resident Care. This is evidenced by: Upon entrance to the facility on [DATE] there were 123 residents residing on 3 units. Nursing Homes are required by New York State Public Health Law and Regulations to meet minimum staffing standards. These minimum standards required every nursing home to maintain daily staffing hours equal to 3.5 hours of care per resident per day by a certified nurse aide, licensed practical nurse, or registered nurse. Of the 3.5 hours required, at least 2.2 hours of care per resident per day must be provided by a certified nurse aide and at least 1.1 hours of care per resident per day must be provided by a licensed nurse. The Facility assessment dated [DATE] documented, under Part 3 listed Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies. Licensed nurses providing direct care: Average Days 3-6; Evenings 3-6; Nights 3. Nurse aides: Average Days 3-12; Evenings 3-9; Nights 3-6. Other nursing personnel (e.g., those with administrative duties) Director of Nursing, Assistant Director of Nursing, Nurse Manager, Nurses (Licensed Practical Nurses, Minimum Data Set, Quality Assurance Performance Initiative, Education). Other nursing personnel did not account for the Director of Nursing as a licensed nurse on any unit. Additionally, there was no Assistant Director of Nursing in the facility at the time of the survey. Nurse Managers were counted as being floor staff for the purposes of counting staff working on the units. All Licensed Practical Nurses were counted as working staff on the units; however, the Minimum Data Set, Quality Assurance and Education positions were not counted as working staff unless they were documented as working on as assigned unit per the staffing sheets provided by the facility. A review of staffing sheets provided by the facility from 2/22/2025 through 3/06/2025 documented the following: Based on facility census, there were not the required number of Registered Nurses or Licensed Practical Nurses on 2/22/2025, 2/23/2025, 2/28/2025, 3/03/2025, and 3/06/2025. On 2/22/2025, the facility census was 123. There were 16 licensed nurses (Licensed Practical Nurses and Registered Nurses) scheduled to work on that day. The required hours of licensed care for the facility were 135.3 hours based on the census. The licensed staff scheduled accounted for 128 hours of care. On 2/23/2025, the facility census was 122. There were 14 licensed nurses scheduled to work on that day. The required hours of licensed care for the facility were 134.2 hours based on the census. The licensed staff scheduled accounted for 112 hours of care. On 2/28/2025, the facility census was 124. There were 16 licensed nurses scheduled to work on that day. The required hours of licensed care for the facility were 136.4 hours based on the census. The licensed staff scheduled accounted for 128 hours of care. On 3/03/2025, the facility census was 125. There were 16.5 licensed nurses scheduled to work on that day. The required hours of licensed care for the facility were 137.5 hours based on the census. The licensed staff scheduled accounted for 132 hours of care. On 3/06/2025, the facility census was 125. There were 15 licensed nurses scheduled to work on that day. The required hours of licensed care for the facility were 137.5 hours based on the census. The licensed staff scheduled accounted for 120 hours of care. A review of staffing sheets provided by the facility from 2/22/2025 through 3/06/2025 documented the following: Based on facility census, there were not the required number of Certified Nurse Aides any day between 2/22/2025 through 3/06/2025. On 2/22/2025, the facility census was 123. There were 23 Certified Nurse Aides scheduled to work on that day. The required hours of Certified Nurse Aide care for the facility were 301.35 hours based on the census. The Certified Nurse Aide staff scheduled accounted for 184 hours of care. On 2/23/2025, the facility census was 122. There were 22 Certified Nurse Aides scheduled to work on that day. The required hours of Certified Nurse Aide care for the facility were 298.9 hours based on the census. The Certified Nurse Aide staff scheduled accounted for 176 hours of care. On 2/24/2025, the facility census was 121. There were 22 Certified Nurse Aides scheduled to work on that day. The required hours of Certified Nurse Aide care for the facility were 296.45 hours based on the census. The Certified Nurse Aide staff scheduled accounted for 176 hours of care. On 2/25/2025, the facility census was 120. There were 24 Certified Nurse Aides scheduled to work on that day. The required hours of Certified Nurse Aide care for the facility were 294 hours based on the census. The Certified Nurse Aide staff scheduled accounted for 192 hours of care. On 2/26/2025, the facility census was 121. There were 21 Certified Nurse Aides scheduled to work on that day. The required hours of Certified Nurse Aide care for the facility were 296.45 hours based on the census. The Certified Nurse Aide staff scheduled accounted for 168 hours of care. On 2/27/2025, the facility census was 123. There were 21 Certified Nurse Aides scheduled to work on that day. The required hours of Certified Nurse Aide care for the facility were 301.35 hours based on the census. The Certified Nurse Aide staff scheduled accounted for 168 hours of care. On 2/28/2025, the facility census was 124. There were 21 Certified Nurse Aides scheduled to work on that day. The required hours of Certified Nurse Aide care for the facility were 303.8 hours based on the census. The Certified Nurse Aide staff scheduled accounted for 168 hours of care. On 3/01/2025, the facility census was 125. There were 28 Certified Nurse Aides scheduled to work on that day. The required hours of Certified Nurse Aide care for the facility were 306.25 hours based on the census. The Certified Nurse Aide staff scheduled accounted for 224 hours of care. On 3/02/2025, the facility census was 125. There were 21 Certified Nurse Aides scheduled to work on that day. The required hours of Certified Nurse Aide care for the facility were 306.25 hours based on the census. The Certified Nurse Aide staff scheduled accounted for 168 hours of care. On 3/03/2025, the facility census was 125. There were 22 Certified Nurse Aides scheduled to work on that day. The required hours of Certified Nurse Aide care for the facility were 306.25 hours based on the census. The licensed staff scheduled accounted for 176 hours of care. On 3/04/2025, the facility census was 125. There were 20 Certified Nurse Aides scheduled to work on that day. The required hours of Certified Nurse Aide care for the facility were 306.25 hours based on the census. The Certified Nurse Aide staff scheduled accounted for 160 hours of care. On 3/05/2025, the facility census was 125. There were 21 Certified Nurse Aides scheduled to work on that day. The required hours of Certified Nurse Aide care for the facility were 306.25 hours based on the census. The Certified Nurse Aide staff scheduled accounted for 168 hours of care. On 3/06/2025, the facility census was 125. There were 23 Certified Nurse Aides scheduled to work on that day. The required hours of Certified Nurse Aide care for the facility were 306.25 hours based on the census. The Certified Nurse Aide staff scheduled accounted for 184 hours of care. During the resident council meeting on 2/24/2025 at 11:38 AM, residents present stated that there were not enough staff members. During an interview on 2/24/2025 at 3:59 PM, Resident #61 stated that they had been at the facility since January, 2025. Resident #61 stated that they had 2 showers since they arrived but were supposed to have at least 1 per week, on Fridays on the 3-11 PM shift. Staff had told Resident #61 they were short staffed, and the resident had to wait. During an interview on 2/27/2025 at 9:03 AM, Registered Nurse #2 stated that the unit was short staffed, and they had never worked with such low staffing numbers. There was no real effective staff appreciation. The facility had monthly staff appreciation days but there's no bonuses for people that pick-up shifts, there's no app to communicate where the staffing holes were in case someone wanted to pick up or trade shifts. Registered Nurse #2 additionally stated that they have had to do all the care plans for unit A and sometimes some of the care plans on unit B. It was very hard to run two units. During an interview on 3/02/2025 at 11:54 AM, Administrator #1 stated that the facility did have agency staff but not a lot. Administrator #1 stated that they did not think that they were significantly understaffed. During an interview on 3/02/2025 at 1:48 PM, Director of Nursing #1 stated that they had never been told something could not be done because of no staff. During a subsequent interview on 3/02/2025 at 2:00 PM, Administrator #1 stated that they had never heard that there were not enough staff at the facility to administer medications or resident care done. 10 New York Code Rules and Regulations 415.13(a)(1)(i-iii)

Based on record review, observations, and interviews during the recertification survey and an abbreviated survey (Case #s NY00369042 and NY00363829), the facility did not ensure residents received treatment and care in accordance with professional standards of practice for five (5) (Resident #s 6, 14, 20, 23, and 77) of 32 residents reviewed. Specifically, [a.] Resident #6 who was newly admitted on [DATE] with diagnoses of diabetes, was to have blood sugar checks 3 times a day, per discharge paperwork. The facility did not check the resident's blood sugar until 1/11/2025 at 4:55 PM; [b.] Resident #14's clothes and bedding were not changed effectively; [c.] Resident #20 did not receive proper footcare; and [d.] for Resident #s 23 and 77, vital signs ordered daily and for changes in condition were not obtained, and did not monitor the resident's condition. This is evidenced by: Cross-referenced to F635: Admission Physician Orders for Immediate Care. The facility Policy and Procedure titled, Change in a Resident's Condition or Status, reviewed 1/2025, documented the nurse would record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Resident #6 Resident #6 was admitted to the facility with the diagnoses of acute respiratory failure (lungs cannot release enough oxygen into the blood), type 2 diabetes (an endocrine system dysfunction when the body cannot use insulin correctly and sugar builds up in the blood), and chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems). The Minimum Data Set, dated dated [DATE], documented the resident was able to be understood, understand others, with minimal cognitive deficits. The Licensed Nurse: Admission/Readmission Evaluation dated 1/10/2025 at 9:48 PM, documented the most recent admission was 1/10/2025 at 9:40 PM. Reason for admission was acute hypoxic respiratory failure due to pneumonia and hyperglycemia (high blood sugar). Discharge paperwork from hospital documented need to check finger sticks 3 times a day daily. The resident was an insulin dependent diabetic who required Insulin Degludec daily and Insulin Lispro before meals.????? Physician Progress Note dated 1/11/2025 at 12:09 PM by the Nurse Practitioner, documented the resident was seen and evaluated that morning for medical follow-up, given they were a new admission to the facility. The resident arrived yesterday evening. The resident had poorly controlled diabetes. The medication regimen that was available was reviewed, which they believed was the most accurate documentation that they were able to obtain at the moment. Plan included monitor blood glucose levels, avoid hyperglycemia. Would adjust therapy if needed. Medication Administration Record dated January 2025, documented an order to monitor blood sugar before meals and at bedtime for diabetes. The order was to start on 1/11/2025 at 4:30 PM. The Blood Sugar Summary Report printed 3/01/2025 at 10:46 AM, documented the resident's blood sugar was 286 on 1/11/2025 at 4:55 PM. The report did not have documented evidence of blood sugar levels prior to that date/time. During an interview on 3/02/205 at 11:55 AM, Director of Nursing #1 stated for admissions that were off shift admissions, staff would follow the admission check list which included things like diets, advanced directives, and medication orders. Director of Nursing #1 stated staff would need to verify the physician orders in order to treat the resident, but there was always a physician on call 24 hours a day. When asked if the staff would be expected to assess the resident upon arrival, Director of Nursing #1 stated that they did not know if the Registered Nurse assessment had to be done within a certain time limit, but it would be expected to be done during the shift that the resident was admitted . Vital signs and a finger sticks would be a part of that assessment. Doing the assessment 12 hours later would not be acceptable. Resident #14 Resident #14 was admitted to the facility with diagnoses of dementia (a group of conditions that cause a progressive decline in cognitive abilities), iron deficiency (a state where the body's iron stores are depleted), and diverticulitis (inflammation of irregular bulging in the large intestine). The Minimum Data Set, dated dated dated [DATE], documented the resident was usually able to understand and be understood by others, with significant cognitive impairment. Resident #14's Comprehensive Care Plan for Assistance with Self-care and mobility, dated 10/2023, documented that the resident required supervision or touching assistance for all personal care. Resident #14's Comprehensive Care Plan for Impaired Skin Integrity, dated 1/06/2023 and revised 1/09/2023, listed the interventions of applying moisturizer as needed to skin, apply protective/preventative skin care, keep skin dry, clean, and well lubricated, and monitor skin condition daily during care and report changes. During an observation on 2/24/2025 at 11:30 AM, Resident #14's bed clothes had not been changed effectively and when the sheets were removed the mattress was covered with dead skin. Resident #20 Resident #20 was admitted to the facility with the diagnoses of schizoaffective disorder (mental health condition that combines symptoms of schizophrenia with mood disorders such as depression), chronic obstructive pulmonary disease, and generalized anxiety order (excessive, frequent, and unrealistic worry about everyday things). The Minimum Data Set, dated dated [DATE], documented the resident was usually able to understand others, usually able to be understood, and was cognitively intact. Resident #20's comprehensive care plan for being at risk of being a victim due to inability to understand their surroundings related to dependence on others for activities of daily living, documented interventions to assess the resident for signs and symptoms of abuse and/or neglect and provide assistance with activities of daily living as needed. During an observation on 2/24/2025 at 9:30 AM, Resident #20 showed surveyor that their toenails were so long they wrapped around the resident's toes and the resident had blisters on multiple toes. There was no documented evidence of care plan related to foot care. A podiatry note dated 11/09/2024 documented all of Resident #20's toenails were elongated and there were no open areas noted. During an interview on 2/28/2025 at 2:28 PM, Licensed Practical Nurse #17 was made aware of Resident #20's feet. Licensed Practical Nurse #17 stated that they did not know about the resident's feet. Resident #20 stated they had told staff and named Registered Nurse #2 as the person they told. Licensed Practical Nurse #17 stated to the resident, Next time tell me. You know I'll get something done. Licensed Practical Nurse #17 thanked surveyor for showing Resident #20's feet to them. During an interview on 3/07/2025 at 2:00 PM, Regional Director of Nursing #1 stated that care plans needed to reflect the resident. It should have been updated for falls, wounds, behavior, something new for the resident and any or all medications. Resident #23 Resident #23 was admitted to the facility with diagnoses of chronic obstructive pulmonary disease, acute on chronic systolic congestive heart failure (a sudden worsening of symptoms of a pre-existing condition of weakened heart muscles), and type 2 diabetes mellitus. The Minimum Data Set, dated dated [DATE], documented the resident was cognitively intact, could be understood, and understand others. Physicians Progress Note, dated 1/26/2025 at 11:01 AM by Nurse Practitioner #1, documented a lab review for Resident #23 with urinary symptoms. Results were completed and showed positive for urinary tract infection. Would order Levaquin 250 milligrams daily for 5 days. There was no documented evidence in Nursing Notes that the resident's condition was monitored until 1/30/2025. The Infection/Antibiotic Note dated 1/30/2025 at 11:38 AM by Licensed Practical Nurse #9, documented the resident started Levaquin today and was tolerating well with no signs and symptoms of discomfort, upset stomach or nausea. No signs and symptoms of allergy. There were no documented evidence in the Nursing Notes about the resident's condition. Treatment Administration Record dated January and February 2025, documented a physician's order for vital signs daily and to report any findings outside of the resident's baseline to the medical provider. Start date 4/06/2024 at 9:00 AM. There was no end date. The resident's vital signs: blood pressure, temperature, pulse, respiration, and oxygen saturation level documented: - 1/26/2025, blood pressure 132/68, temperature 97.4, pulse 68, respirations 17, oxygen saturation level 96. - 1/27/2025 and 1/28/2025, Licensed Practical Nurse #5 documented the same values for all vital signs as was documented on 1/26/2025. - 1/29/2025, Licensed Practical Nurse #8 documented NA for all vital sign values and there was no documented evidence in the nursing note that the medical provider was notified. - 1/30/2025 and 1/31/2025, Licensed Practical Nurse #9 documented the same values for all vital signs as was documented on 1/26/2025, 1/27/2025, and 1/28/2025. - 2/01/2025, vital signs were not documented. All values were blank. There was no documented evidence in the nursing note that the medical provider was notified. - 2/02/2025, vital signs were not documented. Licensed Practical Nurse #4 documented 5 (hold/see nurses notes) and in a medication administration note dated 1/4/2025 at 11:37 AM, documented one time a day. Physician Progress Note, dated 2/04/2025 at 10:49 AM by Physician #1, documented Resident #23 had a cold and a moderate, non-productive cough. Plan was to complete vitals every shift for 3 days. Monitor and notify provider. There was no documented evidence in the in Nursing Notes that the resident's condition was monitored. Medication Administration Record dated February 2025, documented a physician's order for vital signs every shift for CIC (change in condition) monitoring for 3 days. Start date 2/04/2025 at 3:00 PM. Blood pressure, temperature, pulse, respiration, and oxygen saturation level documented: - 2/04/2025 11:00 PM, Licensed Practical Nurse #11 documented NA for all vital sign values and there was no documented evidence in the nursing note that the medical provider was notified. - 2/05/2025 11:00 PM, Licensed Practical Nurse #18 documented NA for blood pressure and there was no documented evidence in the nursing note that the medical provider was notified. Physician Progress Note, dated 2/24/2025 at 4:45 PM by Physician #1, documented the resident was seen that day for a persistent cough and an abnormal chest x-ray finding that was highly suggestive of pneumonia. Plan included to give oxygen at 3 liters/minute, antibiotics, closely monitor the resident and notify the provider. There was no documentation in Nursing Notes that the resident's condition was monitored. Medication Administration Record dated February 2025, documented a physician order for vital signs every shift for 3 days to start 2/25/2025 at 3:00 PM. Blood pressure, temperature, pulse, respiration, and oxygen saturation level documented: - 2/25/2025 11:00 PM, Licensed Practical Nurse #11 documented NA for blood pressure, pulse, and respiration and there was no nursing note that the medical provider was notified. - 2/26/2025 11:00 PM, Licensed Practical Nurse #11 documented NA for all vital signs and there was no nursing note that the medical provider was notified. Progress Note dated 2/26/2025 at 9:08 AM by Nurse Practitioner #2, documented acute care visit for pneumonia follow up. Resident #23 has not had much improvement in their symptoms. The resident had poor appetite, general malaise (a feeling of weakness, overall discomfort, illness, or simply not feeling well), cough, congestion and profound fatigue. The resident continued to require supplemental oxygen. Plan included vitals every shift for 3 days, monitor for changes, and notify provider. Medication Administration Record dated February 2025, documented a physician order for vital signs every shift for pneumonia monitoring for 3 days, to start 2/26/2025 at 7:00 AM. Blood pressure, temperature, pulse, respiration, and oxygen saturation level documented: - 2/26/2025 11:00 PM, Licensed Practical Nurse #11 documented NA for all vital sign values and there was no documented evidence in the nursing note that the medical provider was notified. Resident #77 Resident #77 was admitted to the facility with diagnoses of chronic kidney disease (a condition where the kidneys are damaged and cannot filter blood effectively), cerebral infarction (stroke), and chronic obstructive pulmonary disease. The Minimum Data Set, dated dated [DATE], documented the resident was cognitively intact. The resident made themselves understood and was able to understand others. Physician Progress Note, dated 11/18/2024 at 12:40 PM by Nurse Practitioner #2, documented the resident was seen that day for constipation. There was no bowel movement x5 days per documentation. The resident reported they had a large bowel movement last evening. Plan: upon chart review, the resident's blood pressures were noted to be soft. The resident has had no symptoms. Would discontinue Amlodipine 5 milligrams (lowers blood pressure). Continue to monitor blood pressure daily - current order for daily vitals. Notify provider of abnormal values. Medication Administration Record dated 11/18/2024, documented the resident's blood pressure was 105/51 (normal is between 90/60 and 120/80 mmHg). Nursing Note dated 11/19/2024 at 10:15 AM by Registered Nurse #7, documented they obtained an order for the resident to receive intravenous fluids for decreased oral intake and the fluids were infusing at that time. Physician Progress Note dated 11/19/2024 at 12:15 PM by Physician #2, documented the resident was seen that day for decreased meal and fluid intake for the past 3 days. Plan included, intravenous fluid x1 liter, monitor for changes, and notify the provider. There was no documented evidence in the in Nursing Notes that the resident's condition was monitored. Physician Progress Note dated 11/22/2024 at 12:12 PM by Nurse Practitioner #2, documented the resident was seen that day for chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). The resident wanted to resume their Spiriva inhaler instead of Advair, since they had less chronic obstructive pulmonary disease exacerbations and less shortness of breath. Resident #77 reported they had been laying in bed more as of late and reported their shortness of breath made it hard for them to ambulate or participate in activities and caused extreme fatigue. Plan included monitor for changes and notify the provider. There was no documented evidence in the Nursing Notes that the resident's condition was monitored. Medication Administration Record dated November and December 2024, documented a physician's order for vital signs every dayshift to start 1/30/2024 at 7:00 AM. There was no end date on the order. The resident's vital signs: blood pressure, temperature, pulse, respiration, oxygen saturation level, and pain level documented: - 11/23/2024, Licensed Practical Nurse #16 documented NA for all vital sign values and there was no nursing note that the medical provider was notified. - 11/24/2024, blood pressure 124/60, temperature 97.8, pulse 60, respiration 18, oxygen saturation level 97, and pain level was 0. - 11/25/2024 and 11/26/2024, Licensed Practical Nurse #17 documented the same values for the blood pressure, temperature, and pulse as were documented on 11/24/2024. - 11/27/2024, vital signs were not documented. Licensed Practical Nurse #18 documented 5 (hold/see nurses notes) and in a medication administration note dated 11/27/2024 at 2:31 PM, documented not able to complete, only nurse on unit. There was no documentation the medical provider was notified. - 11/28/2024, 11/29/2024, and 11/30/2024, Licensed Practical Nurse #17 documented the same values for the blood pressure, temperature, and pulse as was documented on 11/24/2024, 11/25/2024, and 11/26/2024. - 12/01/2024, blood pressure 115/56, temperature 97.4, pulse 94, respiration 17, oxygen saturation level 97, and pain level was 0. - 12/2/2024, vital signs were not documented. Licensed Practical Nurse #16 documented NA for all vital sign values and there was no nursing note that the medical provider was notified. - 12/3/2024, Licensed Practical Nurse #17 documented NA for blood pressure, temperature, pulse, and respirations. A Medication Administration Note dated 12/3/2024 at 10:50 AM, documented did not get full vital signs due to being the only nurse on floor. There was no documentation the medical provider was made aware. Physician Progress Note dated 12/3/2024 at 4:21 PM by Physician #2, documented the resident was seen that day for laboratory review related to chronic illness. Repeat chest x-ray still showed pulmonary edema). Plan included, monitor for changes and notify provider. There was no documented evidence in the Nursing Notes that the resident's condition was monitored. Medication Administration Record dated 12/04/2024, Licensed Practical Nurse #17 documented NA for blood pressure and temperature. There was no nursing note that the medical provider was notified. Physician Progress Note dated 12/6/2024 at 9:32 AM by Nurse Practitioner #2, documented the resident was seen that day for medical follow up. The chest x-ray showed prominent lung markings that may be due to pulmonary edema or atypical pneumonia. Continue daily vitals. Medication Administration Record dated December 2024, documented a physician's order for vital signs every dayshift to start 1/30/2024 at 7:00 AM. There was no end date on the order. The resident's vital signs: blood pressure, temperature, pulse, respiration, oxygen saturation level, and pain level documented: - 12/06/2024, no vitals were documented. Licensed Practical Nurse #18 documented 5 (hold/see nurses notes) and in a Medication Administration Note dated 12/06/2024 at 1:49 PM, documented unit short. - 12/07/2024, blood pressure 122/68, temperature 97.9, pulse 60, respiration 18, oxygen saturation level 96, and pain level was 0. - 12/08/2024, Licensed Practical Nurse #3 documented the same values for the blood pressure, temperature, and pulse, as were documented on 12/7/2024. - 12/09/2024, blood pressure 130/66, temperature 97.9, pulse 66, respiration 18, oxygen saturation level 97, and pain level was 0. - 12/10/2024, Licensed Practical Nurse #3, documented the same values for the blood pressure, temperature, and pulse, as were documented on 12/9/2024. During an observation on 2/24/2025 at 10:05 AM, Licensed Practical Nurse #19 was standing in the hall at the medication cart with a resident and placed the blood pressure cuff on the resident in front of surveyor. The blood pressure cuff was on backwards with the bladder of the cuff filling outwardly. Licensed Practical Nurse #19 told the resident they could not understand why the blood pressure cuff was not reading. Licensed Practical Nurse #19 again pushed the button on the blood pressure machine to inflate the cuff. Surveyor asked Licensed Practical Nurse #19 why they thought the cuff was not reading properly. Licensed Practical Nurse #19 stated, I don't know, these don't read right sometimes. Surveyor explained that the cuff was on incorrectly. Licensed Practical Nurse #19 stared at the inflated bladder on the outside and then deflated the cuff and turned the cuff around. Licensed Practical Nurse #19 reapplied the cuff to the same arm they had been using and re-inflated the cuff again. The blood pressure reading was obtained. During an interview on 3/02/2025 at 11:15 AM, Director of Nursing #1 stated they had never been told something could not be done because there was a staffing problem. They stated it would be expected that basic care including vital signs, skin assessments, and finger sticks would be done on the shift that the resident arrived. During an interview on 3/07/2025 at 12:38 PM, Registered Nurse #2 reviewed Resident #77's electronic medical record. They stated they saw the documentation about the vitals not being completely done due to staffing issues and immediately called Licensed Practical Nurse #17 into the room. At 12:43 PM, Surveyor asked Licensed Practical Nurse #17 about their documentation of the resident's vital signs, and they stated, I have done that. They stated they made sure the oxygen and blood pressure were ok and stated they were not able to get the full set of vitals because they were the only nurse on the unit. They stated they notified the Registered Nurse supervisor and the provider. License Practical Nurse #17 stated they had to provide care to both sides of the unit and had both medication carts and were unable to get the full set of vital signs. During an interview on 3/07/2025 at 2:02 PM, Regional Clinical Director #1 was asked why nurses were documenting vital signs the same as was documented the previous day(s). They stated the surveyor would have to ask the nurse. 10 New York Codes Rules and Regulations 415.12 48744 51958

Based on observation, record review, and interview during the recertification survey, the facility did not ensure each resident was treated with respect and dignity and cared for in a manner that promotes maintenance or enhancement of quality of life for two (2) (Resident #s 39 and 61) of 32 residents reviewed. Specifically, Resident #s 39 and 61 were not cared for in a manner that promoted maintenance or enhancement of quality of life by staff providing care. This is evidenced by: The Policy and Procedure titled, Resident Rights, reviewed 1/2025, documented employees would treat all residents with kindness, respect and dignity. Federal and state laws guaranteed certain basic rights to all residents in the facility. These rights included the resident's right to a dignified existence and be treated with respect, kindness, and dignity. The Policy and Procedure titled, Quality of Life - Dignity, reviewed 1/2025, documented each resident would be cared for in a manner that promoted and enhanced quality of life, dignity, respect, and individuality. Residents would be treated with dignity and respect all times. Treated with dignity meant the resident would be assisted in maintaining and enhancing his or her self-esteem and self-worth. Staff would speak respectfully to residents at all times. Resident #39 Resident #39 was admitted to the facility with diagnoses of congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), hypertension, and Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors). The Minimum Data Set (an assessment tool) dated 12/10/2024, documented the resident was cognitively intact., could be understood, and understand others. During an interview on 2/23/2025 at 2:45 PM, Resident #39 stated they had to wait for an hour or 2 hours for personal care. They stated that when the call light was answered some Certified Nurse Aides were rough. Resident #39 stated some Certified Nurse Aides would push and shove them when providing care to get them to turn over. Resident #39 stated, That to me is rough. Resident #39 stated one of the aides was ignoring their request for help one evening and threw a night gown on the side of the bed and then left the room. Resident #39 could not recall who the aide was. Resident #61 Resident #61 was admitted to the facility with diagnoses of fusion of spinal bones (a surgical procedure that permanently joins two or more vertebrae (bones) in the spine) , diabetes mellitus, and hypertension. The Minimum Data Set, dated dated dated [DATE], documented the resident was cognitively intact, could be understood, and understand others. During an observation and interview on 2/24/2025 at 3:59 PM, Resident #61 stated some of the staff would answer their call light and just turn off the light and not do anything to help them. The staff member would tell them they had to wait. Resident #61 stated their arms and legs were partially paralyzed, and they were totally dependent on staff for eating, drinking and all care. Resident #61 was noted to have a call bell device that they had to blow in to activate the call light. They stated they put their call light on, and staff would come into the room and ask them if they needed water. The resident was noted to have 2 cups of water with a straw in each cup on the over the bed table that was next to the bed. Resident #61 stated that although they needed help with drinking, that was not their only need and staff would tell them in a harsh tone they had to wait. Resident #61 stated the only bed available to them was in this facility and they came here expecting to get the help they needed. During an interview on 3/07/2025 at 2:02 PM, the Registered Nurse Regional Clinical Director #1 stated they expected staff to treat residents with dignity and respect. When staff answered call bells, they expected staff to go into the room and greet the resident, ask them how they could assist them, and then turn the call light off. They would not expect staff to go in and turn the call light off without assisting the resident. 10 New York Codes Rules and Regulations 415.5(a) 51131 51958

Based on observation, record review, and interviews conducted during the recertification and abbreviated survey (Case # NY00347964), the facility did not provide effective housekeeping and maintenance services on 3 (A, B, and C) of 3 resident units. Specifically, floors, walls, window blinds, ceilings, and dining tables were not clean or maintained and obnoxious odors were detected. This is evidenced by: During observations on 2/23/2025 at 1:52 PM, a urine and fecal odor was detected on the B-Wing corridor, an unwashed body odor was detected by room B13, and trash was found on the floor in room B19. During observations on 02/24/2025 from 9:45 AM through 11:39 AM: Strong urine odors were detected in the corridor outside rooms A01 through A05 and rooms B14 through B19. The ventilation grid by the emergency exit on the B-Wing was soiled with a heavy dust build-up. Stained ceiling tiles were found in the corridor by the Activity Room, the C-Wing Soiled Utility room, the employee dining room, and rooms B22 and C21. The floors were soiled with a brown build-up where the corridor door frames meet the floor, and next to the walls in the Rehabilitation room, The nurse stations on the A-Wing, B-Wing and C-Wing were soiled with a brown dirt build-up. One ceiling tile was missing in the C-Wing outdoor patio. Chewing gum was found stuck to the underside of the dining tables in the main dining room, A-wing Day Room, and B-Wing Day room. The window blinds were caked with dust in rooms A02, A04, and A08. The lobby furniture upholstery was worn. In room B16, the floor was heavily soiled with dust behind the beds and the room door had chipped paint. Paint was chipped on the walls in room B13 and the B-wing soiled utility room. The plastic edge guards on the wall in the lobby area were chipped. During an interview on 2/24/2025 at 2:02 PM, Administrator #1 stated that they would speak with the housekeeping and maintenance departments regarding the cleaning, maintenance, and ventilation (odor) issues found. 10 New York Codes, Rules, and Regulations 415.5(h)(4)

Based on observations, record reviews, and staff interviews during the recertification survey, the facility did not ensure infection prevention control practices were followed to help prevent the spread, development, and transmission of communicable diseases and infections for three (3) (Residents #s 110, 115, and 231) of 31 residents reviewed for infection control. Specifically for Residents #s 110, 115, and 231, the facility did not implement and maintain enhanced barrier precautions for residents with indwelling medical devices. This is evidenced by: The policy and procedure titled Barrier Enhanced Precautions reviewed 1/2025 documented nursing home resident with wounds and indwelling medical devices were at especially high risk for multi drug resistant organisms and the use of gown and gloves for high contact resident care activities was indicated. Resident #110 Resident #110 was admitted to the facility with the diagnoses of osteoarthritis (degenerative disease that worsens over time, often resulting in chronic pain in the joints), end stage renal disease (a severe and irreversible condition where the kidneys lose their ability to function adequately), and gastro-esophageal reflux disease (a condition in which stomach acid repeatedly flows back up into the tube connecting the mouth and the stomach called the esophagus). The Minimum Data Set (an assessment tool) dated 1/24/2025 documented the resident was usually understood, could usually understand others, and was cognitively intact. During an observation on 3/6/2025 at 10:29 AM, Resident #110's room did not have signage or set up for enhanced barrier precautions. A record review of physician's orders did not have documented evidence of orders for enhanced barrier precautions. The comprehensive care plan for hemodialysis revised 11/20/2024 documented the presence of a hemodialysis catheter (an indwelling medical device used for hemodialysis services). Resident #115 Resident #115 was admitted to the facility with the diagnoses of gastro-esophageal reflux disease, hypertension (high blood pressure), and hyperlipidemia (high level of cholesterol in the blood). The Minimum Data Set, dated dated dated [DATE] documented the resident was understood, was understood by others, and was moderately cognitively impaired. During an observation on 3/06/2025 at 10:25 AM, Resident #115's room did not have signage or set up for enhanced barrier precautions. A Physician's Order dated 2/27/2025 documented the presence of an indwelling urinary catheter with orders to change the catheter monthly and as needed. A Physician's Order dated 3/01/2025 documented treatment orders for a wound on the right lateral ankle daily. A record review of physician's orders had no documented evidence of orders for enhanced barrier precautions. Resident #231 Resident #231 was admitted to the facility with the diagnoses of dysphagia (difficulty swallowing foods and liquids), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), and gastro-esophageal reflux disease. The Minimum Data Set, dated dated dated [DATE] documented the resident could be understood, could understand others, and was moderately cognitively impaired. During an observation on 3/06/2025 at 10:25 AM, Resident #231's room did not have signage or set up for enhanced barrier precautions. A Dietary Note dated 2/20/2025 at 12:03 noted the presence of a surgical gastrostomy site placed on 2/7/2025. A Physician's Progress Note dated 3/02/2025 at 10:01 AM noted the presence of a gastrostomy tube. A record review of physician's orders had no documented evidence of orders for enhanced barrier precautions. During an interview on 3/06/2025 at 10:01 AM, Registered Nurse # 2 stated enhanced barrier precautions should be initiated when the resident had an organism that required infection control. They stated that an indwelling medical device such as a urinary catheter or gastrostomy tube would not need to be on enhanced barrier precautions. They stated that a hemodialysis catheter would not require enhanced barrier precautions because the dressing would be changed at the hemodialysis center and not at the facility. During an interview on 3/06/2025 at 10:10 AM, Licensed Practical Nurse #7 stated enhanced barrier precautions should be initiated when a resident had a wound or external medical devices such as urinary catheters, intravenous access, or gastrostomy tubes. They stated a nurse could initiate the precautions if needed but would require a doctor's order. During an interview on 3/06/2025 at 3:30 PM, Registered Nurse #1 stated they would expect any residents with indwelling device like a urinary catheter, hemodialysis catheter, or gastrostomy tube to also be on enhanced barrier precautions. During an interview on 3/07/2025 at 2:29 PM, Regional Clinical Director #1 stated they would expect residents with indwelling medical devices and wounds to be placed on enhanced barrier precautions. New York Codes, Rules, and Regulation 415.19(a)(1-3)

Based on record review and interviews conducted during a recertification survey, the facility did not ensure medical records were kept in accordance with accepted professional standards. Medical records were not complete and accurate for three of three units and two (2 ) (Resident #'s 23 and 53) of 31 residents. Specifically, (a.) narcotic count record books for 3 of 3 units were incomplete; (b.) Resident #23's documentation of vital signs was either incomplete or duplicated; and (c.) for Resident #53, wound care documentation was inaccurate. This is evidenced by: A review of the narcotic count record book for Unit A, there were no documented evidence of Nurses signatures for the following: - On-coming nurse on 2/04/2025 at 3:00 PM - Off-going nurse on 2/04/2025 at 11:00 PM - On-coming nurse on 2/07/2025 at 11:00 PM - Off-going nurse on 2/08/2025 at 7:00 AM - On-coming nurse on undated at 11:00 PM - Off-going nurse on 2/10/2025 at 7:00 AM - Off-going nurse on 2/11/2025 at 7:00 AM - On-coming nurse on 2/12/2025 at 11:00 PM - Off-going nurse on 2/13/2025 at 7:00 AM - On-coming nurse on 2/13/2025 at 11:00 PM - Off-going nurse on 2/14/2025 at 7:00 AM - Off-going nurse on 2/15/2025 at 3:00 PM - On-coming nurse on 2/17/2025 at 11:00 PM - Off-going nurse on 2/18/2025 at 7:00 AM - On-coming nurse on 2/19/2025 at 11:00 PM - Off-going nurse on 2/20/2025 at 7:00 AM - On-coming nurse on 2/20/2025 at 11:00 PM - Off-going nurse on 2/21/2025 at 7:00 AM - On-coming nurse on an unreadable date at 7:00 AM - Off-going nurse on 2/22/2025 at 3:00 PM A review of the narcotic count record book for Unit B Team 1 there were no documented evidence of Nurses signatures for the following: - On-coming nurse on 1/12/2025 at 11:00 PM - Off-going nurse on 1/13/2025 at 7:00 AM - On-coming nurse on 1/14/2025 at 11:00 PM - Off-going nurse on 1/15/2025 at 7:00 AM - Off-going nurse on 1/16/2025 at 3:00 PM - On-coming nurse on 1/17/2025 at 11:00 AM - Off-going nurse on 1/18/2025 at 7:00 AM - On-coming nurse on 1/31/2025 at 11:00 PM - Off-going nurse on 2/01/2025 at 7:00 AM - Off-going nurse on 2/03/2025 at 3:00 PM - On-coming nurse on 2/04/2025 at 7:00 AM - Off-going nurse on 2/04/2025 at 3:00 PM - On-coming nurse on 2/05/2025 at 7:00 AM - Off-going nurse on 2/05/2025 at 3:00 PM - On-coming nurse on 2/07/2025 at 7:00 AM - Off-going nurse on 2/07/2025 at 3:00 PM - On-coming nurse on 2/08/2025 at 7:00 AM - Off-going nurse on 2/08/2025 at 3:00 PM - On-coming nurse on 2/09/2025 at 7:00 AM - Off-going nurse on 2/09/2025 at 3:00 PM - On-coming nurse on 2/10/2025 at 7:00 AM - Off-going nurse on 2/10/2025 at 3:00 PM -On-coming nurse on 2/12/2025 at 7:00 AM - Off-going nurse on 2/12/2025 at 3:00 PM - On-coming nurse on 2/13/2025 at 7:00 AM - Off-going nurse on 2/13/2025 at 3:00 PM - On-coming nurse on 2/14/2025 at 7:00 AM - Off-going nurse on 2/14/2025 at 3:00 PM - On-coming nurse on 2/14/2025 at 11:00 AM - Off-going nurse on 2/15/2025 at 7:00 AM - On-coming nurse on 2/15/2025 at 7:00 AM - Off-going nurse on 2/15/2025 at 3:30 PM - On-coming nurse on 2/16/2025 at 7:00 AM - Off-going nurse on 2/16/2025 at 3:00 PM - On-coming nurse on an undated date and time - Off-going nurse on 2/17/2025 at 3:00 PM - On-coming nurse on 2/18/2025 at 7:00 AM - Off-going nurse on 2/18/2025 at 3:00 PM - On-coming nurse on 2/19/2025 at 7:00 AM - Off-going nurse on 2/19/2025 at 3:00 PM - On-coming nurse on 2/20/2025 at 7:00 AM - Off-going nurse on 2/20/2025 at 3:00 PM - On-coming nurse on 2/21/2025 at 7:00 AM - Off-going nurse on 2/21/2025 at 3:00 PM - Off-going nurse on 2/23/2025 at an unknown time - On-coming nurse on 2/26/2025 at 7:00 AM Photocopies of the narcotic count record book for Unit B Team 2 were provided to the surveyor on 2/28/2025. Review of the photocopies documented blank spaces for the following dates: - On-coming nurse on 1/20/2025 at 7:00 AM - Off-going nurse on 1/20/2025 at 3:00 PM - On-coming nurse on 1/21/2025 at 7:00 AM - Off-going nurse on 1/21/2025 at 3:00 PM - On-coming nurse on 1/24/2025 at 7:00 AM - Off-going nurse on 1/24/2025 at 3:00 PM - On-coming nurse on 1/25/2025 at 7:00 AM - Off-going nurse on 1/25/2025 at 3:00 PM - On-coming nurse on 1/26/2025 at 7:00 AM - Off-going nurse on 1/26/2025 at 3:00 PM - On-coming nurse on 1/29/2025 at 7:00 AM - Off-going nurse on 1/29/2025 at 3:00 PM - On-coming nurse on 1/30/2025 at 7:00 AM - Off-going nurse on 1/30/2025 at 3:00 PM - On-coming nurse on 1/31/2025 at 7:00 AM - On-coming nurse on 1/31/2025 at 11:00 PM - Off-going nurse on 2/01/2025 at 7:00 AM - On-coming nurse on 2/09/2025 at 7:00 AM - Off-going nurse on 2/09/2025 at 3:00 PM - On-coming nurse on 2/10/2025 at 7:00 AM - Off-going nurse on 2/10/2025 at 3:00 PM - On-coming nurse on 2/14/2025 at 11:00 PM - Off-going nurse on 2/15/2025 at 7:00 AM - On-coming nurse on 2/17/2025 at 7:00 AM - Off-going nurse on 2/17/2025 at 3:00 PM - On-coming nurse on an unknown date at 3:00 PM - Off-going nurse on 2/20/2025 at 11:00 PM - On-coming nurse on 2/24/2025 at 11:00 AM - Off-going nurse on 2/24/2025 at 3:00 PM - On-coming nurse on 2/25/2025 at 7:00 AM - Off-going nurse on 2/25/2025 at 3:00 PM In addition, review of the provided photocopies of the narcotic count record book documented a crossed out signature without a corresponding signature for the off-going nurse on 1/31/2025 at 3:00 PM. An additional copy of Unit B Team 2 narcotic count record book was provided to the surveyor via secure file transfer on 3/02/2025. The following discrepancies were noted: Dates that were previously blank on copies provided on 2/28/2025 were now signed on 3/2/2025: - On-coming nurse on 1/20/2025 at 7:00 AM - Off-going nurse on 1/20/2025 at 3:00 PM - On-coming nurse on 1/21/2025 at 7:00 AM - Off-going nurse on 1/21/2025 at 3:00 PM - On-coming nurse on 1/24/2025 at 7:00 AM - Off-going nurse on 1/24/2025 at 3:00 PM - On-coming nurse on 1/25/2025 at 7:00 AM - Off-going nurse on 1/25/2025 at 3:00 PM - On-coming nurse on 1/26/2025 at 7:00 AM - Off-going nurse on 1/26/2025 at 3:00 PM - On-coming nurse on 1/29/2025 at 7:00 AM - Off-going nurse on 1/29/2025 at 3:00 PM - On-coming nurse on 1/30/2025 at 7:00 AM - Off-going nurse on 1/30/2025 at 3:00 PM - On-coming nurse on 2/09/2025 at 7:00 AM - Off-going nurse on 2/09/2025 at 3:00 PM - On-coming nurse on 2/10/2025 at 7:00 AM - Off-going nurse on 2/10/2025 at 3:00 PM - On-coming nurse on 2/25/2025 at 7:00 AM - Off-going nurse on 2/25/2025 at 3:00 PM A review of the narcotic count record book for Unit C documented blank spaces for: - On-coming nurse on an unknown date at 11:00 PM - Off-going nurse on 2/2/2025 at 7:00 AM - Off-going nurse on 2/4/2025 at 7:00 AM - On-coming nurse on an unknown date at 11:00 PM - Off-going nurse on 2/6/2025 at 7:00 AM - On-coming nurse on 2/11/2025 at 11:00 AM - Off-going nurse on 2/12/2025 at 7:00 AM - On-coming nurse on 2/23/2025 at 11:00 PM - Off-going nurse on 2/24/2025 at 7:00 AM - On-coming nurse on 2/25/2025 at 7:00 AM - Off-going nurse on an unknown date at 3:00 PM - On-coming nurse on 2/27/2025 at 11:00 PM In addition, review of the narcotic count record book for Unit C documented the following dates with signatures crossed out and no corresponding signature in its place: - On-coming nurse on 2/2/2025 at 3:00 PM - Off-going nurse on 2/3/2025 at 7:00 AM - On-coming nurse on 2/3/2025 at 11:00 PM - On-coming nurse on an unknown date at 11:00 PM - On-coming nurse on an unknown date at 7:00 AM - On-coming nurse on 2/15/2025 at 11:00 PM During an interview on 3/03/2025 at 10:36 AM, Director of Nursing #1 stated that staff should not back sign any documentation. The narcotic count record book should be signed when the nurses are performing the count and there should not be any blanks on the signature page. During an interview on 3/03/2025 at 10:46 AM, Licensed Practical Nurse #2 stated if they saw a blank signature space in the book and knew they worked that shift, they would sign it, even if it were days later. They acknowledged the book should be signed by both the on-coming and off-going nurses at the time of the narcotic count. During an interview on 3/7/2025 at 2:02 PM, Regional Clinical Director #1 stated that narcotic counts required 2 nurses, the on-coming and the off-going nurse, to count the narcotics and sign the narcotic count book at the time of the count. Resident #23 Resident #23 was admitted to the facility with the diagnoses of chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), pneumonia (an infection that inflames air sacs in one or both lungs, which may fill with fluid), and chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body). The Minimum Data Set, dated dated dated [DATE], documented the resident was understood, able to understand others, and was cognitively intact. The Treatment Administration Record for January 2025 documented the following repeated vital signs: - 1/06/2025 and 1/07/2025: Blood pressure 122/70, Temperature 97.7, Pulse 80, Respirations 17, Oxygen saturation 99% - 1/16/2025, 1/17/2025, and 1/18/2025: Blood pressure 139/78, Temperature 97.9, Pulse 71, Respirations 17, Oxygen saturation 99% - 1/20/2025 and 1/21/2025: Blood pressure 132/66, Temperature 97.9, Pulse 78, Respirations 18, Oxygen saturation 96% - 1/22/2025, 1/23/2025, 1/25/2025, 1/26/2025, 1/27/2025, 1/28/2025, 1/30/2025, and 1/31/2025: Blood pressure 132/68, Temperature 97.4, Pulse 68, Respirations 17, Oxygen saturation 96% There were no vital signs documented for the following dates: 1/08/2025, 1/13/2025, and 1/24/2025. The Treatment Administration Record for February 2025 documented the following repeated vital signs: - 2/03/2025 and 2/04/2025: Blood pressure 144/81, Temperature 97.4, Pulse 95, Respirations 17, Oxygen saturation 92% - 2/06/2025, 2/08/2025, 2/10/25, and 2/12/2025: Blood pressure 130/68, Temperature 97.9, Pulse 77, Respirations 18, Oxygen saturation 95% - 2/13/2025 and 2/16/2025: Blood pressure 137/76, Temperature 98.2, Pulse 71, Respirations 16, Oxygen saturation 97% - 2/22/2025 and 2/23/225: Blood pressure 127/73, Temperature 97.7, Pulse 100, Respirations 21, Oxygen saturation 93% - 2/24/2025 and 2/25/2025: Blood pressure 139/78, Temperature 98.1, Pulse 86, Respirations 18, Oxygen saturation 98% There were no vital signs documented for the following dates: 2/01/2025, 2/05/2025, 2/07/2025, 2/11/2025, 2/14/2025, 2/15/2025, 2/18/2025, 2/19/2025, 2/20/2025, and 2/21/2025 The Treatment Administration Record for March 2025 documented the following repeated vital signs: - 3/01/2025 and 3/02/2025: Blood pressure 127/71, Temperature 97.8, Pulse 71, Respirations 15, Oxygen saturation 96%. There were no vital signs documented for 3/04/2025. During an interview on 3/06/2025 at 2:39 PM, Licensed Practical Nurse #5 stated they would not expect a resident to have the same vital signs multiple days in a row. They could not explain the duplicate vital signs multiple days in a row for Resident # 23. During an interview on 3/06/2025 at 3:05 PM, Nurse Practitioner #1 stated that duplicate vital signs over several days would be highly unusual. During an interview on 3/7/2025 at 2:02 PM, Regional Clinical Director #1 stated staff should not be documenting that care was provided when it was not, and documentation should not be falsified. Resident #53 Resident #53 was admitted to the facility with the diagnoses of polyosteoarthritis (a condition where pain and inflammation occur in multiple joints at once), obstructive sleep apnea (a condition that occurs when airflow is intermittently blocked during sleep), and hypertension (high blood pressure). The Minimum Data Set (an assessment tool) dated 12/29/2024, documented the resident was understood, able to understand others, and was cognitively intact. A physician's order dated 12/27/2024, documented to apply collagen into wound on left buttocks, cover with foam dressing every Monday, Wednesday, and Friday. A wound assessment note dated 1/14/2025, documented the wound on the left buttocks was healed. A physician's progress note dated 2/11/2025, documented there were no rashes or lesion noted. The March 2025 Treatment Administration Record documented the dressing was completed on 3/05/2025. A provider's note dated 3/05/2025, documented the resident's skin was dry and intact. During an interview on 3/06/2025 at 2:30 PM, Resident #53 denied they had any open areas requiring a dressing. During an interview on 3/06/2025 at 2:39 PM, Licensed Practical Nurse #5 stated there were no open areas on the Resident #53's skin that required a dressing. They were unable to state why they had documented they completed the dressing in the Treatment Administration Record During an interview on 3/07/2025 at 2:02 PM, Regional Clinical Director #1 stated staff should not be documenting that care was provided when it was not, and documentation should not be falsified. 10 New York Codes, Rules, and Regulations 415.22(a)(1-4) 43805 48744 51131

Based on observation, record review, and interviews during the recertification and abbreviated survey (Case #s NY00343930, NY00347964, NY00354057, NY00363829, NY00364424, NY00364701, and NY00369042) , it was determined the facility and governing body failed to ensure that residents received appropriate quality of care by allowing the following deficient practices to exist, placing residents at risk for serious injury, serious harm, serious impairment, or death: F760: Residents are Free of Significant Medication Errors and F684 Quality of Care. Specifically, the facility's governing body did not ensure established policies regarding the management and operation of the facility were implemented. Subsequently, resident care was compromised. This is evidenced by: Facility was cited F760: Residents are Free of Significant Medication Errors Cross-referenced to F684: Quality of Care The undated document titled, Quality Assurance Performance Improvement Plan, documented the purpose of the Quality Assurance Performance Improvement Plan was to evaluate residents' experience of the services provided to determine how the experience could be improved, to realize the facility's vision of innovation and continuous improvement in the delivery of care. To accomplish that purpose, the facility engaged all members of each service to evaluate the quality of care provided to residents and held themselves to the highest standard by continually improving the care on the resident's behalf. Guiding Principles documented Quality Assurance Performance Improvement guided the facility's daily operation, included all members of each service, was encouraged by holding each individual accountable for their performance (professional or otherwise), and the facility was committed to encouraging all members on any level of the organization to identify system breakdowns/deficits in an effort to improve performance. Element II: Governance and Leadership documented the Governing Body and Administration potentiated high quality resident care by developing and leading the Quality Assurance Performance Improvement program. Quality Assurance Performance Improvement would be adequately resourced and promote an atmosphere that encouraged the reporting of quality problems as well as opportunities for improvement. The Quality Assurance Performance Improvement coordinator would utilize systems thinking and assist departments in the methodology and selection of priority concerns impacting resident care safety. The facility would provide in house training/in-service for all employees on Quality Assurance Performance Improvement as well as posters with information specific to Quality Assurance Performance Improvement. The training would be provided by members of the Steering Committee. The facility would designate members of the steering committee to attend training programs/seminars specific to Quality Assurance Performance Improvement. Technical training would be provided by the Nursing Department. Element III: Feedback, Data Systems, and Monitoring documented (1) pertinent resident care information would be reviewed daily by the Interdisciplinary Team, (2) daily morning minutes (running log or needed follow up for each unit) would be reviewed and revised on an ongoing basis by the Interdisciplinary Team, (3) any areas that needed immediate Process Improvement would be identified and followed up by Quality Assurance Steering Committee as indicated, (4) the facility would utilize multiple data sources to monitor performance including Quality Measures, State and National benchmarks as well as tracking and investigating any adverse events affecting residents, (5) feedback from staff would be encouraged and welcomed via Unit Quality Improvement rounds, regular meetings and open door policy by Department Heads and administration, and (6) Quality Improvement alert would be distributed to each Department Head for staff education as indicated. Element IV: Performance Improvement Projects documented (1) focus areas of Performance improvement would be identified by Administration based upon input from staff, residents, and families, (2) for each focus area Root Cause analysis would be used to identify systems, processes and procedures that need revision; (3) for each area a Performance Improvement team would be identified, (4) performance improvement teams would meet weekly, (5) the team was responsible to educate, monitor, and collect data and plan improvement as indicated, (6) the data collection would be reviewed monthly by team members and quarterly by the Quality Assurance Performance Improvement Steering Committee, (7) compliance with Performance Improvement established goals would be evaluated against a benchmark and decision to continue, revise or close Performance Improvement area would be made by Steering Committee, (8) all staff members, residents, and families would be educated regarding performance improvement areas on a regular basis to include but not limited to unit conferences, resident council meetings and comprehensive care plan meetings as indicated, (9) visible signage would be posted to alert all resident, staff, and families of facility progress with Performance Improvement Areas. Element V: Systemic Analysis and Systemic Action documented (1) actions taken would be linked to the root cause and lead to a system or process change, (2) all staff members would receive ongoing education regarding systemic changes, (3) feedback from all staff as well as residents and families would be welcomed and encouraged, (4) residents and families would be educated regarding systemic changes, (5) the Quality Assurance Steering Committee would monitor sustainability of systemic changes on a quarterly basis or more frequently as indicated. Resident #47 did not receive prescribed psychiatric medication to be given at bedtime at 9:00 PM from 11/25/2024 to 12/6/2024 (12 days). On 11/29/2024 at 9:00 AM, the resident decompensated and was sent to the hospital upon their request. Resident #12 received only 10 of 20 doses of antibiotics prescribed. Resident #23 received only 4 of 8 doses of antibiotics prescribed. Resident #77 was prescribed medication to lower their potassium level on 12/21/2024 and did not receive the medication until 12/25/2024. Resident #327 did not receive antibiotics for 2 days after prescribed. Resident #6 did not receive finger sticks to check the blood sugar level for over 12 hours after admission. Resident #14 was not offered personal care assistance. Resident #20's feet were not assessed regularly. Resident #23 and Resident #77 did not have vital signs as ordered and were not monitored for changes of condition. During an interview on 3/2/2025 at 1:48 PM, Director of Nursing #1 stated they were aware that there were medications missing from pharmacy and had been looking into it. Director of Nursing #1 stated they would expect staff who discovered a medication was not in-house, would check the Pyxis to see if the medication was available, obtain vital signs, and contact the Medical Director to inform them of an available substitution. They would expect staff to document in the Electronic Medical Record that the medication was not available, and the dose was missed. They would expect staff to call the pharmacy to ensure the medication would come on next pharmacy delivery. They stated missed medications should have been reported to the supervisor. Director of Nursing #1 stated there was no missed medication form, but it would be documented in the shift to shift 24-hour report that they reviewed every day. They stated nurse managers were responsible for checking the report. They stated Quality Assurance Performance Improvement had met once since their promotion to Director of Nursing and one of the things they were doing was having night nurses review carts and medications to ensure that everything was where it needed to be. During an interview on 3/2/2025 at 2:00 PM, Administrator #1 stated they have reached out to providers to help to determine and resolve issues. They would expect that staff would call the pharmacy for missing doses and to find out when they could be delivered. They would expect that staff would call the Medical Director to see if something else could be given. They would expect staff to monitor the resident and document directions given by the provider. Administrator #1 stated the medication issues in the building just came to light over the last week during survey. They stated there were medication error/missed dose sheets, but the Administrator had not received any in January or February 2025. Administrator #1 stated they would expect the nurses to write a progress note about the missed doses that would be included on the 24-hour report that was reviewed daily. Administrator #1 stated that they had never heard there were not enough staff to get medications administered or resident care done. During an interview on 3/02/2025 at 3:11 PM, Administrator #1 stated they started house- wide education regarding what was available in the Pyxis and what to do when medications were not available. Supervisors and unit managers were reeducated on the policy of checking their reports and checking the clinical dashboard for late and/or missing medications. Daily reports would be run regarding medication errors and missed doses and to if the providers were notified. Administrator stated they would be checking reports for yellow and red colors (indicated late or missed doses) daily and would try to correct inconsistencies in real time. During an interview on 3/03/2025 at 11:22 AM, Medical Director #1 stated they were only here to monitor the physicians. Medical Director #1 stated they attended all Quality Assurance Performance Improvement meetings. They stated communication breakdown was a big part of the problems seen during survey. They stated they were only notified of significant problems. Medical Director #1 stated they became aware of the facility's issues this week and going forward it would be discussed every day. When asked if they would be present in the facility more often to ensure provider and staff compliance, Medical Director #1 stated they believed that because they had talked to the girls they would be compliant, and did not intend to increase visits unless it was needed. During an interview on 3/07/2025 at 2:00 PM, Registered Nurse Regional Clinical Director #1 stated they were able to speak to the general facility and corporate policies, but not resident specific issues. They stated they had just transferred from another facility 5 days prior. They stated they were looking to make immediate improvements. During an interview on 3/07/2025 at 2:30 PM, Administrator #1 stated that they meet with the department heads daily during morning meeting and monthly with the Quality Assurance committee. Administrator #1 stated they were unaware of the multitude of problems that had come to light during the survey. They stated they became the administrator of the facility in the summer of 2024. Administrator #1 stated they intended to be more present on the units and more closely manage the day-to-day operations of the facility. 10 New York Code of Rules and Regulations 415.26(b)(3)(1)

Based on record review and interview during the recertification survey and abbreviated survey (Case # NY00363829), 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 the residents for two (2) (Resident #s 47 and 77) of 5 residents reviewed. Specifically, [a.] for Resident #47 with diagnoses of schizophrenia, the facility did not ensure Clozapine (atypical antipsychotic) was available to administer on 11/25/2024 to 12/26/2024 and, [b.] for Resident #47, the facility did not ensure Lokelma was available on 12/21/2024, when ordered for a high potassium level. The resident did not receive the medication until 12/25/2024. This is evidenced by: Cross-referenced to F760: Residents are Free of Significant Medication Errors Resident #47 Resident #47 was admitted to the facility with diagnoses of schizophrenia (a mental condition characterized by thoughts or experiences that seem out of touch with reality), chronic obstructive pulmonary disease with acute exacerbation (a chronic lung disease that cause progressive and irreversible damage to the airways in the lungs), and type 2 diabetes mellitus without complications (a chronic condition where the body does not use insulin properly or does not produce enough insulin to regulate blood sugar levels). The Minimum Data Set, dated [DATE] documented the resident was cognitively intact. The resident made themselves understood and was able to understand others. Order Summary Report for order date range 11/01/2024 to 3/07/2025, documented an order dated 11/25/2024 for Clozapine oral tablet give 375 milligrams by mouth at bedtime for schizophrenia. Medication Administration Record dated November 2024 documented Clozapine 375 milligrams was to start on 11/25/2024 at 9:00 PM and documented: - 11/25/2024 was not given and documented awaiting pharmacy delivery. - 11/26/2024 was not given and documented medication enroute from pharmacy, will administer upon arrival. Physician notified. - 11/27/2024 was documented as given. - 11/28/2024 was not given and documented the medication was on order and awaiting arrival from the pharmacy. Skilled nursing would follow up. Pharmacy report for Clozapine, dispense date range 2/01/2024 to 3/03/2025, did not document Clozapine was dispensed in November 2024 for Resident #47. The report documented the medication was dispensed on 12/6/2024. Pharmacy Packing Slip Proof of Delivery documented Clozapine was delivered to the facility for Resident #47 on 12/06/2024 at 9:49 PM. Resident #77 Resident #77 was admitted to the facility with diagnoses of chronic kidney disease (chronic kidney damage that makes it harder for kidneys to filter waste and fluid from the blood), cerebral infarction (a medical condition where the blood flow to the brain is interrupted, leading to the death of brain cells), and chronic obstructive pulmonary disease (a chronic lung disease that cause progressive and irreversible damage to the airways in the lungs). The Minimum Data Set, dated [DATE], documented the resident was cognitively intact. The resident made themselves understood and was able to understand others. Laboratory Report dated 12/21/2024, documented the results of a basic metabolic panel that was collected on 12/20/2024. The potassium result was 5.2 (reference range 3.5 - 5.1) and was flagged as being high. Order Summary Report for order date range 11/1/2024 to 3/31/2025, documented an order dated 12/21/2024 for Lokelma oral packet 10 grams (sodium zirconium cyclosilicate), give 1 packet by mouth for hyperkalemia (high level of potassium in the blood often caused by kidney disease). Nursing Note dated 12/21/2024 at 10:54 PM by the Registered Nurse documented they received a call from the provider regarding Resident #77 having a potassium level of 5.2. The provider placed a new order for Lokelma. The Registered Nurse contacted the pharmacy, and they reported they would not be able to get the medication in the facility until the following afternoon. The provider was made aware and confirmed it was ok that the medication would not be available until the following afternoon. Medication Administration Record dated December 2024, did not have documented evidence that Lokelma was given on 12/22/2024 and there was no documented evidence in a Nursing Progress Note that the provider was notified. There was no documented evidence the resident received Lokelma on 12/21/2024, 12/22/2024, 12/23/2024, or 12/24/2024. There was no documented evidence in Nursing Notes that the medical provider was notified. Physician Progress Note dated 12/24/2024 at 3:45 PM by Physician #2, documented the resident's potassium level had increased, and the resident had received 1 dose of Lokelma on 12/21/2024. Plan documented to give Lokelma 2 times a day for 1 day. Order Summary Report for order date range 11/1/2024 to 3/31/2025, documented an order dated 12/24/2024 for Lokelma oral packet 10 grams (sodium zirconium cyclosilicate), give 1 packet by mouth two times a day for hyperkalemia. Order Note dated 12/25/2024 at 2:16 AM by Registered Nurse, documented the order for Lokelma oral packet 10 grams, give 1 packet two times a day for hyperkalemia was outside of the recommended dose or frequency. The frequency of 2 times a day exceeded the usual frequency of every 2 days to daily. It documented the provider was aware. Medication Administration Record dated December 2024 documented Lokelma oral packet 10 grams was given on 12/25/2024 at 9:00 AM. During an interview on 3/02/2025 at 1:48 PM, Director of Nursing #1 stated that they were aware that there were medications missing from pharmacy. They have been looking into it. Haven't run into any reports of missing medications or medication errors, had just been told by staff that pharmacy didn't send medications. Director of Nursing #1 stated they would expect that staff who discovered medications weren't in house would check the PYXIS to see if there was any here already, get vitals, contact Medical Doctor to tell them what was available for substitution, document in the Electronic Medical Record that the medication was not available and that the dose was missed, and call pharmacy to make sure that medication would come on next run. Missed medications should be reported to the supervisor. Director of Nursing #1 stated they were unaware that there was a medication error form and stated that documentation of missed medications should be in the shift to shift 24-hour report that was they reviewed every day. Director of Nursing #1 stated Nurse Managers were also supposed to check. Quality Assurance Plan Initiative had met once with them as a Director of Nursing, and they were having night nurses review carts and medications to ensure that everything was where it needed to be. Pharmacy made 3 deliveries a day early in the morning on the overnight shift, afternoon on day shift, and on the evening shift around 8-9 PM. During an interview on 3/02/2025 2:00 PM, Administrator #1 stated in the past they had reached out to providers themself to help figure out issues. They stated they would expect that staff would call pharmacy for missing doses and to find out when they could be delivered. The Administrator stated they would expect that staff would call Medical Director to see if something else could be given. They stated they would expect staff to monitor the resident and document whatever direction was given by provider. They stated the medication issues in the building just came to light over the last week. During an interview on 3/02/2025 at 3:11 PM, Administrator #1 stated they had started a house wide education regarding what was available in the Pyxis ( and what to do when something was not available. Supervisors and unit managers had been reeducated on the policy of checking their reports, checking the clinical dashboard for late and/or missing medications. Daily reports would be run regarding medication errors and missed doses and if the providers were notified. Administrator #1 stated they would be checking reports for yellow and red colors (indicated late or missed doses) daily and try to correct inconsistencies in real time. During an interview on 3/07/2025 at 12:38 PM, Registered Nurse #2 stated Resident #77 had a result on 12/21/2024 that the potassium was 5.2. When asked about the Lokelma ordered on 12/21/2024 for the high potassium, they stated they had lots of problems with the pharmacy that was located out-of-state. They stated they had issues with medications received in the facility because of the pharmacy location. They stated the facility did not utilize a local pharmacy. During an interview on 3/07/2025 at 2:02 PM, Registered Nurse Regional Clinical Director #1 stated that recently during the survey, they came across the problem with receiving medications from the pharmacy. Administrator #1 was present and stated they reached out to the pharmacy representative and now had access to a pharmacy dashboard. 10 New York Codes Rules and Regulations 415.18(a)

Based on record review and interviews during the recertification and abbreviated survey (Case # NY00363829), the facility did not ensure the physician reviewed the resident's total program of care, including medications and treatments, at each visit for 2 (Resident #s 23 and 77) of 3 residents reviewed. Specifically, Resident #23 was ordered a topical medication for fungal infection that did not indicate where the medication was to be applied and/or the duration of use. For Resident #77, the provider did not evaluate a high potassium level on 12/17/2024, when the result was reported, and on 12/18/2024, when the provider saw the resident. This is evidenced by: Cross-referenced to F554: Resident Self-Administer Medications - Clinically Appropriate Cross-referenced to F760: Residents are Free of Significant Medication Errors Cross-referenced to F773: Laboratory Services Physician Order/Notify of Results Resident #23 Resident #23 was admitted to the facility with diagnoses of chronic obstructive pulmonary disease (a chronic lung disease that causes progressive and irreversible damage to the airways in the lungs), acute on chronic systolic congestive heart failure (a sudden worsening of symptoms of a pre-existing condition of weakened heart muscles), and type 2 diabetes mellitus (a chronic condition where the body does not use insulin properly or does not produce enough insulin to regulate blood sugar levels). The Minimum Data Set (an assessment tool) dated 1/24/2025, documented the resident was cognitively intact, could be understood, and understand others. Order Audit Report dated 2/04/2025 at 11:50 AM, documented an order for Lotrisone Cream 1-0.05% (clotrimazole-betamethasone), apply to per additional directions topically two times a day for fungal skin rash. The order was entered and signed by Physician #1 on 2/04/2025 at 11:52 AM and was confirmed by Licensed Practical Nurse #7 on 2/04/2025 at 4:33 PM. - There were no instructions on where the medication was to be applied and/or the duration of use. Medication Administration Record dated February 2025, documented Lotrisone Cream 1-0.05% (clotrimazole-betamethasone) apply to per additional directions topically two times a day for fungal skin rash. Start date 2/4/2025 at 5:00 PM and was discontinued following interview with Physician #1 on 2/26/2025 at 3:48 PM. - Lotrisone Cream was administered several times from 2/4/2025 to 2/26/2025. During observation and interview on 2/26/2025 at 12:40 PM, Resident #23 stated they were a Registered Nurse. When asked about the fungal skin rash, the resident stated they had a rash under their right breast that was caused from not having a proper fitting bra and from sweat under the breasts. The resident picked up a bottle of antifungal powder that was on their nightstand and stated they had been using it regularly for the rash under their breast. The surveyor asked about the rash that was observed on the resident's face which was red and blotchy across the forehead, nose, and cheeks. Resident #23 reached in a bag and handed the surveyor a tube of cream that was in a clear plastic bag with a pharmacy label on it. The facility pharmacy label documented Clotrim/Beta cream 1-0-0.5 % generic for Lotrisone. Apply to per directions topically every day shift for 14 days. Apply under the breast. Resident #23 stated the nurse left it for them (the resident) to apply themselves. The resident stated they had applied it to the rash on their face as instructed by the nurse. The surveyor told the resident that the directions on the cream stated to apply it under the breast. The resident was not aware it was for the breast and stated they had applied the cream once yesterday afternoon to their face and the rash was gone. There was a red label on the prescription bag that read, for external use only: keep out of the eyes, inside of nose or mouth. Resident #23 stated they read the label and thought it said apply to affected area only. They stated they were normally good at reading labels but do not always wear their glasses. They reported they had no formal assessment to self-administer the medication. During an interview on 2/26/2025 at 3:48 PM, Physician #1 stated they saw Resident #23 on 2/04/2025 because of a rash on their face, nose, and forehead. Lotrisone cream was prescribed for the resident's face. They stated the rash would come and go because the resident was not following proper hygiene. When they saw the resident, they told the resident the plan was for the resident to shower every day and for the Lotrisone cream to be applied to the face on the affected skin. They stated the order for the Lortisone had detailed instructions on where the nurse should apply it. Physician #1 stated they would not expect the patient to use it themselves. They stated, the instructions were for the nurse, not the patient. They stated they were not aware the resident had a fungal infection under their breast and could not explain why the prescription from the pharmacy documented to apply under the breast. The resident only complained about the rash on their face when they saw them on 2/04/2025. Physician #1 stated a fungal infection on the forehead could spread to the rest of the body. Resident #77 Resident #77 was admitted to the facility with diagnoses of chronic kidney disease (a long-term condition where the kidneys gradually lose their ability to filter waste products and excess fluid from the blood), cerebral infarction (stroke), and chronic obstructive pulmonary disease. The Minimum Data Set, dated dated dated [DATE], documented the resident was cognitively intact. The resident made themselves understood and was able to understand others. Laboratory Results Report for a basic metabolic profile collected on 12/12/2024 and reported on 12/13/2024 at 2:36 AM, documented critical/abnormal test list: Glucose, B-type natriuretic peptide, Creatinine, Chloride, Calcium, Calculated Osmolality, and estimated Glomerular Filtration Rate. Physician Progress Note dated 12/13/2024 at 9:10 PM by Nurse Practitioner #4, documented they were notified by the facility to review laboratory results. Labs collected on 12/12/2024 had notable results for the resident's kidney function and the plan was for a repeat basic metabolic profile laboratory test to be done on 12/16/2024. Laboratory Results Report for a basic metabolic profile collected on 12/16/2024 and reported on 12/17/2024 at 3:05 AM, documented critical/abnormal test list: b-type natriuretic peptide, Creatinine, Chloride, Calculated Osmolality, and estimated Glomerular Filtration Rate, as was previously noted on results reported on 12/13/2024. - In addition, a potassium level of 5.2 was documented as high and was in the list of critical/abnormal tests (potassium helps nerves and muscles work properly and too much can be dangerous and cause serious heart problems). The resident's high potassium level was not evaluated by a provider until 12/21/2024 at 10:20 PM: - There was no documentation in Nursing Notes that the provider was notified of the critical/abnormal results on 12/17/2024. - Physician Progress Note dated 12/18/2024 at 9:09 AM by Nurse Practitioner #2, documented the resident was seen for follow up. The resident's basic metabolic profile lab test dated 12/16/2024 was reviewed. The providers had been following the resident's kidney function following acute kidney injury and estimated Glomerular Filtration Rate was slowly improving. Labs were discussed with the resident that day. Plan documented to repeat the basic metabolic profile on 12/30/2024. There was no documentation Nurse Practitioner #2 evaluated the high potassium level. - Laboratory Results Report for a basic metabolic profile collected on 12/20/2024 and reported on 12/21/2024 at 6:39 AM, the potassium level was 5.2, high. - Physician Progress Note dated 12/21/2024 at 10:20 PM by Nurse Practitioner #5, documented the resident was seen by the provider on 12/18/2024 and ordered a repeat basic metabolic profile. Nurse Practitioner #5 ordered Lokelma 10 grams x1 for hyperkalemia (too much potassium in the blood). During an interview on 3/07/2025 at 12:38 PM, Registered Nurse #2 stated laboratory results were accessible on the provider's dashboard. They stated if the potassium result was 5.2 on 12/17/2024, the provider would have been in the facility and would have seen it. Registered Nurse #2 stated nurses were not responsible for monitoring test results because providers could look up results themselves. They stated the providers should watch for the results because they ordered the tests. They stated the provider should have ordered something for the potassium level of 5.2 on 12/17/2024. Registered Nurse #2 reviewed the progress note dated 12/18/2024 by Nurse Practitioner #2 and stated there was nothing ordered for the high potassium. They stated there was another result on 12/21/2024 that the potassium was 5.2. During an interview on 3/03/2025 at 11:46 AM, Medical Director #1 stated that 90% of the orders were entered by the provider. They stated that when the provider evaluated a resident, they should be looking at the resident's clinical picture, meaning the lab results, orders, and progress notes. During an interview on 3/07/2025 at 2:02 PM, Registered Nurse Regional Clinical Director #1 stated labs were done Monday, Wednesday, and Friday unless they were stat orders. They stated the laboratory results were automatically uploaded into the electronic medical record and the provider was able to see the results on the dashboard. Administrator #1 was present and stated the nurse would see the results and notify the provider. 10 New York Codes Rules and Regulations 415.15(b)(2)(iii) 48744

Based on record reviews and interviews during a recertification and abbreviated survey (Case #NY00363829) , the facility did not ensure comprehensive care plans were reviewed after each assessment and revised based on changing goals, preferences, and needs of the resident and in response to current interventions for eight (8) (Resident #'s 20, 23, 28, 47, 51, 84, 114, and 328) of 31 residents reviewed for comprehensive care plans. Specifically, for Resident #20, the care plan was revised to remove a medication that the resident was prescribed. Additionally, Resident #23's care plan for bladder incontinence with an intervention to monitor for signs and symptoms of urinary tract infection was not revised to include an infection diagnosed on [DATE]; Resident #28, the discharge planning care plan was not revised to reflect the resident's current status and goals; Resident #84, the impaired skin integrity care plan was not resolved after the wound was documented as healed in January 2025; Resident #114, the care plan was not updated to reflect the resident's falls; Residents #47, #51, and #328, medications that the residents were no longer prescribed were care planned for. This is evidenced by: The policy and procedure titled Care Plans, Comprehensive Person-Centered, reviewed 1/2025, stated care plans were to be revised as information about the residents and the residents' conditions change and must be reviewed and updated for a significant change in the resident's condition, when the desired outcome was not met, when the resident has been readmitted to the facility from a hospital stay, and/or at least quarterly. Cross-referenced to: F760: Residents are Free of Significant Medication Errors Resident #23 Resident #23 was admitted with the diagnoses of chronic obstructive pulmonary disease (a chronic lung disease that cause progressive and irreversible damage to the airways in the lungs), acute on chronic systolic congestive heart failure (a sudden worsening of symptoms of a pre-existing condition of weakened heart muscles), and type 2 diabetes mellitus (a chronic condition where the body does not use insulin properly or does not produce enough insulin to regulate blood sugar levels). The Minimum Data Set, dated dated dated [DATE] documented the resident was cognitively intact. The resident made themselves understood and was able to understand others. The Care Plan for Resident has Bladder Incontinence related to disease process, revised 2/12/2025, documented the resident had bladder spasms and was on medication to help control signs and symptoms and maintain optimal bladder function. Interventions included to monitor and document signs and symptoms of urinary tract infection. Thesigns and symptoms were documented. A Nursing Progress Note dated 2/22/2025 at 5:22 PM by Registered Nurse #4 documented Resident #23's urine result came back positive for urinary tract infection. The Nurse Practitioner was aware and gave a new order for Augmentin (antibiotic) 875 milligrams twice daily for seven (7) days. A Physician Progress Note dated 2/22/2025 at 6:00 PM by Nurse Practitioner #3, On-call provider note documented a call from nursing staff reporting the resident's urinalysis and culture results that returned positive for a urinary tract infection that was sensitive to Augmentin. Resident #23 was prescribed Augmentin 875 milligrams twice daily. The resident's care plan was not revised to include the urinary tract infection diagnosed on [DATE]. Resident #28 Resident #28 was admitted to the facility with the diagnoses of dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), and chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). The Minimum Data Set (an assessment tool) dated 12/26/2024 documented the resident was usually understood, could usually understand others, and was cognitively intact. The comprehensive care plan titled Discharge Planning stated the goal as long-term care placement. The interventions, including applications for community resources and durable medical equipment, were dated 8/2020 and were aimed at community discharge. During an interview on 3/7/2025 at 10:30 AM, Social Work #1 stated the resident's care plan for discharge to the community should have been resolved as the resident was long-term care. Resident #84 Resident #84 was admitted to the facility with the diagnoses of hyperlipidemia (high level of cholesterol in the blood), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). The Minimum Data Set, dated dated dated [DATE] documented the resident was able to be understood, was able to understand others and was cognitively intact. A Physician's Order dated 1/21/2025 documented wound care to be provided to right above knee amputation site every Tuesday, Thursday, and Saturday. The comprehensive care plan for impaired skin integrity was revised on 2/23/2025 and documented the presence of a surgical wound. During an observation on 2/24/2025 at 10:48 AM, Resident #84 was wearing shorts and their amputation sites were easily visible. The amputation sites had no dressings on them and did not appear to have open areas. Well healed surgical scars were observed. During an interview on 2/24/2025 at 10:48 AM, Resident #84 denied they had need of any wound care. During an interview on 2/26/2025 at 3:00 PM, Director of Nursing #1 stated the area could be observed due to the resident's clothing choice and it was resolved. The Director of Nursing #1 stated they did not know why the care plan was updated to include a wound that was not there. During an interview on 2/27/2025 at 9:03 AM, Registered Nurse #1 stated they had to do all the care plans on their unit and sometimes the care plans on another unit and it was hard for them. Registered Nurse #1 stated the facility had a staff member to handle care plans a month ago, but they did not know who they were or where they went. During an interview on 3/7/2025 at 2:00 PM, Regional Director of Nursing #1 stated they would expect care plans to reflect the resident and their needs. The care plans should be updated to include falls, wounds, behaviors, any or all medications, and any new concerns for the residents. 10 New York Codes, Rules, and Regulations 415.11(c)(2)(i-iii) 43805 48744

Based on record review and interviews during the recertification and abbreviated survey (Case #NY00363829), the facility did not ensure that the development and implementation of comprehensive person-centered care plans included measurable objectives and timeframes to meet residents' medical, nursing, mental, and psychosocial needs for eight (8) (Residents #12, 20, 23, 37, 47, 53, 110, and #231) of 32 residents reviewed for comprehensive care plans. Specifically, (a.) for Resident #12, there was no care plan developed and implemented for urinary tract infection with antibiotic treatment, diagnosed on [DATE]. (b.) for Resident #20, there was no comprehensive care plan in place to address podiatry issues; (c.) for Resident #23, there was no care plan for the use of Lotrisone Cream for fungal skin rash; (d.) for Resident #37, the comprehensive care plan did not include cultural information and interventions for the resident; (e.) for Resident #47, the comprehensive care plan for antibiotics was initiated after antibiotic therapy had been completed; (f.) for Resident #53, the comprehensive care plan did not address the presence of or interventions for a pressure ulcer; (g.) for Resident #110, there was no comprehensive care plan to address the presence of dentures; and (h.) for Resident #231, there was no comprehensive care plan to address the presence of a gastrostomy tube. This is evidenced by: The policy and procedure titled Care plans, Comprehensive Person-Centered, reviewed 1/2025, stated the comprehensive, person-centered would describe the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Resident #12 Cross-referenced to F711: Physician Visits - Review Care/Notes/Order Cross-referenced to: F760: Residents are Free of Significant Medication Errors Resident #12 was admitted to the facility with diagnoses of severe intellectual disabilities (a developmental delay that limits a person's ability to function in social and practical ways), chronic kidney disease stage 3 (a moderate level of kidney damage that makes it harder for kidneys to filter waste and fluid from the blood), and type 2 diabetes mellitus without complications (a chronic condition where the body does not use insulin properly or does not produce enough insulin to regulate blood sugar levels). The Minimum Data Set (an assessment tool) dated 12/09/2024, documented the resident had severe cognitive impairment, could be understood, and sometimes understand others. Physician Progress Note dated 1/02/2025 at 12:28 PM, documented urinary tract infection results on 12/19/2024 showed Enterococcus faecalis in critically high amounts. The resident was prescribed Amoxicillin 500 milligrams by mouth; however, the resident had been spitting out the pills and refusing to take them, according to nursing staff. Based on the resident's behavior, the oral antibiotic was being changed to intravenous antibiotic. The resident was prescribed Ampicillin 2 grams intravenously every 6 hours x 7 days. Review of the comprehensive care plan did not document a care plan for the urinary tract infection with antibiotic treatment, diagnosed on [DATE]. Resident #23 Resident #23 was admitted to the facility with diagnoses of chronic obstructive pulmonary disease (a chronic lung disease that cause progressive and irreversible damage to the airways in the lungs), acute on chronic systolic congestive heart failure (a sudden worsening of symptoms of a pre-existing condition of weakened heart muscles), and type 2 diabetes mellitus (a chronic condition where the body does not use insulin properly or does not produce enough insulin to regulate blood sugar levels). The Minimum Data Set, dated dated dated [DATE], documented the resident was cognitively intact, could be understood, and understand others. Physician's Progress Note dated 2/04/2025 at 10:49 AM by Physician #1, documented the resident was seen today for rash. The rash was a fungal infection that frequently comes and goes, which previously responded to clotrimazole-betamethasone (Lotrisone Cream). Rash on the bilateral face. Plan: fungal skin rash; take regular shower, clotrimazole-betamethasone 1-0.05% ointment on the lesion twice daily. Medication Administration Record dated February 2025, documented Lotrisone Cream 1-0.05% (clotrimazole-betamethasone) apply to per additional directions topically two times a day for fungal skin rash. There were no instructions for where the medication was to be applied. Start date 2/04/2025 at 5:00 PM. Discontinued on 2/26/2025 at 8:57 PM. The medication was administered several times from 2/04/2025 to 2/26/2025. Review of the comprehensive care plan did not document a care plan for the use of Lotrisone Cream for fungal skin rash. Resident #231 Resident #231 was admitted to the facility with the diagnoses of dysphagia (difficulty swallowing), chronic obstructive pulmonary disease (a type of progressive lung disease characterized by chronic respiratory symptoms and airflow limitation), and gastro-esophageal reflux disease. The Minimum Data Set, dated dated dated [DATE] documented the resident could be understood, could understand others, and was moderately cognitively impaired. A Dietary Note dated 2/20/2025 at 12:03 PM documented the presence of a surgical gastrostomy site placed on 2/07/2025. A Physician's Progress Note dated 3/02/2025 at 10:01 AM documented the presence of a gastrostomy tube. A review of the resident's comprehensive care plan did not document a care plan to address the presence and use of a gastrostomy tube. During an interview on 2/27/2025 at 9:03 AM, Registered Nurse #2 stated that they have had to do the care plans for their unit, Unit A and sometimes the care plans on Unit B. They stated this could be a challenge at times for them. During an interview on 3/06/2025 at 9:56 AM, Licensed Practical Nurse #7 stated that the Director of Nursing sometimes had to update their care plans. Licensed Practical Nurse #7 stated that they could not update the care plans themselves so they did their part to update what they could and then told one of the Registered Nurses to finish it. When asked how they were assured the care plan would be completed, Licensed Practical Nurse #7 stated that once they reported to the registered nurse on duty, they moved on with their day. They stated they had too much to do to stay focused on things like that. During an interview on 3/07/2025 at 2:29 PM, Regional Director of Clinical Services #1 stated they would expect a care plan to be initiated for a gastrostomy tube. 10 New York Codes, Rules, and Regulations 415.11 (c)(1) 43805 48744

Based on record review and interviews during the recertification survey, the facility did not ensure that each resident was screened for a mental disorder or intellectual disability prior to admission for 1 (Resident #47) of 32 residents reviewed. Specifically, the Preadmission Screening and Resident Review (PASARR, New York State Department of Health form 695) did not identify Resident #47 as having a serious mental illness when indicated, and a Level II referral was not made. This is evidenced by: The Policy and Procedure titled, Preadmission Screening and Resident Review (PASARR), dated 9/2021, documented the admissions coordinator would obtain a Preadmission Screening and Resident Review for all new residents admitted to the facility and a Level II Screen when required. The admission coordinator and/or social worker would review the screen to ensure completion, and that placement was appropriate for the resident. When a Level II is required based on the screen, the admission coordinator would notify the hospital, so that a Level II could be completed and obtained prior to admission to the facility. Resident #47 was admitted to the facility with diagnoses of schizophrenia (a mental condition characterized by thoughts or experiences that seem out of touch with reality), generalized anxiety disorder (a mental health condition that causes fear, a constant feeling of being overwhelmed, and excessive worry about everyday things), and major depression disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). The Minimum Data Set (an assessment tool), dated 10/01/2024, documented the resident was cognitively intact, could be understood, and understand others. The Preadmission Screen and Resident Review for Resident #47, dated 9/24/2024, Level 1 Review for Possible Mental Illness (MI) (question 23- does this person have a serious mental illness?) documented no, when the resident had a diagnosis of schizophrenia, prior to admission. A Level II referral (questions 33 and 35) were not completed. There was no documented evidence of a Level II referral for Resident #47. A hospital discharge summary dated 11/25/2024, documented Resident #47 was in the hospital from 10/30/2024 to 11/25/2024 for bacterial pneumonia, pleural effusion (a buildup of fluid between the tissues that line the lung and the chest), and acute exacerbation of chronic obstructive pulmonary disease. They transitioned to the Psychiatric unit on 11/21/2024 due to suicidal ideation and required 1 to 1 supervision for safety. Psychotropic medications were adjusted, and the 1 to 1 supervision was lifted prior to discharge back to the facility. A psychiatry note dated 11/27/2024, documented that Resident #47 had a history of Schizophrenia with confusion, paranoid delusions and auditory hallucinations. Resident #47 had multiple inpatient hospitalization s in their lifetime. The Comprehensive Care Plan dated 12/02/2024, documented Resident #47 displayed or reported the following moods; feeling down, depressed, hopeless, feeling tired or having little energy, isolates, little interested or pleasure in doing things. Resident #47 has a history of Suicidal Ideation (last statement 11/25/2024, no plan). Has a diagnosis of Schizophrenia. The Annual Minimum Data Set, dated dated [DATE], documented that Resident #47 received antipsychotics on a routine basis only. During an interview on 3/05/2025 at 9:50 AM, Director of Social Work #1 stated that the Preadmission Screen and Resident Review/Screen comes from the hospital or as part of the admission packet and gets reviewed. Director of Social Work #1 was not screen certified, but they would check the resident's diagnoses to see if the resident needed a level II referral. In the event that a Screen was found to be inaccurate upon a resident's arrival to the facility, they would reach out to the Regional Admissions Coordinator, who is Screen certified, for assistance. 10 New York Code of Rules and Regulations 415.11(e)

Based on record review and interviews during the recertification survey, the facility did not ensure written notice of the facility's bed hold policy was provided to the resident and/or representative upon transfer to the hospital for 2 (Residents #112 and 123) of 2 residents reviewed for hospitalizations. Specifically, a written notice of the facility's bed hold policy was not provided to the resident and/or their representative upon discharge to the hospital. This is evidenced by: The facility policy titled, Bed-Holds and Returns, dated 1/2022, documented residents or resident representatives would be informed in writing of the bed hold and return policy prior to transfers and therapeutic leave. Resident #112 Resident #112 was admitted to the facility with diagnoses of metabolic encephalopathy (a change in how your brain works due to an underlying condition), type 2 diabetes (a chronic condition characterized by insulin resistance and high blood sugar levels), and end stage renal disease (the final stage of chronic kidney disease, where the kidneys have permanently lost most of their ability to function. The Minimum Data Set (an assessment tool), dated 1/26/2025, documented the resident was understood, understands others, and was cognitively intact. A physician progress note, dated 12/31/2024 at 11:55 AM, documented Resident #112 was sent to the hospital to receive dialysis because they had missed their previous dialysis appointment due to feeling lethargic and nauseous. A physician progress note, dated 1/05/2025 at 10:46 AM, documented Resident #112 was sent to the hospital per their request for pain control. A physician progress note, dated 1/11/2025 at 6:17 PM, documented Resident #112 was sent to the hospital due to unresponsiveness and low blood sugars. A nursing progress note, dated 2/25/2025 at 3:36 PM, documented Resident #112 was sent to the hospital due to a critical lab value. There was no documented evidence that a written notice of the facility's bed hold policy was provided to the resident or resident representative upon transfer to the hospital on [DATE], 1/05/2025, 1/11/2025, and 2/25/2025. Resident #123 Resident #123 was admitted to the facility with diagnoses of acute kidney failure (a sudden decline in the functioning of kidneys), absolute glaucoma (increased intraocular pressure that results in permanent vision loss and blindness), and type 2 diabetes (a chronic condition characterized by insulin resistance and high blood sugar levels. The Minimum Data Set, dated [DATE], documented that the resident was understood, could understand others, and had mild cognitive impairments. The resident required substantial/maximal assistance with most activities of daily living. A progress note dated 12/27/2024 at 5:13 AM, documented that Resident #123 was found on the floor during rounds facedown and reported a headache. The Nurse Practitioner ordered the resident be sent to the hospital. Family was made aware. A neurology consult note from the hospital, dated 12/28/2024 at 3:46 AM, documented Resident #123 was admitted to the hospital on [DATE] status post fall. The medical record did not include documentation that the resident and/or resident representative was provided with a copy of the bed hold policy upon their transfer to the hospital on [DATE]. During an interview on 2/26/2025 at 3:30 PM, Social Worker #1 stated that all bed hold notifications should be sent with the resident at the time of transfer. They acknowledged that Resident #123 was sent to the hospital on [DATE] and reported the bed hold policy should have been sent with the resident to the hospital. During an interview on 2/26/2025 at 4:10 PM, Director of Social Work #1 stated on the 7:00 AM to 3:00 PM shift, the social work department was responsible for providing the bed hold policy to the resident and/or representative at the time of transfer. They reviewed the bed hold policy with the resident and/or representative and then documented the conversation in their progress notes. The Registered Nurse supervisor was responsible for providing and reviewing the bed hold policy with the resident and/or representative prior to transfer on the second and third shift. Director of Social Work #1 stated that there was no documentation to support that the bed hold policy was reviewed or provided to Resident #123 when transferred to the hospital on [DATE]. During an interview on 2/27/2025 at 11:35 AM, Administrator #1 stated when a resident was sent to the hospital, the Registered Nurse Supervisor was responsible for calling the resident ' s representative to review the bed hold policy and a notification of bed hold should be sent to the representative by mail. They acknowledged the bed hold procedure had not been followed for Resident #123. Review of the bed hold with the resident ' s representative was not documented in the progress notes and the bed hold notification was not uploaded to the chart as having been mailed. 10 New York Codes Rules Regulations 415.3(h)(4)(iii)(a)

Based on record reviews and interviews during the recertification survey , the facility did not ensure a resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for one (1) (Resident #115) of three (3) residents reviewed. Specifically, for Resident #115, the wound care treatment ordered by provider not was followed. Specifically, on 2/11/2025, when the resident was assessed with a pressure on their left heel and on 2/18/2025, when the resident was seen by the wound care provider for further assessment of the wound. Additionally, the facility failed to ensure a care plan was developed timely and implemented to promote healing of the wound and to prevent infection. A care plan was not developed until 2/27/2025. This is evidenced by: Resident #115 was admitted to the facility with diagnoses of urinary tract infection, acute kidney failure and age-related physical disability. The Minimum Data Set, dated dated dated [DATE], documented the resident had moderate cognitive impairment. The resident made themselves understood and was able to understand others. The facility policy and procedure titled Pressure Ulcers/Injuries Overview and reviewed 1/25 documented the purpose of the policy was to provide information regarding clinical identification of pressure ulcers/injuries and associated risk factors, which were derived from definitions in the Code of Federal Regulations 483.25(b)(1) Pressure Ulcers (F686). The policy documented definitions of medical terms related to pressure ulcers. The facility policy and procedure titled Wound Care and reviewed 1/25 documented the purpose of the policy was to provide guidelines for the care of wounds to promote healing. Preparation for wound care documented to verify there was a physician's order for the procedure. The type of wound care given was to be recorded in the resident's medical record. Care Plan for Resident documented Impaired Skin Integrity related to fragile skin which was initiated 2/5/2025 and revised 2/12/2025. The goals of the care plan dated 2/12/2025 documented the resident's impaired skin area would show signs of improvement/healing and the resident would not develop additional sites of impaired skin integrity. The sites of impairment were not documented. Interventions included apply treatment per physician order and refer to appropriate medical specialist as needed for evaluation and treatment. Wound Assessment and Plan dated 2/11/2025 by the wound care provider documented a stage 3 (F/Thk, Depth to SubQ) (full thickness loss of skin in which subcutaneous fat may be visible in the ulcer and granulation tissue (pink-red moist tissue that fills an open wound when it starts to heal) on the left heel. The wound onset date was documented as 2/11/2025 and measured 7 centimeters length x 8 centimeters width x 0.1 centimeters depth. The wound bed tissue composition was 50% epithelial (superficial pink or white tissue that migrates across the wound and occurs in the final stage of healing)/50% granulation. There were no signs of infection. -Wound care provider treatment order dated 2/11/2025, documented that every Tuesday, Thursday and Saturday: cleanse the wound with normal saline or sterile water and apply to alginate (absorbs wound fluid while creating a moist environment) to wound bed. Cover with dry clean dressing and as instructed. Specialized foam dressing: foam - follow manufacturer recommendations. Treatment Administration Record dated February 2025: - The wound care provider's treatment order for the left heel dated 2/11/2025 was not documented as ordered on the administration record. There was an order dated 2/12/2025 for the left heel: clean area with normal saline/sterile water, apply calcium alginate and cover with dry protective dressing and wrap, every dayshift for wound care. The order did not include the foam dressing and that it was to be done on Tuesday, Thursday, and Saturday. o Treatment was administered from 2/12/2025 to 2/16/2025, was not administered on 2/17/2025 (was blank), was administered on 2/18/2025 to 2/20/2025, and was not administered on 2/21/2025 (was blank). - Additionally, there was a previous physician order dated 2/5/2025 that documented left heel open blister cover with Optifoam (foam dressing) heel dressing every day for wound care. o From 2/11/2025 to 2/18/2025, it was documented that this treatment for the left heel continued to be administered concurrently with the order dated 2/12/2025, except for 2/17/2025, when it was documented as not administered. The Wound Assessment and Plan dated 2/18/2025 by the wound care provider documented a stage 3 wound on the left heel. The onset date of the wound was 2/11/2025, and measured 5 centimeters length x 6 centimeters width x 0.1 centimeters depth on 2/18/2025. The wound bed tissue composition was 70% granulation/30% eschar (dead or devitalized tissue that is hard or soft in texture and usually black, brown, or tan in color and may appear scab-like). Healing status: same/stable. There were no signs of infection. -The wound care provider's treatment order for the left heel dated 2/18/2025 documented no changes from the order dated 2/11/2025. Treatment Administration Record dated February 2025: - The wound care provider's treatment order for the left heel dated 2/18/2025 was not documented as ordered on the administration record. There was an order dated 2/22/2025 for the left heel: clean area with normal saline/sterile water, apply calcium alginate and cover with dry protective dressing and wrap, every dayshift for wound care. The order did not include the foam dressing and that it was to be done on Tuesday, Thursday, and Saturday. o Treatment was administered from 2/22/2025 to 2/25/2025. - Additionally, there was a previous physician order dated 2/5/2025, that documented left heel open blister cover with Optifoam (foam dressing) heel dressing every day for wound care. o From 2/22/2025 to 2/25/2025, it was documented that this treatment for the left heel continued to be administered concurrently with the order dated 2/22/2025, except for 2/24/2025, when it was documented as not administered. A care plan for the pressure ulcer on the left heel was not developed and implemented until 2/27/2025. - The Care Plan for Resident had Alteration in Skin Integrity related to pressure injury to left heel (5x8), initiated 2/27/2025 and revised 3/03/2025. Interventions included assess the wound weekly and document wound measurements, wound bed appearance, odor, drainage, and surrounding tissue and refer to the wound care specialist as needed. During an interview on 3/06/2025 at 2:37 PM, Licensed Practical Nurse #8 stated if a resident refused a treatment, they would write a note and would notify the manager or charge nurse and call the provider if needed. They stated wound treatment orders were documented on the treatment administration record and there should not be blanks on the treatment record, which indicated it was not done. They stated wound care should be done per the physician order. Licensed Practical Nurse #8 was aware that Resident #115 was ordered to have wound care treatments. During an interview on 3/07/2025 at 3:08 PM, Registered Nurse Regional Clinical Director #1 stated if the nurse did not have enough time to complete a treatment during their shift, they should notify the provider and provide a hand off to the next shift. 10 New York Codes Rules and Regulations 415.12(c)(1)

Based on observations, record review, and interviews conducted during the recertification survey, the facility did not ensure that each resident received the necessary respiratory care and services that is in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preference for three (3) (Resident #'s 23, 51 and 231) of 5 residents reviewed for oxygen administration. Specifically, (a.) for Resident #s 23 and 231 who were ordered to have medications via nebulizer, the facility did not ensure documentation of nebulizer maintenance; and (b.) for Resident #51, supplemental oxygen was not provided as ordered by the physician. This is evidenced by: The Policy and Procedure titled, Nebulizer Treatment and Maintenance, effective 1/2025, documented to ensure safe and effective use of the nebulizer for medication administration, all staff and caregivers must follow proper procedures for its operation, cleaning, and maintenance. Regular maintenance of nebulizer tubing and components was required to prevent contamination and ensure optimal function. Nebulizer maintenance included daily cleaning after each use, weekly tubing replacement, filter maintenance per manufacturer's guidelines or when visibly dirty, and storage of the nebulizer. The facility policy titled, Oxygen Administration, date effective 10/1997 and last revised 10/2024, documented under Preparation, (1) verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration; (2) review the residents' care plan to assess for any special needs of the resident; (3) assemble the equipment and supplies as needed. The policy did not include instructions for the documentation of nebulizer maintenance. Resident #23 Resident #23 was admitted with the diagnoses of chronic obstructive pulmonary disease (a chronic lung disease that cause progressive and irreversible damage to the airways in the lungs), acute on chronic systolic congestive heart failure (a sudden worsening of symptoms of a pre-existing condition of weakened heart muscles), and type 2 diabetes mellitus (a chronic condition where the body does not use insulin properly or does not produce enough insulin to regulate blood sugar levels). The Minimum Data Set (an assessment tool) dated 1/24/2025, documented the resident was cognitively intact. The resident made themselves understood and was able to understand others. Care Plan for Resident #23 has an Alteration in Respiratory System related to Chronic Obstructive pulmonary disease and shortness of breath when lying flat, revised 2/12/2025. Interventions included administer treatments (nebulizer) and medications per physician orders. During an observation on 2/24/2025 at 12:08 PM, Resident #23's nebulizer was on the bedside table and was unplugged. There was no date on the nebulizer tubing. Medication Administration Record dated February 2025, documented Ipratropium - Albuterol Solution 0.5-2.5 (3) milligrams/3 milliliters, 3 milliliters inhale orally every 4 hours as needed for shortness of breath or wheezing via nebulizer. Start date 1/3/2025 at 2:50 PM. -The medication was administered on 2/25/2025. During an observation on 2/24/2025 at 12:08 PM, Resident #23's nebulizer was on the bedside table and was unplugged. There was no date on the nebulizer tubing. During an interview on 2/26/2025 at 12:40 PM, Resident #23 stated they received Pulmicort and albuterol via the nebulizer. Treatment Administration Record dated February 2025 did not document nebulizer maintenance was performed. Resident #51 Resident #51 was admitted to the facility with the diagnoses of acute and chronic respiratory failure with hypercapnia (functional failure of the lungs that can result when there is too much carbon dioxide in the blood), chronic obstructive pulmonary disease (a progressive lung disease characterized by chronic respiratory symptoms and airflow limitation), and nondisplaced fracture of medical condyle of left femur (type of fracture where the bone remains in its original position but was still broken). The Minimum Data Set, dated dated [DATE] documented that the resident was able to understand others, be understood and was minimally cognitively compromised. The facility policy titled, Oxygen Administration, date effective 10/1997 and last revised 10/2024, documented under Preparation, (1) verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration; (2) review the residents' care plan to assess for any special needs of the resident; (3) assemble the equipment and supplies as needed. The Comprehensive Care Plan for Alteration in Respiratory System, date initiated 9/20/2024 and last revised 2/11/2025, documented under Focus: Resident #51 has an alteration in respiratory system related to shortness of breath when lying flat. Under Goal, the plan documented Resident #51 will receive adequate oxygenation as evidenced by resident's acceptable pulse oximetry level through the review date. Under Interventions include: administer treatments (nebulizer) and medications per medical doctor orders; elevate head of bed greater than 35 degrees to prevent shortness of breath; and provide oxygen per medical director orders. Maintain/change tubing per protocol. During an observation on 2/24/2025 at 11:15 AM, Resident #51's oxygen concentrator was set to 4 liters nasal cannula. During an observation on 3/06/2025 at 9:44 AM, Resident #51's portable oxygen flow rate was set for 2 liters nasal cannula. A Physician order dated 1/16/2025 at 11:00 PM documented Resident #51 should have oxygen via nasal cannula at 4 liters per minute to keep stats above 88%. Resident #231 Resident #231 was admitted to the facility with diagnoses of cerebral infarction (stroke), acute cough, and chronic obstructive pulmonary disease (a progressive lung disease characterized by chronic respiratory symptoms and airflow limitation). The Minimum Data Set, dated dated dated [DATE], documented the resident had moderate cognitive impairment. The resident usually made themselves understood and was usually able to understand others. Care Plan for Resident #231 has an Alteration in Respiratory System related to chronic obstructive pulmonary disease, shortness of breath, and acute laryngitis, revised 3/05/2025. Interventions included administer treatments (nebulizer) and medications per physician orders. Resident #231 observation on 2/26/2025 at 11:13 AM. The resident's nebulizer tubing was not dated. Medication Administration Record dated February 2025, documented Albuterol Sulfate Nebulization Solution (2.5 milligrams/3 milliliters) 0.083%, 3 milliliters inhale orally via nebulizer every 6 hours as needed for shortness of breath. Start date 2/18/2025 at 1:45 PM. - The medication was administered on 2/23/2025 and 2/24/2025. Treatment Administration Record dated February 2025 did not document nebulizer maintenance was performed. During an interview on 3/07/2025 at 11:56 AM, Licensed Practical Nurse #5 stated that when the nebulizer treatment was complete, they would clean the mask and leave it to dry on clean paper towels. When asked by what they meant as clean, Licensed Practical Nurse #5 stated that they ran it under hot water. Licensed Practical Nurse #5 stated that the tubing needed to be labeled and should be good for a week. When asked what they would do if the tubing wasn't labeled, or the Licensed Practical Nurse #5 would do if the tubing was not labeled. They stated that they would get new supplies. Anytime the tubing was changed, the mask should have been changed too. The changing of the tubing and supplied should be documented on the Treatment Administration Record and believed that the night shift changed the tubing. During an interview on 3/07/2025 at 2:00 PM, Regional Director of Nursing #1 stated that licensed staff was responsible for oxygen administration and well as the nebulizer treatments. Licensed staff were supposed to check the order for the set flow rate, document the administration time, how long the treatment took, and the assessment after the respiratory treatment. The tubing and mask should be covered when not in use and cleaned after the treatment was complete. Regional Director of Nursing #1 stated that they believed that was in an order set that was set up when the orders for nebulizer treatments were ordered. 10 New York Code of Rules and Regulations 415.12(k)(6) 48744

Based on observation, record review, and interview, during the recertification survey, the facility did not ensure a resident was assessed by the interdisciplinary team to determine a resident's ability to safely administer their own medications if clinically appropriate for 1 (Resident #23) of 1 resident reviewed. Specifically, Resident #23 was observed with topical steroid cream in their room and there was no assessment in the medical record and/or physician order for the resident to self-administer the medication. This is evidenced by: Cross-referenced to F656: Develop/Implement Comprehensive Care Plan Cross-referenced to F711: Physician Visits - Review Care/Notes/Order Resident #23 was admitted with the diagnoses of chronic obstructive pulmonary disease (a chronic lung disease that cause progressive and irreversible damage to the airways in the lungs), acute on chronic systolic congestive heart failure (a sudden worsening of symptoms of a pre-existing condition of weakened heart muscles), and type 2 diabetes mellitus (a chronic condition where the body does not use insulin properly or does not produce enough insulin to regulate blood sugar levels). The Minimum Data Set, dated dated dated [DATE], documented the resident was cognitively intact. The resident made themselves understood and was able to understand others. The Policy and Procedure titled, Self-Administration of Medications, reviewed ,d+[DATE], documented residents had the right to self-administer medications if the interdisciplinary team had determined that it was clinically appropriate and safe for the resident to do so. As part of their overall evaluation, the staff and practitioner would assess each resident's mental and physical abilities to determine whether self-administering medications was clinically appropriate for the resident. In addition to general evaluation of decision-making capacity, the staff and practitioner would perform a more specific skill assessment including but not limited to the resident's a) ability to read and understand medication labels, b) comprehension of the purpose and proper dosage and administration time for his or her medications, c) ability to remove medications from a container and to ingest and swallow (or otherwise administer) the medications, and d) ability to recognize risks and major adverse consequences of his or her medications. The staff and practitioner would document their findings and the choices of residents who were able to self-administer medications. Self-administered medications must be stored in a safe and secure place, which was not accessible by other residents. If safe storage was not possible in the resident's room, the medications of residents permitted to self-administer would be stored on a central medication cart or in the medication room. Nursing staff would review the self-administered medication record on each nursing shift, and they would transfer pertinent information to the medication administration record kept at the nursing station, appropriately noting that the doses were self-administered. Resident #23 was admitted to the facility with diagnoses of chronic obstructive pulmonary disease (a chronic lung disease that cause progressive and irreversible damage to the airways in the lungs), acute on chronic systolic congestive heart failure (a sudden worsening of symptoms of a pre-existing condition of weakened heart muscles), and type 2 diabetes mellitus (a chronic condition where the body does not use insulin properly or does not produce enough insulin to regulate blood sugar levels). The Minimum Data Set, dated dated dated [DATE], documented the resident was cognitively intact. The resident made themselves understood and was able to understand others. Physician's Progress Note dated [DATE] at 10:49 AM by Physician #1, documented the resident was seen today [DATE] for rash. The rash was a fungal infection that frequently comes and goes, which previously responded to clotrimazole-betamethasone (Lotrisone Cream). Rash on the bilateral face. Plan: fungal skin rash; take regular shower, clotrimazole-betamethasone ,d+[DATE].05% ointment on the lesion twice daily. Medication Administration Record dated February 2025, documented Lotrisone Cream ,d+[DATE].05% (clotrimazole-betamethasone) apply to per additional directions topically two times a day for fungal skin rash. There were no instructions for where the medication was to be applied. Start date [DATE] at 5:00 PM and was discontinued following interview with Physician #1 on [DATE] at 3:48 PM. - Lotrisone Cream was administered several times from [DATE] to [DATE]. During an observation and interview on [DATE] at 12:40 PM, Resident #23 stated they were a Registered Nurse for [AGE] years. When asked about the fungal skin rash, the resident stated they had a rash under their right breast that was caused from not having a bra that properly fit them and being sweaty under the breasts. The resident then picked up a bottle of antifungal powder that was on their nightstand and stated they had been using it regularly for the rash under their breast and pointed to their right breast. The surveyor asked about a rash that was noted on the resident's face which appeared red and blotchy across the forehead, nose, and cheeks. Resident #23 than reached in a bag and handed the surveyor a tube of cream that was in a clear plastic bag with a pharmacy label on it. The facility pharmacy label documented Clotrim/Beta cream [DATE].5 % generic for Lotrisone. Apply to per directions topically every dayshift for 14 days. Apply under the breast. Resident #23 stated the nurse left it for them (the resident) to apply themselves. The resident stated they had applied it to the rash on their face. They stated the nurse told them to look in the mirror and apply it to their face. The surveyor told the resident that the directions on the cream stated to apply it under the breast. The resident was not aware it was for the breast and stated they had applied the cream once yesterday afternoon and the rash on their face was gone. There was a red label on the prescription bag that read, for external use only: keep out of the eyes, inside of nose or mouth. Resident #23 stated they read the label and thought it said to affected area only. Resident #23 stated they were normally good at reading labels but does not always wear their glasses. Resident #23 stated they had no formal assessment to self-administer the medication. During an interview on [DATE] at 3:48 PM, Physician #1 stated they saw the resident on [DATE] because of a rash on the face, nose, and forehead. Lotrisone cream was prescribed for the resident's face. They stated the rash comes and goes because the resident was not following proper hygiene. When they saw the resident, they told the resident the plan was for the resident to shower every day and for the Lotrisone cream to be applied on the face on the affected skin. They stated the order for the Lortisone had detailed instruction on where the nurse should apply it. They stated they would not expect the patient to use it themselves. They stated, The instructions were for the nurse, not the patient. They stated they were not aware the resident had a fungal infection under their breast and could not explain why the prescription from the pharmacy documented to apply under the breast. They stated the resident only complained about the rash on their face when they saw them on [DATE]. They stated a fungal infection on the forehead could spread to the rest of the body. During an interview on [DATE] at 4:15 PM, Resident #23 stated the Lotrisone cream was removed from the room shortly after the surveyor left the room earlier that afternoon. The resident stated they told them the medication had expired. Upon further investigation, the surveyor identified a previous order dated [DATE], for Lotrisone Cream to be applied topically every dayshift for dermatitis (inflammation, redness, and itching) for 14 days, to be applied under the right breast. The order ended on [DATE]. During an interview on [DATE] at 2:02 PM, the Registered Nurse Regional Clinical Director #1, stated for self-administering medications, the physician would look at the resident's capacity and determine if they were able to safely administer the medications. A self-administration of medication form would then be completed. The physician would then write an order to leave medications at the bedside. 10 New York Codes Rules and Regulations 415.3(f)(1)(vi)

Based on interview and record review conducted during a recertification survey, the facility did not ensure residents were aware of the grievance process. Specifically, (1.) grievance forms were not readily available to residents; (2.) residents did not have the option to file a grievance anonymously; and (3.) 12 of 12 residents present at the Resident Council meeting reported they did not know the process by which to file a grievance. This is evidenced by: The facility policy, Filing A Grievance/Complaint dated 11/2016, documented any resident or resident representative may file a grievances and/or complaint regarding care, treatment, staff members etc. without fear of retaliation. Grievances could be made orally or in writing. The facility had a designated Grievance Officer who investigated grievances and/or complaints. During the Resident Council meeting held on 2/24/2025 at 10:34 AM, residents present did not know how to file a grievance and were unsure who the Grievance Officer was. Residents stated they would bring concerns to the Resident Council President or the Activity's Director. Some residents reported that they feared retaliation if they made a complaint. During an interview on 2/24/2025 at 10:34 AM, Activity's Director #1 stated that when they received a complaint or grievance, they informed the appropriate department and the social worker. They were not aware of a grievance form. During an interview on 2/24/2025 at 2:57 PM, Director of Social Work #1 stated they were the Grievance Officer and had grievance forms in their office. They believed there were forms in the supervisor's office, but they were not sure if forms were available on the units. Staff collected statements from residents, provided them to Director of Social Work 1, they collaborated with the appropriate department to resolve the complaint, and provided follow up to resident and/or resident representative. They had an open-door policy and received many informal complaints. Director of Social Work #1 reported they were not sure if there was anyway to file a grievance anonymously. During an interview on 3/07/2024 at 2:00 PM, Regional Clinical Director of Nursing #1, stated if a resident made a complaint, the staff would take down the grievance, have the Social Worker talk with the resident, then the complaint would be brought to the Administrator and Director of Nursing to have it addressed. They acknowledged that the facility had already taken corrective action to address the process for filing grievances. During an interview on 3/07/2025 at 2:41 PM, Administrator #1 stated that they were unaware of the issues surrounding grievances but as soon as the concern was raised during survey, the process was examined and the staff educated on officially filing grievances. Additionally, a locked box for grievances was installed outside the social work office in order to facilitate residents being able to file grievances anonymously. 10 New York Code Rules and Regulations 415.3(c)(1)(i) 51131 51958

Based on record review and interviews during a recertification survey, the facility did not ensure that all alleged violations involving abuse were reported immediately, or no later than 2 hours after the allegation was made for 2 (Residents #68 and #113) for 6 reviewed for abuse. Specifically, an allegation of a resident-to-resident altercation was reported by Resident #113 on 12/13/2024. The incident was not reported to the New York State Department of Health. This is evidenced by: The policy and procedure titled, Abuse Prevention Program/Abuse and Neglect - Clinical Protocol/Abuse Investigation and Reporting reviewed 1/2023 documented all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and .federal agencies (as defined by current regulations). Resident #68 was admitted to the facility with the diagnoses of Alzheimer's disease, osteoarthritis, and thrombocytopenia (a condition characterized by abnormally low levels of platelets. The Minimum Data Set (an assessment tool) dated 1/28/2025 documented the resident was understood by others, able to understand others, and was severely cognitively impaired. Resident #113 was admitted to the facility with the diagnoses of alcoholic cirrhosis of the liver (a permanent scarring that damages your liver and interferes with its functioning. It can lead to liver failure), acute kidney failure, and hypotension. The Minimum Data Set, dated dated dated [DATE] documented the resident was understood by others, able to understand others and was cognitively intact. The Incident Report dated 12/13/2024 at 3:30 PM documented Resident #113 reported to staff that Resident #68 had entered their room, knocked off their hat and tapped them on their cheek. Both residents were assessed with no injury. The Summary of Investigation documented Resident #113 felt safe in the facility. It documented that Resident #68 was not malicious and had no intent to cause injury or harm to Resident #113. The facility declined to report the incident to the New York State Department of Health. During an interview on 03/07/25 at 2:30 PM, Administrator #1 stated Resident #113 had self-reported to staff that Resident #68 had taken off their hat and tapped them on the head. It was determined in the investigation that the incident was playful in manner and not malicious and was not reported to Department of Health because of that. 10 New York Codes, Rules, and Regulations 415.4(b)(2)

Based on interviews and record review during a recertification survey, the facility did not ensure that written notification was sent to the resident, the resident's representative, and to the Office of State Long-Term Care Ombudsman of the resident's transfer or discharge for 2 (Residents #112 and 123) of 2 residents reviewed for hospitalization. Specifically, (a.) for Resident #112, written notification of transfer to the hospital was not provided to the Ombudsman for 3 out of 4 hospital admissions; (b.) for Resident #123, written notification of transfer was not provided to the resident, the resident's representative, or the Ombudsman when the resident was admitted to the hospital from the facility on 12/27/2024 . This is evidenced by: The facility policy titled, Transfer or Discharge Notice revised on 10/2022, documented the resident and/or resident representative was to be notified in writing of the reason for the transfer or discharge, the effective date of transfer or discharge, location at which the resident was being transferred or discharged , and of the resident's appeal rights. When a resident was temporarily transferred to an acute care facility on an emergency basis, notice of the transfer may be provided to the resident or resident representative as soon as practicable according to 42 Code of Federal Regulations 483.15(c)(4)(ii)(D). Copies of notices of emergency transfers would also be sent to the Ombudsman when practicable, such as providing a list of residents to the Ombudsman on a monthly basis. Resident #112 Resident 112 was admitted to the facility with diagnoses of metabolic encephalopathy (a change in how your brain works due to an underlying condition), type 2 diabetes (a chronic condition characterized by insulin resistance and high blood sugar levels), and end stage renal disease (the final stage of chronic kidney disease, where the kidneys have permanently lost most of their ability to function). The Minimum Data Set (an assessment tool) dated 1/26/2025, documented the resident was understood, understands others, and was cognitively intact. A physician progress note, dated 12/31/2024 at 11:55 AM, documented Resident #112 was sent to the hospital to receive dialysis because they had missed their previous dialysis appointment due to feeling lethargic and nauseous. A physician progress note, dated 1/05/2025 at 10:46 AM, documented Resident #112 was sent to the hospital per their request for pain control. A physician progress note, dated 1/11/2025 at 6:17 PM, documented Resident #112 was sent to the hospital due to unresponsiveness and low blood sugars. A nursing progress note, dated 2/25/2025 at 3:36 PM, documented Resident #112 was sent to the hospital due to a critical lab value. During an interview on 3/07/2025 at 10:10 AM, Director of Social Work #1, stated the transfer/discharge notices for Resident #112 for dates 12/31/2024, 1/05/2025, and 1/11/2025 were not documented as sent to the Ombudsman as they should have been. During an interview on 3/07/2025 at 2:24 PM, Regional Clinical Director of Nursing #1, reported that a paper copy of the transfer/discharge notice needed to be sent to the resident and Ombudsman anytime someone transfer/discharges. During an interview on 3/07/2025 at 2:25 PM, Administrator #1, stated that they believed that transfer/discharge notifications were sent to the Ombudsman monthly and was unaware that the notices were not being sent as expected. Resident #123 Resident #123 was admitted to the facility with diagnoses of acute kidney failure (a sudden decline in the functioning of kidneys), absolute glaucoma (increased intraocular pressure that results in permanent vision loss and blindness), and type 2 diabetes (a chronic condition characterized by insulin resistance and high blood sugar levels). The Minimum Data Set, dated [DATE], documented that the resident was understood, could understand others, and had mild cognitive impairments. The resident required substantial/maximal assistance with most activities of daily living. A progress note dated 12/27/2024 at 5:13 AM, documented that Resident #123 was found on the floor during rounds facedown and reported a headache. The nurse practitioner ordered the resident be sent to the hospital. Family was made aware. A neurology consult note from the hospital, dated 12/28/2024 at 3:46 AM, documented Resident #123 was admitted to the hospital on [DATE] status post fall. During an interview on 2/26/2025 at 4:10 PM, Director of Social Work #1 stated that a final discharge notification was never sent to Resident #123, the resident's representative, or the Ombudsman. They stated they did not provide the resident or resident representative with a transfer/discharge notice when they were sent to the hospital. They reported discharge notification forms were only sent to the Ombudsman for voluntary or against medical advice discharges, not for hospital transfers or discharges. During an interview on 2/27/2025 at 11:35 AM, Administrator #1 stated when a resident is sent to the hospital, they should be sent with the transfer/discharge form. Administrator #1 acknowledged the Ombudsman was not notified of Resident #123's transfer to the hospital. 10 New York Code of Rules and Regulations 415.3(i)(1)(iii)(a-c)

Based on observation, interview and record review during a Focused Infection Control COVID-19 survey completed on 11/18/2020 through 11/20/2020, the facility failed to maintain an infection prevention and control program to ensure the health and safety of residents to help prevent the transmission of COVID -19. Specifically, for three of three units on droplet and contact precautions, the facility failed to ensure staff appropriately donned (applied) and doffed (removed) Personal Protective Equipment (PPE) and performed hand hygiene between residents. Additionally, the facility did not ensure staff practiced social distancing and wore masks, did not ensure residents were socially distanced, did not ensure transmission-based precaution signage clearly indicated the need for facility wide contact and droplet precautions and that the signage in use was understood by facility staff. This resulted in no actual harm with the potential for more than minimal harm that is Immediate Jeopardy to resident health and safety. The Immediate Jeopardy was lifted on 11/20/2020. This is evidenced by: On 11/17/2020, the Hospital Electronic Response Data System (HERDS) report documented the following information: Facility census-117, COVID-19 positive residents-4, Residents on isolation-117, presumed COVID-19 positive-0. During an interview on 11/18/20 at 9:15 AM, the Infection Control Preventionist (ICP) stated all residents in the facility were on droplet and contact precautions. The ICP stated staff were expected to don PPE before entering a Resident's room and doff prior to exiting a Resident's room. A document titled COVID Line List dated 11/18/20, documented four Residents residing in rooms on the C Unit were positive for COVID-19. During an interview on 11/18/20 at 12:30 PM, the Infection Control Preventionist (ICP) provided the following information: 11/10/20 - A Licensed Practical Nurse (LPN) that worked on the Unit C tested positive for COVID-19. 11/13/20 - A Certified Nurse Assistant (CNA) that worked on Unit A tested positive for COVID-19. 11/14/20 - Three residents that resided on Unit C tested positive for COVID-19. 11/15/20 - Two residents that resided on Unit C tested positive for COVID-19. 11/17/20 - One resident on Unit C and one resident on Unit A tested positive for COVID-19. The ICP stated there were four COVID-19 positive residents in the facility on Unit C and three COVID-19 residents were hospitalized . The remaining 114 residents had a COVID-19 unknown (status) and were on droplet and contact precautions, as they were all potentially exposed to a COVID-19 positive staff or Resident. Finding #1: The facility failed to ensure staff appropriately donned and doffed PPE and performed hand hygiene between residents. The U.S. Centers for Disease Control and Prevention (CDC) guidance titled Using Personal Protective Equipment (PPE), updated on 8/19/20, documented PPE was needed for a patient with confirmed or possible COVID-19patients with confirmed or possible [CONDITION(S)]-CoV-2 infection should wear a facemask when being evaluated medically and Healthcare personnel should adhere to Standard and Transmission-based Precautions when caring for patients with [COVID-19] infection. The guidance documents instructions for donning (applying) PPE, including the following initial steps before entering a patient's room: identify PPE needed, perform hand hygiene using hand sanitizer, put on isolation gown, put on N95 respirator or facemask, put on face shield or goggles, put on gloves. The guidance further documents the following instructions for doffing (removing) PPE before exiting a patient's room: remove gloves and remove gown; hand hygiene is to be performed after exiting the patient's room. CDC guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated November 4, 2020, provides that recommended PPE when entering the room of a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection includes a N95 respirator, gown, gloves, and eye protection. Regarding gowns, the guidance states: Put on a clean isolation gown upon entry into the patient room or area. Change the gown if it becomes soiled. Remove and discard the gown in a dedicated container for waste or linen before leaving the patient room or care area. Disposable gowns should be discarded after use. Reusable (i.e., washable or cloth) gowns should be laundered after each use. The NYSDOH Health Advisory titled COVID-19 Cases in Nursing Homes (NH) and Adult Care Facilities dated 3/13/20 revised 7/10/20, documented: 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. A facility policy titled, Handwashing/ hand hygiene last reviewed on 3/2020, documented to wash hands before and after direct contact with residents, after contact with objects in the immediate vicinity of the resident, after removing gloves and before and after entering isolation precaution settings. A facility Policy titled Updated Guidance on COVID-19, dated 7/2020 documented to put on a clean isolation gown upon entry into a patient room or area. Remove and discard the gown in a dedicated container for waste or linen before leaving the patient room or care area. Disposable gowns should be discarded after use and cloth gowns should be laundered after each use. It documented hand hygiene should be performed before and after all resident contact, and before and after putting on and removal of PPE, including gloves. It documented health care providers would receive training on and demonstrate an understanding of when to use PPE, what PPE was necessary, how to don and doff PPE to prevent self-contamination, and how to properly dispose or disinfect and maintain PPE. During an observation on Unit C on 11/18/20 at 9:20 AM, Certified Nurse Assistant (CNA) #3 was observed repositioning a resident. CNA #3 was not wearing a face shield or gloves. CNA #3 exited the room without doffing the gown or performing hand hygiene and proceeded to assist another resident with the telephone at the nurse's station. CNA #3 did not doff the gown, don a clean gown or perform hand hygiene prior to entering another resident's room, and exited the resident's room carrying a bedpan. CNA #3 did not doff the gown or perform hand hygiene. CNA #3 entered another resident's room carrying the same bedpan and a cup with a straw. CNA #3 did not doff the contaminated gown, don a clean gown or perform hand hygiene. During an observation on Unit B on 11/18/20 at 9:30 AM, CNA #2 exited a resident's room wearing a gown and entered another resident's room and did not doff the gown, perform hand hygiene or don a clean gown. CNA #2 exited the resident's room. CNA #2 did not doff the gown or perform hand hygiene and assisted another resident in the hallway. During an observation on Unit A on 11/18/20 at 9:45 AM, Housekeeper (HK) #1 was cleaning the resident sink in room A-7 with a gown, gloves, mask and face shield in place. HK #1 exited room A-7 with the cloth used to cleanse the sink in her gloved hand. HK #1 did not doff PPE or perform hand hygiene. HK #1 entered room A-6 and was observed cleaning the resident sink with the same cloth used in room A-7. HK #1 exited room A-6 with the cloth used to clean the sink in her gloved hand. HK #1 did not doff PPE or perform hand hygiene. During an interview on 11/18/20 at 9:45 AM, HK #1 stated he/ she was told to don PPE prior to entering the unit and doff PPE when exiting the unit. HK #1 stated she couldn't remember what she was educated on regarding changing gloves or performing hand hygiene. HK #1 stated she thought she could use the cloth for all the sinks in the resident rooms as she was using a Clorox spray cleaner. During an observation on Unit C on 11/19/20 at 12:50 PM, CNA #9 was in a Resident's room and was not wearing a face shield or gloves. CNA #9 placed a face shield on after the surveyor's observation and attempted to reposition the resident. CNA #9 doffed the gown, mask and face shield, and exited the Resident's room without performing hand hygiene. CNA #9 opened a clean PPE cart outside of the room and removed a clean gown, walked down the hall to another clean PPE cart, opened the cart and removed a face mask. CNA #9 proceeded to walk to the end of the hall of Unit C while applying a face mask, opened a PPE cart, removed a gown and returned to the same Resident's room in the middle of the hall of Unit C. CNA #9 handed a gown to another staff member, donned his face shield, gown and gloves and entered the resident's room. CNA #9 did not perform hand hygiene during any of these observations. During an interview on 11/19/20 at 12:55 PM, CNA #9 stated he received education on donning and doffing PPE and hand hygiene today. CNA #9 stated he doesn't know why he did not have appropriate PPE on while in the Resident's room. He was aware of the sign outside of the Resident's room to wear a gown, gloves, face shield and mask before entering the room. CNA #9 stated he was moving fast and forgot to perform hand hygiene. During an observation on 11/18/20 at 9:12 AM, CNA #5 exited Unit C wearing a yellow isolation gown. CNA #5 removed the gown, placed it in a Ziploc bag labeled with her name, and placed the Ziploc bag in a plastic storage bin on the floor. During an interview on 11/18/20 at 9:12 AM, CNA #5 stated she was educated to reuse gowns throughout the unit. CNA #5 stated when they exit the unit, they place their gown in a Ziploc bag and place it in a plastic bin. CNA #5 stated when she re-entered the unit, they would take a used gown out of a Ziploc bag in a plastic bin and place it on prior to entering the unit. During an observation on 11/18/20 at 11:30 AM, Occupational Therapist (OT) #1 and Certified Occupational Therapy Assistant (COTA) #1 exited Unit C, removed their gowns, placed their gowns in a Ziploc bag, and placed the bag in a plastic storage bin on the floor. During an interview on 11/18/20 at 11:30 AM, OT #1 stated gowns should be removed when exiting the unit and placed in a labeled Ziploc bag. The gown should be removed from the labeled Ziploc bag and reused prior to entering the unit. During an observation on 11/18/20 at 11:50 AM, CNA #5 obtained a Ziploc bag from a storage bin on the floor outside of Unit C, removed an isolation gown from the Ziplock bag, donned the gown and entered Unit C. During an observation on 11/18/20 at 12:00 PM, Activities Aide (AA) # 1 exited the unit wearing an isolation gown, removed and placed the isolation gown in a plastic Ziplock bag and placed the bag in a plastic storage bin on the floor. During an interview on 11/18/20 at 12:15 PM, CNA #4 (Unit C) stated he/she placed the used gown on a hook when he/she exited a resident's room and reused the gowns when re-entering the resident's room. During an interview on 11/18/20 at 8:15 PM, the Director of Nursing (DON) stated she was not aware all residents in the facility had a potential exposure to staff or residents that tested positive for COVID-19. During an interview on 11/18/20 at 9:00 PM, the Administrator stated he was unaware PPE could not be reused between residents of unknown COVID-19 status. During an interview on Unit B on 11/18/20 at 9:33 AM, Registered Nurse (RN) #1 stated staff do not change their gowns between residents' rooms because there are no residents on isolation. When staff leave the unit to go on break the gowns are placed in plastic bags labeled with the staff members name and placed in a plastic storage bin and were to be reused upon returning to the unit. At the end of the shift the gowns are placed in the laundry bin. During an interview on 11/19/20 at 1:10 PM, Licensed Practical Nurse (LPN) #7 stated he/she would expect staff to don PPE as noted on the signs outside of each resident's room on Unit C including a gown, gloves, mask and face shield. LPN #7 stated PPE should be removed prior to exiting the resident's room and hand hygiene should be performed. During an interview on 11/19/20 at 1:35 PM, the ICP stated she would expect staff to don a gown, gloves, mask and face shield prior to entering a resident's room that was on contact and droplet precautions, doff PPE prior to exiting the resident's room and perform hand hygiene. ICP stated CNA #9 was educated today on donning and doffing PPE as well as hand hygiene. The ICP stated all residents in the facility remained on droplet and contact precautions. Finding #2: The facility did not ensure all staff practiced social distancing and wore masks and did not ensure residents were socially distanced. The CDC guidance titled, Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated 11/4/20, documented patients wear a mask (if tolerated) upon arrival to and throughout their stay in the facility. It documented health care providers should wear a facemask at all times while they are in the healthcare facility, including in breakrooms or other spaces where they might encounter co-workers. The guidance documented physical distancing (maintaining at least 6 feet between people) is an important strategy to prevent [CONDITION(S)]-CoV-2 transmission. The CDC guidance, titled Preparing for COVID-19 in Nursing Homes, updated November 20, 2002, documented: Residents should wear a cloth face covering or facemask (if tolerated) whenever they leave their room, including for procedures outside the facility. Cloth face coverings should not be placed on anyone who has trouble breathing, or anyone who is unconscious, incapacitated, or otherwise unable to remove the mask without assistance. The NYSDOH Health Advisory COVID-19 Cases in Nursing Homes and Adult Care Facilities, dated March 13, 2020 and updated July 10, 2020, provides that when there are confirmed COVID-19 positive residents in a nursing home: 3. Assure that all residents in affected units remain in their rooms. Cancel group activities and communal dining. Offer other activities for residents in their rooms to the extent possible, such as video calls. 4. Residents must wear facemasks when HCP or other direct care providers enter their rooms, unless such is not tolerable. During an observation of Unit A on 11/18/20 at 9:32 AM, eight residents were seated in the hall. Four residents were seated in wheelchairs on the right side of the hall, two residents (Resident #12 and Resident #13) were reclined in [NAME] loungers and two residents were self-propelling on the left side of the hallway. The residents self-propelling in the hall and the residents in the [NAME] loungers were not wearing face masks and the residents were less than six feet apart. During an interview on 11/18/20 at 9:40 AM, CNA #10 stated the Resident #12 required assistance to move the [NAME] lounger to mobilize and was brought into the hallway at 6:30 AM and will remain in the hall until after lunch. CNA #10 stated Resident #13 was brought into the hall by staff at 7:30 AM to eat breakfast and would be returned to their room after lunch. CNA #10 stated Resident #12 and #13 were not on isolation precautions and could be left in the hallway. CNA #10 stated the Resident #12 that was positive for COVID-19 was moved to another unit yesterday. During an observation on 11/20/20 at 12:09 AM, the Director of Rehabilitation was not wearing a mask and was seated at a computer less than 3 feet from another staff member. The Director of Rehab placed a facemask on when the surveyor entered the room. During an observation on 11/20/20 at 2:29 PM, the ICP was not wearing a mask and was less than 3 feet from another staff member. The ICP placed a facemask on when a surveyor entered the room. During an interview on 11/20/20 at 2:29 PM, the ICP stated staff were always expected to wear a facemask while in the facility unless eating. The ICP stated if a facemask was removed then a minimum distance of six feet should be maintained. The ICP stated she was aware the facility staff did not regularly follow this, and she should have had a mask in place. Finding #3: The facility did not ensure transmission-based precaution signage clearly indicated the need for facility wide contact and droplet precautions and that the signage in use was understood by facility staff. During an interview on 11/18/20 at 8:45 AM, the ICP stated all residents on Unit A, Unit B and Unit C were on contact and droplet precautions. The ICP stated signs regarding isolation precautions were posted in the facility and were colored to indicate the type of isolation needed for each resident. The ICP stated the sign colors were pink, red, blue and white. PPE requirements for all colored signs included mask (N95 for Pink signs), eye protection, gown and gloves. The ICP stated there were 4 residents positive for COVID-19 residing on Unit C. During an observation of each unit on 11/18/2020 between 9:20 AM and 9:31 AM, red colored copy paper was observed on the doors of entrance to Unit A & Unit B. Unit C had colored copy paper - pink, red, blue and white located on each resident's door (pink = COVID-19 positive, blue = quarantine, white = negative COVID-19, red = unknown status). The colored papers did not specify the type of isolation or the PPE required. During an observation on Unit B on 11/18/20 at 9:20 AM, isolation precautions signs were not observed outside of resident rooms. During an observation on Unit A on 11/18/20 at 9:31 AM, isolation precautions signs were not observed on resident doors throughout Unit A. During an interview on Unit A on 11/18/20 at 9:40 AM, CNA #10 stated the residents on Unit A were not on isolation precautions. CNA #10 stated the resident that was positive for COVID-19 was moved to another unit yesterday. During an interview on Unit B on 11/18/20 at 9:45 AM, CNA #2 stated that they can go from room to room with the same gowns. If there was a sign on the door of a room, they would need to change their gown for that room. During an interview on Unit B on 11/18/20 at 12:20 PM, CNA #1 stated there are no residents on isolation on Unit B but the whole unit is on precautions to protect the residents from the staff. During an interview on 11/18/20 at 12:20 PM, Licensed Practical Nurse (LPN) #1 stated she did not know what the red signs indicated. The facility's allegation of compliance to remove the Immediate Jeopardy, dated 11/18/20, included the following: a. Staff would be educated on infection control practices including, but not limited to, proper handwashing, donning and doffing of PPE, proper PPE to wear with Contact and Droplet precautions and when PPE should be changed. Compliance will be at 91%. b. Signage in the facility will be replaced with CDC approved Contact and Droplet precautions signs. All residents will be placed on contact and droplet precautions and education will be provided to staff on correct PPE to wear based on posting. The Immediate Jeopardy was removed on 11/25/20 based upon surveyor observations and verifications which included the following: a. Observations revealed that all residents had appropriate signage that directed staff on type of PPE needed and procedure for donning and doffing. Staff were donning PPE prior to entering and doffing PPE prior to exiting a resident's room and performing hand hygiene. b. Staff were educated on infection control policies and procedures related to COVID-19 including PPE requirements, donning and doffing PPE, and hand hygiene. The facility provided a copy of the education material used and signature sheets for those that completed the education. As of 11/20/20, 91 percent of the staff had been educated with a plan to educate all staff prior to working their next scheduled shift. 10 NYCRR 415.19 and 10 NYCRR 400.2

Based on record review and staff interviews during an abbreviated survey (Case #'s NY 165), the facility did not ensure that it immediately consulted with the resident's physician and notify, consistent with his or her authority, the resident representative for a significant change in the resident's physical condition (a deterioration in health, in either life-threatening conditions or clinical complications) for one resident (Resident #6) of eight residents reviewed. Specifically, Resident #6 had significant progressive changes in physical condition from [DATE] - [DATE] that were documented on the 24 Hour Supervisory Report (RN Supervisor communication report), but were not reported to the resident's physician and the resident's HCP was not notified of the significant changes. This resulted in the resident's transfer to the hospital on [DATE]. The resident expired on [DATE] at 1:20 pm due to UTI (urinary tract infection), hypoxic [MEDICAL CONDITION]. This resulted in actual harm that is not immediate jeopardy. This is evidenced by: Resident #6: The resident was admitted to the facility on [DATE], and readmitted on [DATE] and [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident's cognitive skills for daily decision making as modified independence (some difficulty in new situations only), sometimes understood, and sometimes understands others. The resident's health care proxy (HCP) was making medical decisions for the resident. The P&P entitled Change in Resident Condition dated ,[DATE], documented that when a resident experiences a medical change in condition, it is the expectation that the RN on duty will perform a full assessment of the resident and document such change in the medical record and notify the physician of such changes. It documented that upon determining that a change in the resident's condition has occurred, the licensed nurse on duty will promptly notify the RN Supervisor and make him/her aware. The P&P entitled Foley Catheter dated ,[DATE], documented that if medically indicted, output is measured and the nurse is notified if output is less than 200 ml/shift. The Facility and Hospital records dated [DATE] and [DATE], documented the resident had significant changes in medical condition consistent with a UTI (fever, changes in characteristics of urine, and mental status changes; sluggish/drowsy). The resident was sent to the hospital, and was diagnosed with [REDACTED]. Findings: 1. Review of the medical records revealed that from [DATE] - [DATE], the resident had significant progressive changes in physical condition. The records did not contain documentation that the resident's physician was contacted by the Registered Nurse (RN). On [DATE], the resident was transferred to the hospital and expired at 1:20 pm due to UTI and [MEDICAL CONDITION]. 2. Review of the medical records revealed that from [DATE] - [DATE], the resident had significant progressive changes in physical condition. On [DATE] at 7:47 pm, the LPN documented that the resident's HCP was called and a message was left to call the facility ASAP. There was no other documentation that the HCP was notified of the significant changes. The Progress Note dated [DATE] at 9:09 pm ([DATE] evening shift), written by LPN (Licensed Practical Nurse) #10 documented significant changes in the resident's condition: Resident had a pulse of 138 (normal resting heart rate is ,[DATE] beats per min), an O2 SAT (saturation) (the level of oxygen in the blood) of 87% (normal is ,[DATE]%), temperature 98.6 and respirations 24 (normal is ,[DATE] breaths per min). The LPN received instructions from the RN Supervisor to start the resident on 2 liters of oxygen to increase the resident's O2 SAT. The LPN documented the resident was not himself, was not eating or drinking much, was very quiet, and that the supervisor was made aware. The changes in condition were also documented on the 24 Hour Supervisory Report dated [DATE], (3p - 11pm evening shift). There was no documentation in a progress note regarding the resident's condition during the night shift (11p - 7am) on [DATE], however, significant changes in the resident's condition were documented on the 24 Hour Supervisory Report dated [DATE] (11p -7am night shift). It was documented that the resident continued to have an increased heart and respiratory rate; heart rate 122, respirations 24, and blood pressure ,[DATE]. The Progress Note dated [DATE] at 11:01 am, written by Registered Nurse Unit Manager (RNUM) #4, documented the resident had signs and symptoms of a possible UTI. It documented that at 8:00 am, the resident had a temperature of 100, the Foley catheter was draining cloudy urine, the NP (Nurse Practitioner) was called, and new orders were given. The details of the new NP orders were not documented in the progress note, but were documented on the 24 Hour Supervisory Report dated [DATE] (7 am - 3pm shift): [MEDICATION NAME] IM Q12 h x 2d (an antibiotic to be injected into the muscle every 12 hours for 2 days), and a U/A, C&S (urinalysis; test of the urine, and a culture and sensitivity; a test to find germs/bacteria and a test to determine the sensitivity of bacteria to an antibiotic). The Progress Note dated [DATE] at 2:51 pm (day shift), written by RNUM #4, documented the resident's appetite was excellent, and the resident eats additional snacks between his meals. The Progress Note dated [DATE] at 7:29 pm (evening shift), written by LPN #10 documented significant changes in the resident's condition: temperature 99.7, only taking a few bites at dinner time, taking small amounts of liquids only, sleeping most of the shift, and continues antibiotics for UTI. The changes in condition were also documented on the 24 Hour Supervisory Report dated [DATE] (evening shift). It was documented: the resident was taking fluids reluctantly and needs a U/A, C&S. The Progress Note dated [DATE] at 1:40 am ([DATE] night shift) written by LPN #2, documented significant changes in the resident's condition: Tylenol suppository given for a temperature of 100.7. Oxygen started at 2 liters for O2 SAT of 88%, O2 SAT increased to 92%. The changes in condition were also documented on the 24 Hour Supervisory Report dated [DATE] (night shift): Tylenol suppository was given for a temperature of 100.7, temperature decreased to 100.1, the resident was refusing fluids, and had not voided. The Progress Note dated [DATE] at 5:32 am ([DATE] night shift), written by RNS #4, documented the urinary drainage bag contained approximately 200 cc's (cubic centimeters) of dark amber urine with mucous-like sediment. The Foley catheter was irrigated prior to changing the drainage bag, fluids were encouraged, the resident was reluctant, consumes sips when offered, and the O2 SAT was 93%. The Progress Note dated [DATE] at 8:41 am ([DATE] day shift), written by LPN #9, documented a significant change in condition: Resident is currently taking NPO (nothing by mouth). The 24 Hour Supervisory Report dated [DATE], (7a - 3p day shift) documented: poor PO intake, antibiotics for possible UTI, temperature 98.8, took 900 cc, and no output. Review of the Order Summary Report revealed the physician did order NPO for the resident. The Progress Notes dated [DATE] at 4:26 pm (evening shift), written by LPN #9, documented that the following medications were not given: Prostat (protein supplement) because hard time swallowing, and [MEDICATION NAME] tablet (beta blocker; lowers heart rate, blood pressure, and takes strain off the heart) prescribed for [MEDICAL CONDITION] (an irregular and often rapid heart rate that can increase the risk for stroke) because reported by night nurse taken no NPO. The 24 Hour Supervisory Report dated [DATE] (3p - 11p evening shift) documented: 97.9 no issues. The Progress Note dated [DATE] at 7:47 pm (evening shift), written by LPN #11, documented significant changes in the resident's condition: Resident was noted with mottling (blood vessel changes in the skin that cause a patchy appearance; a sign of that blood is flowing inadequately through organs or tissues) to both lower extremities. The RN Supervisor was made aware, the HCP was called, and a message was left for the HCP to return the call ASAP (as soon as possible). The 24 Hour Supervisory Report dated [DATE] (3p - 11p evening shift) documented: 97.9 no issues. The Medication Administration Notes dated [DATE] at 9:14 pm (evening shift), included documentation that LPN #11 held the medication Donepezil (for dementia) and nutritional supplement Ensure, because the resident was dysphasic (impairment of speech and verbal comprehension) (Use of the term dysphasic was clarified through interview with the LPN whose intent was to relay that the resident was unable to swallow). The 24 Hour Supervisory Report dated [DATE] (3p - 11p evening shift) documented: 97.9 no issues. The Progress Note dated [DATE] at 1:53 am ([DATE] night shift), written by LPN #2 documented significant changes in the resident's condition: a Tylenol suppository for a temperature of 101 was given, heart rate was 54 (below normal; a possible sign of a problem with the heart's electrical system), blood oxygen level was 80 (below normal; a sign of a problem related to breathing or circulation), started on 3 liters of oxygen, and Will monitor. At 2:30 am, LPN #2, documented; temperature 100.6 and Tylenol administration was ineffective. The changes in condition and interventions were documented on the 24 Hour Supervisory Report dated [DATE] (night shift): temperature 100.7, O2 SAT of 80%, O2 applied, Tylenol suppository, unable to swallow, and no output. The Progress Note dated [DATE] at 6:07 am ([DATE] night shift), written by LPN #2, documented the LPN's observation of significant changes in the resident's condition on [DATE] at 5:28 am: Resident continues to be basically unresponsive to verbal commands. Does respond to painful stimuli. Vital signs documented: temperature 100.5, heart rate 80, and blood oxygen level 90% on 3 liters. The resident had not voided this shift. Belly is firm and beginning to distend, a Tylenol suppository was given, and a cool cloth was applied to the resident's forehead. Will continue to monitor. The changes in condition were not documented on the 24 Hour Supervisory Report. The Progress Note dated [DATE] at 7:01 am, written by RNS #3, documented that the HCP called the facility for an update on the resident and requested that the resident be sent to the hospital. It documented that the Medical Director (MD #4) was called regarding the request. MD #4 stated he would like to treat the resident here (in the facility). New orders documented to start the resident on IV fluids, administer IV [MEDICATION NAME], call the hospital for a U/A & C&S, encourage PO fluids, and instruction to give Tylenol suppository for increased temperature. The Progress Note dated [DATE] at 7:42 am, written by LPN #9 documented; Resident is in a failing state and unable to take PO. Also, being sent to the hospital. The Progress Note dated [DATE] at 9:10 am, written by RNS #3, documented: The HCP was in to visit this am and demanded that the resident be sent to the hospital. Per MD #4, call ER (emergency room ) and give report and explain that we wanted to treat him in house with IV fluids and IV antibiotics, but HCP wanted him evaluated at ED (Emergency Department). The Hospital emergency room Physician Notes dated [DATE] at 10:01 am, documented: short of breath, respiratory distress, agonal (abnormal pattern of breathing characterized by gasping) breathing, O2 Sat ,[DATE]% on 6 liters of oxygen via nasal cannula, color gray, skin diaphoretic (sweating heavily), patient has UTI, fever since Friday, reported advanced dementia and that on Friday the patient was noted to have a fever and UTI. Patient is obtunded (a greatly reduced level of consciousness, arousing with only very strong stimulus), unresponsive with agonal breathing. The resident's skin was mottled with cyanosis (bluish discoloration due to a lack of oxygen in the blood) to both hands, both feet, and lower extremities. After the evaluation in the Emergency Department, my clinical impression is UTI,[MEDICAL CONDITION], acute [MEDICAL CONDITIONS], and [MEDICAL CONDITION]. Review of the Hospital Post Mortem Information Form documented the following: Date and Time of Death [DATE] at 1:20 pm. The principal [DIAGNOSES REDACTED]. During an interview on [DATE] at 10:15 am, with NP #1, she stated she would want to know if the resident's abdomen was distended, because it could be a sign of urosepsis. The NP stated that if a resident was going septic, she would expect an RN assessment and MD notification. She also stated that she would have expected to be notified when the resident couldn't swallow, and for mottling with decreased circulation; usually a sign of death. The NP stated that if the LPN notices it, the RN and MD should be notified. During an interview on [DATE] at 2:00 pm, with RNUM #1, regarding the change in condition on [DATE] during the 3p - 11p shift, the RNUM stated she would expect an RN assessment, and the MD to be notified. With all changes in condition she would expect an RN assessment, and MD notification. During a phone interview on [DATE] at 7:45 am, with RNS #4, she stated that she would expect an RN assessment for the resident's change in condition on [DATE]. She stated the resident should have been assessed by the RN when he was not swallowing, and the MD should have been notified. It's a serious change, possible dehydration. Things can go bad quickly. Regarding changes in the resident's urine, RNS #4 stated I would think I would have called the MD. RNS #4 stated that a heart rate of 138 was alarming. She stated that at the time, they would have applied oxygen for comfort, and stated Now we apply oxygen, and call the MD immediately. Regarding the resident's heart rate of 54 and oxygen level of 80%, the RNS stated that the LPN should have notified the RN. The amount of supplemental oxygen a resident is receiving, can't be changed without an RNs or a Provider's direction. During an interview on [DATE] at 8:45 am, with MD #4, he stated If a resident can't eat, who normally eats, I would expect an RN assessment. The MD stated that for mottling he would expect the RN to be checking the resident to see if there was mottling and that the MD should have been notified. In regards to the resident's firm belly, and unresponsiveness, he stated that there needs to be an evaluation by the RN or MD. The MD stated that for the resident's changes in condition, the resident should have had an RN assessment. He stated the MD should have been notified, and stated, I assume it was just not documented. He stated that it was okay to administer oxygen under the direction of the RNS, with MD notification afterwards. Regarding the [MEDICATION NAME] not given, the MD stated I would expect notification. During an interview on [DATE] at 12:40 pm, with RNS #1, he stated they would need an order from the MD for oxygen. The LPN should have notified the RN for the resident's heart rate of 54 and oxygen level of 80%. He stated that no voiding is a red flag, that a firm belly is not good and that the MD should have been notified. In regards to mottling, he stated he would expect vital signs, and an RN assessment. He stated that oncoming RNs need to look at the 24 Hour Supervisory Report sheet which goes to morning report, and that the IDT team meet daily, Monday - Friday. The RN stated that he did not recall a note about a resident with an increased heart rate, and low oxygen level. He stated, I must have went to see him. It must not have made it to documentation. He stated he normally documents an assessment. Vital signs should have been taken. RNS #1 stated that a 24 hour change in condition should be on the 24 Hour Report, the MD should be called, and the resident should be send out for an evaluation. RNS #1 stated that if the resident's oxygen level was low I am sure that I would have said to put oxygen on. I wouldn't think that she (LPN) would do it on her own. During an interview on [DATE] at 2:55 pm, with the Director of Nursing (DON), regarding the resident's changes in condition, she stated she would expect an RN assessment. She stated, No automatic oxygen. If in distress, the RN assesses, and the MD orders it. RNs do the 24 Hour Supervisory Report. LPNs don't usually. If they did, would expect RN follow up. She would have expected RN assessments with changes in condition, and would expect monitoring of the resident while he was on antibiotics to see the resident's response. The DON stated the RN should have assessed the resident, and notified the MD when medications were not given. The previous day's 24 Hour Supervisory Report is discussed in morning report, and she would instruct the RNUM to follow up and assess the resident. She stated that she Expects the RNs to do as per her direction. She stated that the purpose of the morning report was so that the RNUM could follow up, assess, and notify MD and family. She stated, If it's not on the 24 Hour Supervisory Report, or no RNUM follow up, she would not be aware. In regards to documentation, the DON stated that she would expect documentation for change in condition, RN assessment, fever, wounds, new orders. She considers the computer system the primary source of documentation. She would expect the specimen for the UA/C&S to be obtained, and it is the responsibility of the RN to ensure that it's done. During a phone interview on [DATE] at 1:20 pm, with RNUM #4, she stated that for a resident on an antibiotic, she would expect that a temperature and if on oxygen, an O2 SAT would be done. If a resident did not eat well, provide adequate fluid intake. For resident's with a Foley, need to know what the urine looks like. Regarding reports that the resident slept most of the shift, the RNUM stated Not during the day. Resident #6 was awake and alert. I would say that the Supervisor would be notified. The resident did not have difficulty swallowing. She stated, The supervisors should be reviewing the 24 Hour Supervisory Report. Regarding orders for oxygen, the RNUM stated If I thought it was an emergency, I would put it on, then get the order. Regarding LPNs administering oxygen without an order, she stated that she would hope the LPN would go to the RN, and the RN would assess the resident. She stated Obviously, if the resident was put on oxygen and wasn't on it before, there's a problem. The RNUM stated, the RN should have been notified when the resident was having a hard time swallowing. Regarding the resident's heart rate of 54, blood oxygen level of 80%, and an assessment by an RN, the RNUM stated I don't even know what to say. I would have expected that he was in the hospital before that note took place. Regarding the resident's firm and distended abdomen, RNUM #4, stated Maybe the Foley is clogged. If the Foley is fine, and no output, then his kidneys have shut down. She stated, Even if you're super and extremely busy, you still make rounds. The report (24 Hour) is on a clipboard on each unit. They should be seeing the critical people, the sick people. She stated I think he should have been sent out. The call to MD #4 should have been made on Saturday morning. We should have been the ones calling the HCP to tell her that we are sending him out. MD #4 doesn't see the residents on a regular basis, and at that moment, he wasn't there. Maybe he didn't get the whole picture of the resident at that time. Mottling would have scared me. She stated The problem is with staffing. In regards to RN Supervisor assessments of residents, she stated, If she has to take a medication cart and pass medications, she can't be on the unit seeing sick people. The biggest medication pass is in the morning. During a phone interview on [DATE] at 8:42 am, with LPN #11, regarding the resident's difficulty swallowing, the LPN stated The MD needs to be made aware. A lot of the time, the RN calls the MD. In regards to a change in condition, she stated, I call the supervisor, the supervisor should come, see the resident, and call the MD if needed. During a phone interview on [DATE] at 9:07 am, with LPN #2, regarding standing orders for oxygen and mottling, the LPN stated, As soon as they go below 90, we generally put them on oxygen. I should have gotten an order for [REDACTED]. Normally what I do is throw them on the oxygen, and then let the supervisor know. She stated that if she did tell the RN She would probably come down and do assessment, maybe it's a UTI, etc. LPN #2 stated that for mottling she would at least let the Supervisor know. It could be he's taking a turn for the worst. Regarding the O2 SAT of 80% and heart rate of 54, the LPN stated would like to think that I got the Supervisor. Regarding the resident being dysphasic, she stated That's a bad thing. At that point you better be calling the doctor. Regarding the note on [DATE] at 6:07 am, the LPN stated, I know I told the Supervisor about that. If he has a Foley and is not voiding, not taking PO, we should call the doctor. Maybe he needs to go to the hospital. He should have been shipped. During a phone interview on [DATE] at 11:25 am, with RNS #3, regarding mottling she stated It means I really hope she talked to the night Supervisor, Resident #6 is on his way out. She stated that she spoke with the HCP on the phone on [DATE] regarding the resident's change in the condition. She could not recall if she called the HCP or if the HCP initiated call, but the HCP wanted the resident to go to the hospital. RNS #3 called MD #4 about the request. MD #4 wanted to treat him in the facility. RNS #3 told MD #4 That he just doesn't seem himself. It was a change in the way he usually was. She stated I think he (Resident #6) was lethargic, and didn't want to get up. He is usually energetic. Monday through Friday they usually have residents get up. Since it was Sunday, at first I didn't think anything of it, but then I knew something was different. The HCP came into the facility, demanding Resident #6 go to the hospital. She stated The DON says, if family is demanding, you have to send them. She stated that the resident was sent to the hospital within 45 minutes of the HCP arriving at the facility. During a phone interview on [DATE] at 2:11 pm, with LPN #9, she stated NPO means nothing by mouth. It's a change in condition, so I wrote a note about it. I always notify the Supervisor of everything. During a phone interview on [DATE] at 2:28 pm, with LPN #10, regarding a change in condition and orders for oxygen, she stated we always get Supervisor permission for oxygen, and they would call the MD. The LPN stated, Depending on the resident's status (code status), notify the Supervisor immediately, they would notify the MD. During a phone interview on [DATE] at 11:18 am, with RNS #2, in regards to the absence of documentation of an assessment on [DATE], during the night shift, she stated I never met the man. If I was told he was sick, I would have assessed him. Whenever I see somebody, I always write an assessment. Just because they (LPNs) write 'supervisor aware', doesn't mean that they always call the supervisor. 10 NYCRR 415.3(e)(2)(ii)(b)

br>Based on record review, observation and interviews during an abbreviated survey, (Case # NY 682), it was determined that the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Specifically, the facility failed to ensure effective systems were in place for the assessment, supervision, and careplanning for residents who smoke. Additionally, the facility lacked consistent policies and procedures for resident safety. This resulted in no actual harm, but there was a potential for serious harm for all residents in the facility and this resulted in Immediate Jeopardy to Resident Health and Safety and Substandard Quality of Care. This was evidenced by: Refer to F Tag 323 Scope/Severity K Quality of Care The Policy and Procedure (P&P) titled No Smoking Policy (undated) documented that the facility is a smoke free facility and covers all tobacco and smoking products. The policy documented that all residents, employees and visitors were covered by the policy and that residents admitted prior to initiation of a smoke free environment will be permitted to smoke in the designated area. The policy further documented that smoking shall not be permitted within the facility or on any grounds and No smoking and/or Smoke Free Environment signs will be posted at the primary entrances. The P&P titled Resident Smoking Policy (undated) documented that the facility would permit residents to smoke in a designated area on the facility property. The policy documented that if a resident was identified as a smoker, Occupational Therapy (OT) would complete a smoking assessment (initially, quarterly, annually and change in status). The Interdisciplinary Team (IDT) would review the completed smoking assessment and formulate a care plan. Nursing would meet with the resident and/or family to review the smoking policy and obtain the resident's signature on the Resident Smoking Agreement. Documented as zero tolerance is that the facility will possess all smoking and lighting material at all times and that the smoking materials would be kept at the reception desk. The Designated Smoking Area is documented as seating to the right of the main entrance. Designated staff, a Certified Nurses Assistant (CNA) or designee would accompany smokers as need. During an interview on 8/26/15 at 1:00 pm, the Director of Nursing (DON), responded to a request from the surveyor for the facility smoking policy, by providing the Policy and Procedure titled No Smoking Policy (undated). The surveyor questioned the DON regarding the accuracy of the policy provided, based on an observation of resident's smoking on facility grounds, as the policy documented that the facility was a non-smoking facility. The DON stated that he didn't know and would check into it. During an interview on 8/26/15 at 1:20 pm, the DON stated it IS a smoking facility, here is the policy and handed the surveyor a Policy and Procedure titled Resident Smoking Policy (undated). The DON was asked why there was a No Smoking Policy and a Resident Smoking Policy, the DON stated, I don't know. The DON stated that all staff have access to the smoking policy, as they are on the individual units and available on the computer. During an interview on 8/26/15 at 1:35 pm, RNM #1 was asked for the facility policy on smoking and handed the surveyor a facility memorandum dated 1/27/12, from a former Administrator, documented that effective 2/1/12, three new policies would be instituted, including a Smoking Policy. The memo documented that the policies would be available in all departments for review and that probably the most difficult policy for adherence is going to be the initiation of the facility as a SMOKE FREE FACILITY. There will be no smoking anywhere in the facility or on the facility grounds. Attached to the memorandum was handwritten Smoking Policy (undated, but identical to the policy provided by the DON at 1:20 pm) and documented that the facility is a smoke free facility and covers all tobacco and smoking products. The policy documented that all residents, employees and visitors were covered by the policy and that residents admitted prior to initiation of a smoke free environment will be permitted to smoke in the designated area. The policy further documented that smoking shall not be permitted within the facility or on any grounds and No smoking and/or Smoke Free Environment signs will be posted at the primary entrances. During an interview on 8/26/15 at 2:41 pm, RNM #3 stated that she has read the No Smoking policy and procedure but has not seen the Resident Smoking Policy. During interview on 8/26/15 at 4:48 pm, the DON stated that he is aware that the policy and procedure books on the units do not match. The DON further stated that he is aware that the unit managers do not have Internet access to the policies. The DON stated that some of the policies are on his personal computer drive and therefore no one else would be able to access them, just me. 10 NYCRR 415.26

Based on observation, record review, and interviews during an abbreviated survey (Case #NY 682) it was determined that the facility failed to have an effective system in place to assess, supervise, and care plan for residents who smoke. Further investigation revealed that the facility lacked consistent policies and procedures for resident safety and failed to implement safety measures. Specifically, Resident #201 was observed wearing oxygen via nasal cannula at 2 liters per minute while seated next to Resident #202 who was smoking a tobacco product. Further investigation, revealed that nine (9) (#'s 202, #203, #3, #205, #207, #208, #209, #210, and #218) of nine (9) identified smokers did not have a smoking assessment upon admission to the facility and one (1) (#202) of nine (9) residents did not have a care plan for smoking. Additionally, the facility made available two (2) different policies, one that did not allow for smoking on facility grounds, and another that permitted resident's to smoke after assessments and care plans were completed. However, these assessments were not completed timely and safety measures were not implemented. This resulted in no actual harm, but with the potential for serious harm that resulted in Immediate Jeopardy to resident health and safety. Additional findings: During abbreviated surveys (Case #'s NY 235 and NY 772), the facility did not ensure the safety of two (2) residents (Resident #'s 3 and 4) of three (3) residents reviewed for safety. Specifically, Resident's #3 and #4, who had exit seeking behaviors and were to wear Wander Guard (WG) bracelets, left the facility unobserved. This is evidenced by: Policy and Procedure titled No Smoking Policy (undated) documented that the facility is a smoke free facility and covers all tobacco and smoking products. The policy documented that all residents, employees and visitors were covered by the policy and that residents admitted prior to initiation of a smoke free environment will be permitted to smoke in the designated area. The policy further documented that smoking shall not be permitted within the facility or on any grounds and No smoking and/or Smoke Free Environment signs will be posted at the primary entrances. Policy and Procedure titled Resident Smoking Policy (undated) documented that the facility would permit residents to smoke in a designated area on the facility property. The policy documented that if a resident was identified as a smoker, occupational therapy (OT) would complete a smoking assessment (initially, quarterly, annually and change in status). The Interdisciplinary Team (IDT) would review the completed smoking assessment and formulate a care plan. Nursing would meet with the resident and/or family to review the smoking policy and obtain the residents' signature on the Resident Smoking Agreement. Documented as zero tolerance is that the facility will possess all smoking and lighting material at all times and that the smoking materials would be kept at the reception desk. The Designated Smoking Area is documented as seating to the right of the main entrance. Designated staff, a Certified Nurses Assistant (CNA) or designee would accompany smokers as need. Job Description for the Receptionist (undated) documented the primary duties of the position involved greeting and directing the general public to appropriate staff members and operating a phone system. Occasionally the incumbent would be required to perform routine clerical and typing assignments and does related work as required. There is no documentation that supervision of resident smokers is within the receptionist's job responsibilities. During an interview on 8/26/15 at 1:00 pm, the Director of Nursing (DON), responding to a request from the surveyor for the facility smoking policy, provided the Policy and Procedure titled No Smoking Policy (undated). The surveyor questioned the DON regarding the accuracy of the policy provided, based on an observation of residents' smoking on facility grounds, as the policy documented that the facility was a non-smoking facility. The DON stated that he didn't know and would check into it. During an interview on 8/26/15 at 1:20 pm, the DON stated it is a smoking facility, here is the policy and handed the surveyor a Policy and Procedure titled Resident Smoking Policy (undated). The DON was asked why there was a No Smoking Policy and a Resident Smoking Policy, the DON stated, I don't know. The DON stated that all staff have access to the smoking policy, as they are on the individual units and available on the computer. The DON stated that the receptionist is responsible for monitoring the residents while they smoke. During an interview on 8/26/15 at 1:25 pm, Receptionist #1 stated that she only kept smoking materials in her desk for two (2) Residents; Resident #203 and Resident #205. During an interview on 8/26/15 at 1:30 pm, Resident #202 and Resident #207 stated that they keep all of their smoking material in their possession at all times. During an interview on 8/26/15 at 1:35 pm, RNM #1 was asked for the facility policy on smoking and handed the surveyor a facility memorandum dated 1/27/12 from a former Administrator documented that effective 2/1/12, three new policies would be instituted, including a Smoking Policy. The memo documented that the policies would be available in all departments for review and that probably the most difficult policy for adherence is going to be the initiation of the facility as a SMOKE FREE FACILITY. There will be no smoking anywhere in the facility or on the facility grounds. Attached to the memorandum was handwritten Smoking Policy (undated, but identical to the policy provided by the DON at 1:20 pm). During an interview on 8/26/15 at 2:41 pm, RNM #3 stated that she has read the No Smoking policy and procedure, but has not seen the Resident Smoking Policy. During an interview on 8/26/15 at 4:00 pm, Receptionist #1 stated she was not aware she was responsible for monitoring smokers. During an interview on 8/26/15 at 4:05 pm, Receptionist #2 stated she was not aware she was responsible for monitoring smokers. During an interview on 8/27/15 at 10:45 am, the Administrator and DON stated that all residents should have a smoking assessment, conducted by Occupational Therapy (OT) upon admission and if a resident is identified as a smoker, a care plan should be initiated. Finding #1: Resident #201 wearing oxygen was observed, unsupervised, seated next to Resident #202 who was smoking a tobacco product to the left side of the front entrance. Resident #201 was later observed unsupervised with oxygen on, in close proximity to Resident #205 who was smoking immediately outside of the entrance door. Resident #201 was admitted to the facility on [DATE] diagnosed with [REDACTED]. Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14/15, cognitively intact. Resident #202 was admitted to the facility on [DATE] diagnosed with [REDACTED]. Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14/15, cognitively intact. Resident #205 was admitted to the facility on [DATE] diagnosed with [REDACTED]. Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15/15; cognitively intact. Observation on 8/26/15 at 11:15 am exiting the facility, Resident #201 was seated in his wheelchair to the left side of the facility main entrance wearing oxygen via nasal cannula at 2 liters per minute while seated next to Resident #202 who was smoking a tobacco product. During an interview on 8/26/15 at 11:16 am, the Director of Nursing stated that resident's that are wearing oxygen should not be seated next to a resident smoking. The DON observed the proximity of Resident #201 to Resident #202 and immediately removed Resident #201 to the right side of the entrance. During an interview on 8/26/15 at 11:45 am with Resident #202, who was seated on the left side of the facility's main entrance, stated that he had been a smoker since his admission. Resident #202 stated that he and the other residents who smoke gather in this area each morning to smoke and in the afternoon they smoke under the tree to the right of the facility. Resident #202 stated that he was familiar with Resident #201, that he would sit with the group of smokers occasionally. Resident #202 was asked if he was aware that Resident #201 was wearing oxygen and Resident #202 stated, no, I didn't know that, but my wife had oxygen, so I know that it is a dangerous situation, maybe that's why he was moved away. During an interview on 8/26/15 at 11:47 am, Resident #209 and Resident #210, who were seated on the left side of the facility's main entrance and next to Resident #202, both stated that they smoke in this area and had done so since their admission. There were no staff observed to be present in the smoking area during this interview. During an interview on 8/26/15 at 12:00 pm, the driver for the facility stated that Resident #201 was brought outside by the someone (not identified) in the therapy department and left outside to the left of the main entrance. The driver stated that he witnessed the resident there and thinks he was there for awhile and does not know when the smoking residents came outside. The driver identified the area to the left of the entrance as the facility's smoking area. Observation on 8/26/15 at 12:14 pm, Resident #201 was assisted by a staff member, identified as a corporate Director of Social Work (DSW), while seated in his wheelchair, back to the left side of the facility's main entrance. During an interview on 8/26/15 at 12:15 pm, the DSW stated that she is assigned to the facility temporarily and stated that she assisted Resident #201 outside by moving him from the right side of building's entrance to the left side because the DON stated that someone with oxygen had been seen sitting next to a resident smoking. The DSW stated she thought the left side was the non-smoking area. The DSW left and returned at 12:25 pm after speaking with the DON and stated I was wrong so I moved Resident #201 back to the right side. Observation on 8/26/15 at 12:34 pm of Resident #205 was seated in her wheelchair up against the building to the left side of entrance door, Resident #201 was seated in his wheelchair approximately 10 feet away. During an interview on 8/26/15 at 12:35 pm, the activity aide assigned to another resident was asked to direct her attention to Resident #205. The activity aide was asked if Resident #205 could smoke at the entrance door where she was seated smoking. The activity aide stated that she was not sure Resident #205 should be smoking there, and thought that the smokers should be to the right of the entrance, where the ash tray was placed by the tree. During an interview on 8/26/15 at 12:40 pm, the DON was called out of the facility to observe the activities and proximity of Resident #205 and Resident #201. The DON stated that Resident #205 should not be smoking next to the doorway and he would take care of the situation. The DON advised Resident #205 that when she was done smoking, she could no longer smoke there. Finding #2: Nine (9) (#202, #203, #3, #205, #207, #208, #209, #210, and #218) of nine (9) identified smokers were not assessed for smoking upon admission. Resident #202 was admitted to the facility on [DATE] diagnosed with [REDACTED]. Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14/15, cognitively intact. Smoking assessment dated [DATE] signed by RNM #1 documented a completed assessment with no additional comments. During an interview on 8/26/15 at 2:45 pm, RNM #1 stated that she was not sure why the resident was not assessed for smoking but that she had completed one today. Resident #210 was admitted to the facility on [DATE] diagnosed with [REDACTED]. Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14/15, cognitively intact. Smoking assessment dated [DATE] signed by RNM #2 documented that the resident only smokes occasionally and is safe with all supplies and handling. During an interview on 8/27/15 at 11:45 am, RNM #2 stated that smoking assessments are not conducted on all residents' that are admitted . RNM #2 stated that if residents' smoke, they usually let us know because they want to know where to go to smoke. RNM #2 stated that she did not know that Resident #210 was a smoker, but she heard at some point that he was going outside to smoke so she did the assessment when it was brought to her attention. Resident #209 was admitted [DATE] [DIAGNOSES REDACTED]and chronic airway obstruction. Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15/15, cognitively intact. Smoking assessment dated [DATE] signed by RNM #3 documented a completed assessment with no additional comments. During an interview on 8/27/15 at 12:30 pm, RNM #3 stated that she became the Unit Manager recently and found that Resident #209 did not have a smoking assessment completed so she completed it. Finding 3: One (1) (#202) of nine (9) residents identified as smokers were not care planned. Resident #202 was admitted to the facility on [DATE] diagnosed with [REDACTED]. Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14/15; cognitively intact. Smoking assessment dated [DATE] signed by RNM #1, documented a completed assessment with no additional comments. In an interview on 8/26/15 at 2:45 pm, RNM #1 stated that she was not sure why the resident was not assessed or care planned for smoking but that she had completed one today. Additional Findings: The facility did not ensure the safety of two (2) (Resident #'s 3 and 4) of three (3) residents reviewed for safety. Resident #3 This resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], indicated the resident had severe cognitive impairment. The Elopement/Unsafe Wandering Risk Assessment completed on 5/7/15 by the admitting Registered Nurse (RN), resulted in a score of 10. The assessment tool notes: a score of 10 or higher is at risk. The RN's admission narrative note dated 5/7/15, documented resident is in room, alert, wants to go home. The Activities of Daily Living (ADL) Information Card dated 5/7/15, did not indicate the resident had a Wander Guard (WG). The Code Alert Transmitter Log for Resident #3 documented a WG was signed out on 5/8/15 by Licensed Practical Nurse (LPN) #1. A Comprehensive Care Plan (CCP) dated 5/8/15, for Potential/Actual Alteration in Mood related to wandering for this resident documented on 5/8/15: WG in use and 1:1 supervision. The Order Summary Report documented effective 5/11/15, Check Wander Bracelet every shift for safety. A Treatment Administration Record (TAR) documented the first shift check for WG placement was 5/8/15 on the 11 pm - 7 am shift. There was no documented evidence that the shift check was done on 5/10/15, 7 am - 3 pm shift or 5/15/15, 3 pm - 11 pm shift. The Disaster Plan-Missing Resident (MR) Policy for Code MR revised on 4/7/13, documents that when an employee becomes aware that a person is missing, the Charge Nurse is notified. The unit staff searches the area. If resident is not found, the Charge Nurse is to notify the Administrator or Director of Nursing, and if not present notify the Nursing Supervisor. The Responsible Person will set up a command post and notifies the staff by: Having the receptionist announce: CODE MR, male or female and unit three times over the intercom. A Disciplinary Action dated 5/8/15, documented the Activities Director failed to forward the picture of a WG resident at the front desk. The Communication of Wandering Risk Procedure, Section D, which was reviewed/revised 2/2012, documented The Activities Department or designee will take a picture of the resident and forward to the receptionist. A Disciplinary Action dated 5/8/15, documented the Receptionist failed to watch the front door with the recommendation made that the employee would monitor the door closely. During observation on 5/14/15 of the security camera video from 5/8/15 at 1:19 pm, the resident entered the lobby, 1:20 pm, resident walked by reception desk and out front door. The receptionist's head was down. Resident was recorded walking away from the facility and turned left out of the facility parking lot. At 1:45 pm the video shows staff exiting the building to alert the Director of Nursing (DON) who was reportedly outside. At 1:53 pm, the video documented the return of the resident to the facility by the DON and the Admission Coordinator. There was a time span of twenty-five (25) minutes from the time the resident left the facility until staff noticed he was missing. During observation on 5/14/15 at 1:00 pm, the resident gave permission for access to closet, drawers and cupboards in his room. There were no personal belongings in any of those areas. There was a duffle bag next to his bed with his clothes and personal belongings. The resident was wearing a WG on his right leg. There was an aide sitting next to his bed. The Resident made the statement I'm going home on Saturday. During observation on 5/15/15 at 11:00 am, there was an aide sitting outside of resident's room. During observation on 5/15/15 at 12:58 pm, a WG bracelet was taken to the front exit. The doors locked automatically and unable to exit. During observation on 5/18/15 at 9:06 am, an aide was sitting in resident's room. During observation on 5/22/15 at 11:45 am, the surveyor drove from the front door of the facility to 521 Route 146. It was 0.8 mile from the facility and on the opposite side of the road from facility. Observed it was busy two lane highway with narrow shoulders and fast moving traffic. During interview on 5/14/15 at 12:31 pm with the Activities Director, she stated she took resident's picture approximately 1:00 - 1:30 pm on 5/8/15. Stated earlier in day when she attempted to enter the first picture she had taken into the computer, she accidentally deleted it. I do the majority of pictures; I think our Assistant Administrator is just starting to take some. During interview on 5/15/15 with Rehabilitation Director, he stated when taking a resident outside, two residents sitting outside informed him there was a man with a green shirt and a bag walking down the driveway and they saw him turn left. Came back inside to therapy room and asked if anybody had worked with a man with a green shirt on. One person recalled seeing him. The Rehab Director did not recall who that was. Thinks he then went to front desk and asked Receptionist if she had seen anybody in a green shirt walk out. At that time I did not know if it was a resident or not, so did not request a Code MR be announced. Then went to B-wing and asked if anybody knew where Resident #3 was. He was not in his room. Immediately went outdoors to notify the DON who was on a break and then went to the end of driveway to look for resident. During interview on 5/15/15 at 9:36 am with the Receptionist, she stated the Activities Director and Rehabilitation Director were both at the front desk and told her they didn't know where Resident #3 was. She stated neither asked for Code MR (nor did anyone else) to be called. She stated there was no picture of Resident #3 in the wandering book kept at the reception desk. Stated policy for Code MR stated that Receptionist only activates a Code MR when told to. She also stated she had known the resident for many years and would have recognized him. During an interview on 5/15/15 at 10:09 am with the Activities Director, she requested to be excused from the room and would be right back. When she arrived back at 10:12 am, the Assistant Administrator was with her. Explained that Assistant Administrator wanted to ask Activities Director if the picture of the resident had been taken prior to, or after the elopement. He stated it was after. He then exited the room and the Activities Director stated she couldn't remember the exact time the resident's picture was taken but it may have been after (the resident eloped). She then stated the staff that needed the photo for the wandering book were given the photo after the elopement. During interview on 5/15/15 at 11:10 am with LPN (Licensed Practical Nurse) #5, who stated LPN #4 told her on 5/8/15 that she had applied WG to resident that day at 12:15 pm. She stated the resident talked to her about wanting to leave. Stated she was unaware resident had left because she was on lunch break from 1:00 -1:30 pm. She stated she never heard an overhead page for Code MR. During interview on 5/15/15 at 11:55 am with LPN #4, she stated that on 5/8/15, the RN (Registered Nurse) who did Resident #3's admission on 5/7/15 told her that the resident needed a WG; that she didn't know where the WG's were kept. LPN #4 stated she placed the WG on resident at 12:15 pm on 5/8/15. Then off unit for lunch. Returned at 12:45 pm and Rehabilitation Director on unit and stated Resident #3 was missing. Started searching then notified resident found. Told by DON, resident did not have WG on. While assisting the DON in assessing the resident for any injuries, she found the WG under clothing at the foot of the bed. She stated approximately 2:00 pm WG was placed back on resident's ankle. Stated appeared band had been cut with a knife. During interview on 5/15/15 at 12:30 pm with Registered Nurse Unit Manager (RNUM) #1, who stated she was not working on 5/8/15. She stated the WG's are checked every shift for placement and function and documented on the TAR. The 11:00 pm-7 am RN supervisor checks them weekly and documents in WG alarm book. During interview on 5/18/15 at 9:38 am with the Assistant Administrator, he stated he was in the administrator's office on 5/8/15 discussing a family's concerns. He stated he was notified approximately 1:48 pm by the Rehabilitation Director that Resident #3 was missing and approximately 1:50 pm was notified the resident was found. He stated nobody announced a Code MR (missing resident). During interview on 5/18/15 at 11:06 am with the Administrator, he stated he and the Assistant Administrator were in his office on 5/8/15 speaking with a family member. Stated he did not hear a Code MR called, but not sure he would have with his door closed. He stated he should have been notified as soon as it was noted that the resident was missing. During interview on 5/19/15 at 10:26 am with the Admitting RN, who stated resident scored high on the Wandering and Elopement assessment. Stated she told RN #2 she needed a WG because she was new and didn't know where they were. Stated RN #2 told her he put one on Resident #3. She stated she worked 10:00 am-6:00 pm on 5/8/15. Also stated she was in the nursing office on the wing the resident resided and two nurses informed her resident was trying to get out the front door. Stated she asked where is his WG?. Nurses told her he didn't have one. Instructed one of the LPN's (doesn't remember which one) to get a WG and put it on the resident. She stated she saw the WG had been placed on resident's ankle by the LPN. Stated she should have checked the prior evening to be sure that RN #2 had placed the WG on the resident. During interview on 5/20/15 at 3:12 pm, RN #2 (who stated he had worked at facility for one month) stated he put a WG on resident on 5/7/15. Stated resident asked what it was for. He stated the Admitting RN asked him to sign it out because she did not know where the WG's were kept. Stated really no place to sign out WG. I was unaware of a sign out book and just put one on him. He must have taken it off . Resident #4 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) indicated the resident had severe cognitive impairment. During observation on 5/20/15 of the security camera video from 5/18/15, at 4:26 pm, the receptionist was at the front desk talking with the evening nursing supervisor. The resident was in the lobby hallway and walked out the door unobserved. The receptionist was not watching the door. The Assistant Administrator and two staff members were outdoors at the opposite edge of the driveway. The Assistant Administrator and two (2) staff members saw the resident and took action to bring the resident back inside the facility. The Elopement/Unsafe Wandering Risk Assessment completed on 3/27/15 by the admitting Registered Nurse (RN) resulted in a score of 13. A re-assessment completed on 5/19/15 by the Registered Nurse Unit Manager #2 (RNUM) resulted in a score of 14. The Elopement/Unsafe Wandering Risk Assessment tool notes: a score of 10 or higher is at risk. A Comprehensive Care Plan (CCP) dated 3/27/14 for Risk of Unsafe Wandering/Elopement, was updated on 5/18/15 (the date of the elopement) to document the incident: WG checked, worked, but was replaced and Medical Doctor (MD) was notified. The Form for 15 Minute Checks for the resident had gaps of several hours at a time on fifteen (15) of fifteen (15) forms reviewed when there was no documented evidence that 15 minute checks were done. On 5/17/15 at 11:00 pm, the resident had been restarted on 15 minute checks due to escalating exit seeking behaviors (per RNUM). On 5/18/15, there was no documented evidence on the 15 minute check form that 15 minute checks were conducted between the hours of 7:15 am thru 4:30 pm. A 15 minute check was done at 4:45 pm after the resident had exited the building at 4:26 pm. The Managing Wandering Behaviors Protocol established 9/2007 documented as Policy; all facility personnel will receive training about the management of wandering behaviors/risk of elopement including their responsibility to contribute to resident safety as it pertains to wandering behaviors and elopement. The Nurses' notes dated 5/2/15, 5/11/15 (six exit attempts made), 5/18/15, 5/19/18 (4:00 pm and 5:00 pm respectively), document resident's exit seeking behavior. On 5/18/15, the resident was successful at exiting the facility through the front door undetected and unsupervised. An Employee Counseling Form for the Receptionist documented she was terminated from employment on 5/21/15 for violation of facility policy, unsatisfactory work and inappropriate conduct. Infraction: Second time employee showed inability to perform the duties of the job by not monitoring the exit door, i.e. Resident #4 exited without the receptionist's knowledge. During interview on 5/20/15 at 9:54 am with the resident's MD, he stated he had calls from the facility on 5/18/15 at 4:54 pm, 5:07 pm and 5:09 pm. Stated he called the facility back at 5:07 pm. He stated he did not believe the call was to report the elopement. He stated that during that phone call he ordered Valium, lab work and a urinalysis with a culture and sensitivity. He stated he did not recall being told she left the building, but did recall report of agitation. Stated he would have remembered something that big. The MD stated he did hear about it the next day on 5/19/15, when staff were discussing concerns with him regarding the behavior of the resident. During interview on 5/20/15, at the time the security video was viewed, the Assistant Administrator stated he was facing the front door of the facility and was talking with two other employees whose backs were toward the door. He stated he saw the resident leave the facility and immediately went to get the resident to take her back inside. The other two employees assisted him. During interview on 5/20/15 at 10:30 am with the Receptionist, she stated a receptionist is at the front desk from 8:00 am to 4:00 pm. The relief receptionist is at the front desk from 4:00 pm to 8:00 pm. She stated at 8:00 pm the door were supposed to lock and a code for the key pad was needed to exit or enter the building after 8:00 pm. She stated any residents in the lobby at 8:00 pm are requested to return to their wings. She also stated the 11:00 pm to 7:00 am RN supervisor sits at the reception desk when not on one of the units. 10 NYCCR 415.12(h)(1)

Based on record review and interview it was determined during standard recertification survey the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well- being of each resident. Specifically: The facility purchased new beds that had attached siderails with forty-five (45) new beds in use on the residential units. These beds had siderails attached that had a gap of approximately seven (7) inches from the top of the mattress to the bottom of the side rail. The facility failed to recognize that the seven (7) inch gap posed a potential risk of entrapment for the residents using these beds with attached siderails. This resulted in no actual harm but had the potential for more than minimal harm that was immediate jeopardy and substandard quality of care to resident health and safety. The immediate jeopardy was removed prior to exit. This is evidenced by: Refer to F- 323 Free of Accident Hazards- Scope/Severity K. During interview on 3/11/15 at 12:40 pm the Acting Administrator and Supervising Administrator (SA) stated they were not involved in ordering the beds. The SA stated he saw the new beds when they came in and did not think the side rails were an entrapment issue. He stated he did not think they were a risk to all their residents. The SA stated they were going through all the residents and determining if residents were at risk for entrapment. He stated they did not feel there was a general risk to their population- that the new bed with the side rails were used for less than half their population. Later in the day (approximately 3:45 pm) the SA reported to the surveyor that they had decided to remove all the new side rails from the rooms and that they will make sure that everyone at risk to fall has mats, alarms, etc in place for safety. The Immediate jeopardy was removed when the facility took the following measure: all side rails were removed from the new beds; staff reassessed the entire population for the need of side rails; for those residents insisting on side rails to assist with mobility, the rail in question was modified with input from the manufacturer. This modification involved reducing the length of the "stem" thereby lowering the side rail and eliminationg the entrapment risk. 10 NYCRR 415.26

Based on observation, record review and interview the facility failed to ensure the resident environment remained as free of accident hazards as is possible on three (3) of three (3) units and for forty-five (45) of one-hundred and twenty (120) residents in the facility during the recertification survey. Specifically: The facility purchased new beds that had attached side rails/enabler bars. At the time of survey, forty-five (45) of these new beds were in use on the residential units. (Residents # 28, 39, 49 are examples of use of these side rails/enabler bars.) These beds had a gap of approximately seven (7) inches from the top of the mattress to the bottom of the side rail/enabler bars. The facility did not recognize that this posed a potential risk of entrapment to the residents using these beds with side rails/enabler bars. This resulted in no actual harm with a potential for more than minimal harm that was immediate jeopardy and substandard quality of care to resident health and safety. The immediate jeopardy was removed prior to exit. This is evidenced by: During initial tour of the facility on 3/11/15 at approximately 8:22 am B unit was observed with several beds that had side rails/enabler bars that appeared to be an entrapment risk related to the large gap between the mattress and the bar. During initial tour on 3/11/15 at approximately 8:30 am to 9:30 am random measurements of side rails/enabler bars gaps were completed on the newly acquired beds on Units A, B, and C. The measurement included the distance from the highest level of the bed mattress to the lowest level of the side rails/enabler bars. The gap measured consistently at seven (7) inches to eight (8) inches. Subsequently to this the surveyors went into an empty room on the C unit at 10:15 am. The room had the new beds/side rails/enabler bars. Three (3) surveyors were able to wedge their necks between the mattress and the side rail/enabler bars (fourth surveyor did not try). The trial included small to large necks. The side rails/enabler bars created a gap of seven (7) inches between the upper surface of the mattress and the lower end of the side rails/enabler bars. The side rails/enabler bars were fixed and could not be lowered or removed from their position. Surveyors went to the units and observed twenty-five (25) of the new beds/side rails/enabler bars were on the C unit. Sixteen (16) new/beds/side rails/enabler bars were observed on Unit B and four (4) new bed/side rails/enabler bars were observed on Unit A for a total of forty-five (45) currently in use in the facility. At approximately 12:15 pm on 3/11/15 this surveyor and another surveyor went to a room on the B Unit that had a new bed/side rails/enabler bars on it. The Supervising Administrator(SA) and the Nurse Consultant were there. The SA stated he had talked with the manufacturer of the bed/side rails/enabler bars. He stated that the manufacturer had told him that they had provided a 7-8" gap between the mattress and bottom of the side rail/enabler bar to prevent entrapments of body parts. This surveyor laid in the bed, slid off the bed and her neck was able to become entrapped in the side rail/enabler bar. She could feel pressure on the trachea and got herself out of the situation. The SA stated he could see that entrapment was possible. The Guidance for Industry and FDA Staff ( the industry standard) for The Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, with an issue date of March 10, 2006 and presented by the Center for Devices and Radiological Health documented on page 18 under the title "Zone 4- Under the title "Under the Rail at the Ends of the Rail": This space is the gap that forms between the mattress compressed by the patient, and the lowermost portion of the rail, at the end of the rail. Factors that may increase the gap size are: mattress compressibility, lateral shift of the mattress or rail, and degree of play from loosened rails. The space poses a risk for entrapment of a patient's neck. At the time of this publication, the IEC (International Electrotechnical commission) international standard recommends a dimensional limit of less than 60 mm (2 3/8 inches) measured between the mattress support platform and the lowest portion of the rail at the rail end to prevent neck entrapment. The FDA recommends that the dimensional limit for this space also be less than 60 mm (2 3/8 inches). The following residents were observed with the new bed and side rails/enablers in place on 3/11/15: Resident #39: The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) of 2/4/15 assessed that the resident understands, was understood and had a Brief Interview of Mental Status of 15/15 or no cognitive impairment. It documented the resident needed extensive assist of two staff for bed mobility. During observation on 3/11/15 at 10:00 am the resident was observed to have a new bed/side rails/enabler bars. The gap between the top of the mattress and the bottom of the side rails/enabler bars was measured at seven (7) inches. The Safety Device/Restraint assessment dated [DATE] identified the type of device as Side Rails, top- right and left upper 1/2. Nothing else was filled out except the care plan and care card were circled as "updated". A physician order [REDACTED]. The back of this form documented: Periodic Reviews (Quarterly Requirement). On 2/12/15 it documented the resident uses the side rails for bed mobility effectively and to continue. The Comprehensive Care Plan for Side Rails in use on bed secondary to decreased bed mobility dated 1/28/15. An evaluation on 2/12/15 documented to continue with the plan of care. During interview on 3/16/15 at 9:23 am the Registered Nurse Manager ( RNM) # 2 stated that the resident uses the side rails/enabler bars to move up and down in the bed. She stated he wanted them. She looked at the Safety Device form in the chart. She saw the blanks and said it was not completed. She stated the resident got the new bed before she came here. She stated there was no reassessment of the bed at that time. She stated these new side rails/enablers are not adjustable. Resident #28: The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] assessed that the resident understands and was understood and had a BIMS 11/15 or mild cognitive impairment. The MDS assessed the resident as requiring extensive assist of 2 staff for bed mobility. During observation of the resident's room on 3/11/15 at approximately 9:15 am bilateral side rails/enabler bars extending to the mid-point of the bed were in use. A gap of seven (7) inches was measured from the highest point of the mattress to the lowest point of the side rail/enabler bar. A Safety Device/Restraint Assessment with an admission date of [DATE] documented the type of device as side rails, to top right and top left (of the bed). Nothing else was filled out. It was circled that the care plan and care card were updated. it was also circled that the family was notified and approved and that a physician order [REDACTED]. An Interdisciplinary Care Plan (ICP) dated 1/13/15 documented side rails in use secondary to: (rest of statement blank). The number in use documented 2 (two)- one half (1/2) side rails with no duration of use noted, but with bed mobility noted. The ICP documented that the side rails are non-restrictive. The ICP further documented the goal as independent in bed mobility. During interview on 3/11/15 at 11:00 am Certified Nurse Aide (CNA) #7 stated with the new beds the side rails/enabler bars attached to the bed cannot be lowered, they are in a fixed position and higher than other beds with side rails attached to them. CNA #7 stated that when providing care to the resident one has to work over the side rails/enabler bars in order to complete an activity such as assisting the resident up in bed. Resident #49: The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented a BIMS score of 15/15, cognitively intact. The MDS documented the resident required extensive assistance of two staff for bed mobility. During observation on 3/11/15 at approximately 8:30 am the resident was observed in her room in a wheelchair. Her bed was new with the new side rails/enabler bars. The ADL Information Card (care card) updated 2/4/15 documented Side Rails: enablers (both) upper for positioning and bed mobility. A Comprehensive Care Plan (CCP) updated 1/26/15 documented Side Rails in use secondary to impaired mobility. The type was 2, ¼ upper side rails, determined to be nonrestrictive. A Safety Device/Restraint Assessment form dated 2/4/15 documented Side Rails, top- right and left. The identified problem, was upper SR for bed mobility and enabling. The rest of the form was not filled out. During interview on 3/11/15 at 2:14 pm the resident stated that the side rails/enabler bars help her in rolling over and make it easier for her to get out of bed. She stated that they did not go down however. Interviews: During interview on 3/11/15 at 8:34 am the Registered Nurse Manager, (RNM #1), stated that the facility was in the process of replacing the beds and stated the old beds have the silver side rails, and the new beds are the ones with the oval side rails/enabler bars. RN #1 stated the side rails/enabler bars are used for mobility and not as a restraint. When asked who checks to see if the side rails/enabler bars are secure and measures any gap between the mattress and the side rail, RNM#1 stated, "You're stumping me". During interview on 3/11/15 at 9:34 am on Unit A CNA #1 stated residents use side rails/enabler bars to pull themselves side to side. The CNA stated the new side rails/enabler bars are too high and did not like them. The CNA stated not aware the rail should touch the mattress, and not aware a resident could die in a side rail. During interview on 3/11/15 at 9:45 am Licensed Practical Nurse (LPN) #2 stated that all of the residents are getting new beds and that the side rails/enabler bars are used for mobility, not safety. The LPN stated that she would call the supervisor if there was an entrapment of a resident in a side rail/enabler bar. During interview on 3/11/15 at 9:50 am LPN #3 stated that there were no loose side rails/enabler bars. The LPN also stated that on one of the new beds, the bed rail/enabler bar was turned sideways and was stuck and maintenance came to fix it. The LPN stated that the side rails/enabler bars are for mobility. During interview on 3/11/15 at 10:58 am CNA #2 stated residents like the side rails/enabler bars for security reasons. She stated that she did not like the new side rails/enabler bars, you cannot move them up and down but they wobble side to side. She was asked if there should be a gap between the mattress and the side rail/enabler bar. She thought about it and stated she would think there should not be a gap. She stated she had not been told or taught to look for that however. During interview on 3/11/15 at 11:30 am RNM #2 stated she was not aware of a seven (7) inch gap between the upper part of the bed mattress and lower part of the side rails/enabler bars. RNM #2 stated this gap is a possible hazard where a resident could have an arm or other body part stuck. RNM #2 stated that possible remedies to this problem include obtaining a new mattress or adjusting the side rail/enabler bar to reduce the gap. During interview on 3/11/15 at 10:35 am the Maintenance Director stated the facility received approximately eighty (80) new beds a few months ago. He stated he did not have the purchase or delivery invoices as they were located in the corporate office. He stated approximately half of the new beds were assembled by him and his staff per the assembly instructions and the other half of the new beds were located in the storage bin outside. He stated all the new beds were assembled with the side rails/enabler bars in place. He stated he was then informed by nursing where to place the new beds. He reported he was not requested to take the side rails/enabler bars off of any of the beds nor was he instructed not to place the side rails/enablers bars on the beds. He stated the side rails/enabler bars could not be lowered because there was a cap at the bottom of the rail holder. He reported he was not involved in the selection or the purchase of the bed. He stated he was not aware of any issue with the new side rails/enabler bars being wobbly but would check maintenance requests. During interview on 3/11/15 at 11:53 am the Maintenance Director brought in maintenance slips since [DATE]st. He stated that there were no work orders recently for side rails/enabler bars, if there had been they would have been taken care of right away. He stated there had no training given to him about side rail/enabler bar safety, the position of the mattress and the side rail/enabler bar. He stated he had started here last May. He stated he was not told to look for gaps between the mattress and side rails/enabler bars. He stated he does fire safety rounds, but not environmental rounds in the rooms. On 3/11/15 at 2:40 pm the Acting Administrator and Supervising Administrator were interviewed. They stated they were not involved in ordering the beds. The SA stated he saw the new beds when they came in and did not think the side rails/enabler bars were an entrapment issue. He stated he did not think they were a risk to all their residents. He stated the manufacturer said they used the above sited Document to develop the side rails for these beds (specifically page 18 and 19). The SA stated they were going through all the residents and determining if residents were at risk for entrapment. He stated they did not feel there was a general risk to their population- that the new bed with the side rails/enabler bars were used for less than half their population. Later in the day (approximately 3:45 pm) the SA reported to this surveyor that they had decided to remove all the new side rails/enabler bars from the rooms after reading the above sited document. They will make sure that everyone at risk to fall has mats, alarms, etc in place for safety. During interview on 3/11/15 at 1:45 pm the Physical Therapy Director stated that all new residents receive an assessment by them to assess bed mobility. He stated they did not make decisions if a resident needed side rails, they can recommend. Nursing can make the decision on side rails. He stated they reassessed a resident for side rail use if nursing requested it. He stated they did not currently reassess residents to determine ability to use side rails on a quarterly basis, only if it was requested. He stated that not every resident who comes in needs a side rail or gets one. He further stated he had not seen this style of side rail before. Interview with RNM #3 on 3/16/15 at 10:40 am. The RNM reported residents are assessed on admission by the Registered Nurse for side rails or enabler use. She stated prior to 3/11/15 beds and specifically all the new beds had enabler bars already in place. The RNM reported the new policy as of 3/11/15 is that when a resident is discharged all devices are removed form the bed. Nursing and therapy will determine whether a resident could benefit from side rails/enabler bars. The Immediate jeopardy was removed when the facility took the following measure: all side rails were removed from the new beds; staff reassessed the entire population for the need of side rails; for those residents insisting on side rails to assist with mobility, the rail in question was modified with input from the manufacturer. This modification involved reducing the length of the "stem" thereby lowering the side rail and eliminationg the entrapment risk. 10 NYCRR 415.12(h)(1)

Based on medical record review and staff interview the facility failed to provide routine and emergency medications in a timely manner as ordered by the physician for 11 (Resident #s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11) of 11 resident's reviewed during a partial extended abbreviated survey. Specifically, the facility failed to ensure medications were obtained timely from their contract pharmacy. Additionally, staff interviews revealed staff were unaware of policies and procedures provided by the contract pharmacy that were located in the Nursing Office and on each nursing unit. Investigation further revealed the facility failed to address the availability of medications from the pharmacy and lacked a system to monitor medications ordered and received. This has been an ongoing issue at the facility since changing pharmacy vendors in July 2012. This caused actual harm (Resident #3) that is Immediate Jeopardy to resident health or safety and Substandard Quality of Care. This had the potential to affect all 112 residents at the facility. This is evidenced by the following: The undated Pharmacy Organization Policy and Procedure (P&P) Authorization documented that the pharmacy P&P manual should be referred to on a regular basis for policies governing facility pharmacy procedures and pharmacy operational procedures. A copy of the manual was to be maintained at each nursing station and in the Director of Nursing's (DON) office. The undated Pharmacy Organization P&P for Back-up Pharmacy documented that in the event that the provider pharmacy was unable to meet the delivery needs of the facility, the facility was to contact the pharmacist to advise the pharmacist of the medication order that needed immediate delivery. The pharmacist would then call the designated back-up pharmacy to place the order. The back-up pharmacy was to fill the prescription for a twenty four hour supply and deliver the medication directly to the nurses station. The P&P identified the local back-up pharmacy that was to be used. The Pharmacy Organization P&P for Medication Ordering and Prescribing: New Orders, documented that the facility was to fax to the pharmacy orders for new admissions on a blank Physician order [REDACTED]. The undated Pharmacy P&P for Medication Ordering and Prescribing: New Orders, documented that nurses were to examine the supply of medications available for a resident and reorder medications when a four day supply remained. The label on the medication packet had a "reorder after" date on it. The nurse was to affix that label to a pharmacy Reorder Form and fax that form to the pharmacy. The facility was then to check in the medications when the delivery was received from the pharmacy. The undated Pharmacy P&P for Medication Medication Dispensing: Back-Up Medications, documented that a Back-Up Box was to be maintained in the faciilty and that it would contain a supply of oral medications for use in stat/emergency situations. When a nurse received a physician order [REDACTED]. Prior to removing the medication, the nurse was to call the pharmacy for a first dose review, and upon authorization from the pharmacist, the nurse would remove the medication and administer it to the resident. The nurse/nursing supervisor was to document the removal of the medication from the Back-Up box and fax the form to the pharmacy for replacement of the used medication. Resident #3: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident with severe cognitive impairment. Policy and Procedure titled "Notification of Resident Change" last reviewed and renewed 4/12, documented that the facility will communicate in a timely manner changes in conditions and plan of care to the resident's physician, including but not limited to a change in physical status, a change in medication or in a treatment plan. The stated purpose of the policy was to to keep all parties aware of the current information to provide appropriate care and services to meet the needs of the resident. The policy documented that all notifications with the physician must be documented in the appropriate section of the medical record. Wound Care Clinic note dated 10/24/12 documented that the resident was seen for debridement (removal of the dead tissue in a wound) of a Stage IV pressure ulcer (a deep would that involves multiple layers of tissue, including muscle and sometimes bone caused by prolonged direct pressure on a body part) to the right buttock using sterile technique. It was documented that, after the debridement, the wound was not overly reddened,and that there was no evidence of further tissue breakdown or remaining dead tissue in the wound. Nurse's notes dated 11/4/12 at 3:15 documented that the resident was noted with a large amount of foul smelling drainage, the MD was contacted and ordered a wound culture at the next dressing change. Nurse's note dated 11/5/12 at 4:15 pm, documented that the wound culture was obtained and sent, and noted a moderate amount of green drainage. Labratory Results faxed from the hospital on [DATE] at 3:01 pm, documented that the resident ' s swab of the right buttock wound was positive for infection (Cocci and Rods). Documented on the results is the Registered Nurse Managers initials dated 11/9/12 and a telephone order taken from physician #2 on 11/10/12 to start Doxycycline 100mg twice per day for 10 days, signed by LPN # 2. Nurse's notes dated 11/10/12 (untimed) documented the telephone order from physician #2, Doxycycline 100mg for 10 days for a wound to the right buttocks and that the final lab report had been received on 11/9/12. Nurse's notes dated 11/11/12 at 2:00 pm documented that the Doxycycline not started in the morning because the medication was not delivered by the pharmacy and there were no antibotics in the emergency kit. The note documented that the next scheduled dose for the resident was due at 12:00 am and that it should arrive by then. The note documented that the supervisor was aware. Nurse's note dated 11/11/12 at 9:00 pm documented that the Doxycycline was to start at 12:00 am, waiting for the pharmacy to deliver the medication and that the resident did not receive Clozaril as it was unavailable. The note documented that the pharmacy was faxed the order and the supervisor was aware. Nurse's note dated 11/12/12 at 4:10 am documented awaiting antibotics and no deliveries from the pharmacy. Nurse's note dated 11/12/12 at 3:00 pm documented that the Medical Director (MD) was contacted and ordered the antibotics to start when it arrived from the pharmacy. Nurse's note dated 11/12/12 at 4:00 pm documented that the both medications, the Doxycycline and Clozaril were still unavailable and the pharmacy was contacted and stated that the medications would be delivered in an hour or two at the most. Nurse's note dated 11/12/12 at 9:15 pm documented that the resident was found unresponsive to verbal and painful stimuli, skin was very warm and had a temperature of 101.4. An order was received for transport to the hospital and 911 was called. Nurse ' s note dated 11/13/12 at 6:00 am documented that the resident was admitted to the hospital diagnosed with [REDACTED]. During an interview on 11/14/12 at 1:30 pm, the Medical Director stated that he should be notified immediately of a change in resident condition, which would include changes in physical condition, labratory reports and physician ordered medications that were not administered due to unavailability or refusals by residents. The MD stated that he did not think there was a problem related to staff not reporting changes in resident's conditions. The MD stated that he does not recall all of the calls made to him but stated that if he or another physician were contacted regarding a resident change in condition, it would be documented in the medical record. During an interview on 11/16/12 at 1:30 pm, the RNM # 1 reviewed her entry on 10/26/12 on the resident's wound sheet. The RNM stated that she tried to really describe the condition of the wound and wrote that the wound was foul smelling and had a tan/green drainage. The RNM stated that the tan/green drainage could mean that the wound was becoming infected, but that she did not contact the physician to report the change in the condition of the wound. The RNM reviewed the lab report dated 11/6/12 and stated that she had reviewed the report on 11/9/12 and had initialed the report. The RNM stated that she does not recall if she contacted the physician but typically she would have for a lab report which revealed an infection. The RNM stated that possibly she left a message and maybe the physician didn't get back to her before she left for the day but she would have documented a nurse's note. The RNM reviewed the nurse's notes for 11/9/12 and stated there were no nursing notes on 11/9/12 for the resident and noted the 11/10/12 note documented a call to the physician, more than 24 hours after she would have reviewed the report. The RNM stated that the physician should be contacted right away so that antibotics can be ordered. The RNM further stated that on 11/12/12 she was made aware that the Doxycycline had not been delivered over the weekend and that the physician was notified on 11/12/12. Resident #1: The facility failed to ensure that this resident received Protonix (a medication used to control acid reflux in the stomach) as ordered by the physician. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had modified independence in cognitive decision-making. A Physician Re-admission Evaluation dated 09/25/12 included hospital admission 09/13/12 for upper GI bleeding due to erosive esophagitis and returned to the facility on [DATE]. The physician order [REDACTED]. The original order date for this medication was 09/25/2012. The Medication Administration Record (MAR) dated 10/2012, documented that the resident was to receive 40 milligrams (mg) of Protonix by mouth twice daily. For the dates of 11/01/2012 through 11/14/2012 the nurse's initials are circled in 18 out of 27 boxes on the front of the MAR. On the back of the MAR it is documented that the Protonix was not available on 11/3/2012, 11/4/12, 11/5/12/, 11/7/12, 11/8/12, 11/10/12, and 11/12/12. It was further documented on 11/10/12 that the physician and pharmacy were to be notified that day. Review of the Medication Error Reports for 8/2012, 9/2012,10/2012 and 11/2012 revealed there were no error reports completed for the resident not receiving a total of 18 doses from 11/01/2012 through 11/14/2012. A Nurses Note written by a Registered Nurse (RN) and dated 11/08/12 documented that the RN spoke with the pharmacy about the protonix order. The pharmacist explained to her that protonix was not covered by insurance and the order had been changed in 10/2012 to prilosec. The RN left a note in the physician's communication book (a book used to make the physician aware of concerns and/or issues on the physician's next visit to the facility) for clarification from the physician. During an interview on 11/14/12 at 12:10 pm, Licensed Practical Nurse (LPN) #11 stated that to reorder medications they pull the refill tab off the medication card and stick it on the reorder sheet and then it is faxed to the pharmacy. The reorder sheet was then placed in a basket by the fax machine to be kept by the Director of Nursing (DON). The LPN stated the reorder sheet needed to be faxed by 11:00 am and the delivery would be on the 11:00 pm to 7:00 am (night) shift. She stated she would follow up on the order if it did not arrive in a couple of days and that there was not a system to track the ordered medications. The LPN stated newly ordered meds were also faxed and if they were needed right away they would call the pharmacy. If the medications did not arrive, the pharmacy would use their back up pharmacy but you would have to call and ask for this. The LPN stated that when the medications did not arrive the nurses circled their initials on the MAR and document on the back that the medication was not available. She stated that this should have been documented in a nurses note and the nursing supervisor and physician should have been notified. She also stated that a Medication Error Report would not be completed because it was a pharmacy error. During an interview on 11/14/12 at 12:25 pm, the RNM#3 stated that if medication orders were faxed to the pharmacy by noon (12:00 pm) that sometimes they would be delivered by 6:00 pm, sometimes 11:00 pm and sometimes on the night shift. Immediate orders would be called to the pharmacy and it would have to be made clear that they were needed and the pharmacy would use a local pharmacy to deliver. She stated that sometimes she would have to argue with the pharmacy to get a medication to be delivered to the facility. The RNM stated that the nurses should report to her when there were medications that were not available. The RNM sated she didnot know why it took eight days before she was notified Protonix was unavailable. She stated that when she called the pharmacy about this medication, she was told the medication needed physician approval because the insurance did not cover Protonix. She further stated she could not get the pharmacy to understand that the resident needed the Protonix as ordered by the physician. She stated a medication error should have been completed for unavailable medications. During an interview on 11/14/12 at 1:15 pm, LPN#12 stated the medication orders were faxed to the pharmacy and the forms were left in a basket for the DON. He stated that the nurses did their own follow-up of the medications ordered and would call the pharmacy if they were not delivered. The LPN stated "it's ridiculous," that it could take from 24 hours to 48 hours and longer for delivery from the. He stated that when there was a seven day supply of a medication remaining, he reordered those medications to ensure that the medication did not run out, but that they sometimes still did not arrive in the facility on time. During an interview on 11/14/12 at 2:00 pm, RNM #1stated that the medication orders were faxed to the pharmacy in the afternoon and medications were delivered at 6:00 pm or on the night shift. Reorders should be done three days ahead and new orders should be delivered the same night. She stated that when a medication was unavailable and a call was made to the pharmacy that the call was documented on the "pharmacy log" to track all of these issues and there were many. When a medication did not arrive from the pharmacy, the RNM and the physician were to be notified. She stated a Medication Error Report would not be completed for pharmacy missed medications unless there was a medical event related to the omission of a medication. Resident #4: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Nursing assessment dated [DATE] documented that the resident was alert and oriented to person, place and time. A nurses note dated 11/2/12 at 1:00 pm, documented that the resident was admitted to the facility from the hospital. The physician orders [REDACTED]. Metoprolol (a blood pressure medication) 25mg by mouth twice daily (BID). Colace (a medication to help with bowel movements) 100mg by mouth BID. Senna (another bowel medication) 17.2mg by mouth daily at bedtime (qHS). Simvastatin (a cholesterol medication) 10mg by mouth qHS. Spironolactone (a diuretic) 50mg by mouth BID. Bumetanide (another diuretic) 3mg by mouth BID. The Medication Administration Record (MAR) dated 11/2012 documented that the nurses initials for each of these medications for the evening shift was circled which indicated that there was a note on the back of the MAR. On the back of the MAR was documented that on 11/2/12 all evening shift oral medications were unavailable and were awaiting delivery from the pharmacy. Another note on the back of the MAR documented on 11/3/12 at 5:00 pm, that all oral medications were not available and were awaiting pharmacy delivery. Additionally, on the 11/2012 MAR it was documented that the resident did not receive Lanthanum Carbonate from 11/2/12 until he received his first dose of the medication on 11/7/12 for a total of 15 missed doses. On the back of the MAR it was documented on the following dates that the Lanthanum Carbonate was not available: 11/4/12, 11/5/12, 11/6/12, and for the day shift of 11/7/12. Review of the Medication And Treatment Error forms revealed that there were no reports documented for the medication omissions from 11/2/12 through 11/7/12. Review of the physician notes revealed that there was no documentation related the medication omissions from 11/2/12 through 11/7/12. A Re-Order Medication form dated 11/4/12, which had been faxed to the pharmacy, documented that the resident's Lanthanum Carbonate had never been received. Review of the nurses notes for 11/2/12 revealed that there was no documentation that the nursing supervisor or the physician were notified that the resident did not receive the evening medications as ordered by the physician. A nurses note dated 11/5/12 at 2:00 pm, documented that the 7:30 am and 11:30 am Lanthanum Carbonate was not given for three days. The pharmacy was called and the physician was aware. A nurses note dated 11/8/12 at 10:40 pm, documented that on 11/4/12 at 5:00 pm, the resident's Lanthanum Carbonate was not given. The pharmacy was called and the physician was aware. During an interview on 11/14/12 at 11:22 am, Licensed Practical Nurse (LPN) #7 stated that when this resident arrived on the unit on 11/2/12 she faxed the physician orders [REDACTED]. When she left for the day at 3:30 pm, the medications had not yet arrived from the pharmacy. When she returned to work on 11/5/12, the medications had arrived with the exception of the Lanthanum Carbonate. She stated that she called the pharmacy and again faxed to the pharmacy an order for [REDACTED]. She stated that she notified the physician on 11/5/12 that the resident had not received the medication. She also stated that when medications arrived from the pharmacy, there was no system to reconcile what was ordered with what arrived. The LPN stated that she did not know there was a P&P book. When the surveyor showed her the P&P book that was on the unit, the LPN stated that she had never looked for that and did not know it was there. During an interview on 11/14/12 at 4:27 pm, LPN#8 stated that when she received report on this resident on 11/2/12 at 3:00 pm, the resident's evening medications had not yet arrived from the pharmacy. At the end of her shift at 11:00 pm, the medications still had not arrived from the pharmacy. She stated that the resident did not receive his evening medications and that she did not notify the nursing supervisor or the physician about the unavailability of the medications. She also stated that she did not complete a Medication And Treatment Error form for the omission because medications from the pharmacy were unavailable so often that they (the nurses) just kept calling and hassling the pharmacy in an attempt to get the medications. She no longer notified the physician or supervision about the problems because it happened too often. She said that not a day goes by when some resident's medication is not available and that she spent considerable time on the phone with the pharmacy every day. During an interview on 11/14/12 at 1:25 pm, the DON stated that there had been a significant problem in the facility with medications being unavailable from the pharmacy since they switched to a new pharmacy in 7/2012. There was no P&P in place to instruct staff what to do if medications were unavailable, that the nurses would refax orders or fax a pharmacy form, and they often called the pharmacy about the unavailable medications. The DON also stated that the nurses were doing the best they could to get missing medications for the residents and that it was, "a crap shoot," if the residents would get their medications, especially if it was a new admission or if the medication was not available on the weekends. The DON also stated that she had frequent communication since 7/2012 with the faciilty owner and the owners of the pharmacy with complaints that there were problems with consistently obtaining medications from the pharmacy. During her conversations with the pharmacy owners, they wanted specific problems identified and she told them that the issues were too numerous and that she just wanted the problem fixed. She stated that the problem was not that the facility owner and the pharmacy owners were not aware of the problems, "we just haven't figured out how to fix it." During an interview on 11/14/12 at 3:49 pm, the Administrator stated that the facility had significant problems with medications not being available from the pharmacy since switching pharmacies in 7/2012. She stated that she had repeated complaints from nurses and had repeated conversations with the facility owner and the two owners of the pharmacy but that the problem still had not been resolved. The Administrator stated that she had complained on several occasions to the facility owner that residents were not getting all of their medications and that they could not get the system fixed and she told the facility owner that they should switch pharmacies. The Administrator stated that the whole system is no good but felt that it was not from the facility's lack of communication. She also stated that recently the DON had begun tracking the unavailability of medications from the pharmacy but felt that the nurses were not always notifying the DON or her because there were so many occurrences that it could not be kept track of. During a telephone interview on 11/15/12 at 8:28 am, Pharmacy Owner (PO) #1 stated that he was not aware of ongoing issues concerning unavailability of medications at this facility. He stated that he was only aware of a few isolated cases and that these seemed to be an issue with nurses following ordering procedures. During an interview on 11/15/12 at 1:03 pm, the Pharmacist Vice President of Client Services (PVP) stated that she had been in this role since 8/2012. She stated that part of her job was to go to facilities that were having pharmacy problems to assist in resolving the problems, do inservices on pharmacy P&Ps and generally troubleshoot issues. She stated that she was not informed of or aware that this facility was having problems with medications not being available for residents due to the pharmacy not delivering the medications until 11/14/12, and that was the first time she had heard of this issue here. 10 NYCRR 415.18(a)

Based on record review and interview, the Governing Body failed to ensure the establishment and implementation of policies and procedures related to the management and operation of the facility regarding the management and operation of the facility; and timely administration of routine and emergency physician ordered medications to residents. The facility failed to: ensure that medications were obtained timely from the contracted pharmacy, address the availability of medications from the contracted pharmacy, ensure that staff were aware of policies and procedures related to the ordering and delivery of medications from the pharmacy and failed to ensure a system to monitor medications ordered and received. This resulted in Immediate Jeopardy to resident health and safety and had the potential to affect all 112 residents in the facility. This was evidenced by: During an interview on 11/15/12 at 3:00 pm, the facility owner stated that she took over the facility in April, visits the facility one to two times per week for a couple of hours and was responsible for contracting with the new pharmacy in July 2012. The owner stated that she may have heard about issues with medications not being available from the Administrator, however, she had no idea of the scope and severity of the situation. The owner stated that a couple of months ago she began to have concerns that she wasn't getting the full information from the facility Administrator and had advised the Administrator and Director of Nursing that they should contact the owner of the pharmacy to deal with the problems. When questioned about the actions she took when she became aware of the medication unavailability in the facility along with her concerns that she may not be getting all of the pertinent information from the facility Administrator, the owner stated " I wasn't involved directly in anything, she didn't tell me." The owner further stated that the Medical Director should have told her if he was aware of the problem. The owner stated that during her visits to the facility she didn't ask any of the nursing staff about the availability of medications nor did she ask the administrator to provide any audits or reports to determine for herself what the problem may have been. Refer to F 333 scope and severity- L- Medication Errors Refer to F425 scope and severity - L - Pharmaceutical Services, Refer to F490 - Administration Refer to F520 - scope and severity- L - Quality Assurance 415.26 (b)(3)(1) . .

Based on observation, medical record review, and staff interview the facility failed to ensure resident's advanced directive wishes were correctly identified for 7 (#s 20, 29, 81, 83, 87, 91, and 93) of 113 residents reviewed during the extended survey. Specifically, 1 (Resident #29) was observed not wearing a wrist band, had a Non-Hospital Do Not Resuscitate (DNR) Form in the back of her chart, there was a green dot on the spine of the chart (indicated full code) and the resident stated she wanted to be a DNR; 1 (Resident #93) had a green dot on his wristband (indicated full code), a red dot ( indicated DNR) on the spine of his chart and a DNR order in the chart; 1 (Resident #20) had a wristband with no visible dot, a Non-Hospital DNR order in the chart, and a green dot on the spine of his chart; and 4 (#s 81, 83, 87 and 91) residents did not have current physician's orders [REDACTED]. This resulted in no actual harm but has the potential for serious harm that is Immediate Jeopardy to resident's health and safety and Substandard Quality of Care for the residents. This is evidenced by: The facility's policy entitled Advanced Directives Policy, dated [DATE] documented "Residents that make advance directive decisions shall be informed and repeatedly advised that they have the option to negate such directives at anytime they wish to do so." This same policy also documented "social services will educate the residents upon admission, throughout stay, and PRN (as needed); respond to questions and assist residents in creating, revoking or changing an advance directive. Documentation regarding changes, education, implementation of advance directives, etc will be reflected in the Advance Directive Progress Note and/or the Social Work Assessment note." The facility's policy entitled cardiopulmonary resuscitation-CPR which was effective ,[DATE] and most recently reviewed/revised ,[DATE], documented under "Procedural Steps": The first staff member on the scene will: 1. Identify that an arrest is present This same policy documented under "Key Points": 1) Check name band for color Green=Full code/resuscitation Red = Do not resuscitate (DNR) There was no documentation in this policy regarding red or green dots. Finding #1: During an interview on [DATE] at 7:50 am the Registered Nurse Manager (RNM) #1 on the A unit stated the process for identifying the advanced directives were a red dot on the wrist band if the resident did not want to be resuscitated (DNR), if the resident wished to be resuscitated (Cardiopulmonary Resuscitation (CPR)) the resident have a green colored dot on their wrist band. The alternate place to check is the spine of the chart for a colored dot. For the residents who do not wear a wrist band the RNM further stated that the code status or the band would be placed on the wheelchair or walker. During an interview on [DATE] at approximately 8:00 am the Registered Nurse Manager (RNUM) #3 on the C unit stated that if a resident in this facility was a DNR they would have a red dot on their wristband and a red dot on the spine of the chart. If they wanted CPR they would have a green dot on their wristband and a green dot on the spine of the chart. During an interview on [DATE] at approximately 8:15am the Registered Nurse Unit Manager (RNUM) #2 on the B unit stated if a resident in this facility had a DNR order, the facility's policy is to put a red dot on the resident's wristband, and a red dot on the spine of the resident's chart. The RNUM also stated if the resident was to be a full code (wanted cardiopulmonary resuscitation-CPR) a green dot was to be placed on the spine of the chart and the resident's wristband. Resident #29: The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] assessed the resident's cognitive skills for daily decision making were intact. The Nurse's Notes dated [DATE] from 3:00pm-11:00pm documented the resident was displaying behaviors on this shift. The note documented the resident removed her wrist band with code status, and stated she wanted a red sticker. The note also documented the nurse explained to the resident her code status must be signed off by the physician, and the resident refused to put on another band until her status was changed to DNR. The Social Progress notes dated [DATE] documented the MSW (Social Worker) was contacted by the registered nurse (RN) to meet with the resident regarding the resident's request for DNR. The note documented the DNR paperwork was placed in the physician's book and the MSW would continue to document the resident's needs. On [DATE] at approximately 10:30am a green dot (full code) was observed on the spine of the resident's chart. On [DATE] at 10:35am, there was a "DNR Consent Form 1A Adult Resident With Capacity" form in the Advance Directive section of the resident's medical record. The consult section in the back of the resident's chart contained a "Non-Hospital Order Not to Resuscitate (DNR Order)" form. This form documented the resident's name, date of birth, and the statement "Do not resuscitate the person named above" which was signed and dated by the physician on [DATE]. During an interview on [DATE] at 10:50 am the resident was asked to show her wristband, the resident stated that she does not wear a wristband because she wants a wristband with a red dot and they keep giving her one with a green dot. She stated they would not do anything to bring her back if she has a red dot on her band. During an interview on [DATE] at 1:10 pm the Licensed Practical Nurse (LPN#4) on the unit stated if she were to find a resident unresponsive with no pulse or respirations, she would check the resident's wrist band to determine if the resident's was a DNR or full code status. The LPN stated if the resident was a DNR, there would be a red dot on the wrist band and if the resident was a full code, the dot would be green on the wrist band. The LPN also stated if the resident had no wrist band, she would check the spine of the resident's chart, and the color of the dot should be the same as above. The LPN also stated she would check the physician's orders [REDACTED]. If the physician's orders [REDACTED]. [REDACTED]. During an interview on [DATE] at 3:20pm the LPN on the evening shift (LPN#5) stated if she were to find a resident unresponsive with no pulse or respirations, she would check the resident's wrist band to determine if the resident's DNR or full code status. The LPN stated if the resident was a DNR, there would be a red dot on the wrist band and if the resident was a full code, the dot would be green on the wrist band. The LPN also stated if the resident had no wrist band, she would either go to the resident's chart or she would look in the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. During an interview on [DATE] at approximately 8:45am the Social Worker (MSW) stated she talks to the residents or their family members about their wishes for advance directives. The MSW stated she will put the appropriate forms in the physician's folder to be completed by the physician, and the nurses are responsible for placing the correct dots on the spine of the chart and the resident's wrist band. The MSW stated she spoke with this resident about her advance directive wishes approximately 2 weeks ago. The MSW stated the resident was very adamant about the fact she did not want to be resuscitated. The MSW stated the resident said she did not want to be intubated (have a breathing tube inserted) and did not want "any machines". The MSW stated she spoke with the registered nurse unit manager about this, and left the forms for the physician to complete. During an interview with the RNUM #1 on [DATE] at approximately 2:00 pm, the RNUM #1 stated that she removed the signed "Non Hospital DNR "form dated and signed [DATE], from the residents chart because it was not supposed to be there since the physician and resident did not sign the capacity paperwork. On [DATE] at approximately 2:00 pm, the resident's chart still had a green dot on the spine, but the "DNR Consent Form 1A Adult Resident With Capacity" and the "Non-Hospital Order Not to Resuscitate (DNR Order)" forms were no longer in the resident's medical record. During an interview on [DATE] at approximately 3:15 pm the RNUM #1 stated she had removed the above forms from the resident's chart and placed the in the physician's box for his review on his next visit to the facility. The RNUM stated she was aware the physician completed the forms on [DATE] and the resident wished to be a DNR, but the resident still had to sign the capacity form. During an interview on [DATE] at 8:25am the Director of Nursing (DON) stated the only concern with advance directives she was aware of was with Resident #29 who changes her mind frequently. The DON stated the resident removed her wrist band, stating she didn't want to be a prisoner. The DON stated the physician signed a DNR status on [DATE], but it was still in the physician's book, as the resident had not yet signed this. During an interview on [DATE] at 9:10 am the Medical Director stated that the DNR paperwork that he was earlier questioned about was signed by him on rounds on Sunday. He stated he did not understand why the paperwork was taken out of the residents chart and placed in his mailbox where he found it today (Thursday). He further stated that he wrote the order on [DATE] and the resident was sent out to the hospital on [DATE], he further stated the order should have remained in the residents chart. The paperwork was requested by staff for his signature, he did not initiate the paperwork on his own. Resident #20: The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. During an observation on [DATE] at approximately 10:45am there was no dot on the spine of the resident's medical record, there was a "Non-Hospital Order Not to Resuscitate (DNR Order)" form in the resident's medical record, which was signed by the physician, and the resident was observed wearing a wrist band with no visible dot. On [DATE] at approximately 10:25 am 2 surveyors observed the resident's wrist band and there was no visible dot on the band. The medical record was observed to have a green dot on the spine, and there was no "Non-Hospital Order Not to Resuscitate (DNR Order)" form in the resident's medical record. During an interview on [DATE] at 1:10 pm the Licensed Practical Nurse (LPN) # 4 on the unit stated if she were to find a resident unresponsive with no pulse or respirations, she would check the resident's wrist band to determine if the resident's DNR or full code status. The LPN stated if the resident was a DNR, there would be a red dot on the wrist band and if the resident was a full code, the dot would be green on the wrist band. The LPN also stated if the resident had no wrist band, she would check the spine of the resident's chart, and the color of the dot should be the same as above. The LPN also stated she would check the physician's orders [REDACTED]. If the physician's orders [REDACTED]. [REDACTED]. During an interview on [DATE] at 3:20pm LPN #5 on the evening shift stated if she were to find a resident unresponsive with no pulse or respirations, she would check the resident's wrist band to determine if the resident's DNR or full code status. The LPN stated if the resident was a DNR, there would be a red dot on the wrist band and if the resident was a full code, the dot would be green on the wrist band. The LPN also stated if the resident had no wrist band, she would either go to the resident's chart or she would look in the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. During an interview on [DATE] at approximately 8:25am the DON stated the Social Worker (MSW) will speak with the resident or their family regarding their wishes for advance directives. The MSW then places the appropriate paperwork in the physician's box for review (the physician's usually come to the facility twice a week). Once the forms are signed, the DON stated nursing is responsible to initiate the order. The DON stated the resident should have a written physician's orders [REDACTED]. During an interview on [DATE] at approximately 8:45 am the MSW stated she talks to the residents or their family members about their wishes for advance directives. The MSW stated she will put the appropriate forms in the physician's folder to be completed by the physician, and the nurses are responsible for placing the correct dots on the spine of the chart and the resident's wrist band. During an interview on [DATE] at approximately 9:30 am the Administrator and DON discussed Resident #20. The surveyor was told that Resident #20 had a green dot on his wrist band and questioned why was he included in the sample. The surveyor checked with the three surveyors who identified this and informed the above staff of what they witnessed, there was no green dot visible on the bracelet when they were checked on [DATE]. There was a fine line of green barely visible which was taped over. The Surveyor then questioned the RNUM #1 regarding the wrist band. The RNUM stated that the LPN put a new bracelet on the resident earlier this morning with a green dot. The LPN stated to the RNUM that the green dot on the old bracelet was barely visible. During an interview on [DATE] at approximately 2:30 pm the Administrator stated she was told that earlier in the day, one of the licensed practical nurses (LPN) on the unit went in to check the resident's wrist band, and was unable to see a dot. The LPN promptly changed the wrist band and placed a green dot on the band. During an interview with the Medical Director on [DATE] at approximately 9:15 am, he stated that if the facility has an identification process in place ie: colored dots on wristbands they should be accurate, there is no margin for error when this is utilized as a deciding factor. Resident # 93: The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. During an observation on [DATE] at approximately 10:30 am the resident was observed to have a green dot on the wristband. During an observation on [DATE] at approximately 2:50 pm the resident was observed with a wristband with a green dot. Review of the advanced directives section of the medical record revealed the resident had a physician order [REDACTED]. The medical record further documented a Non-Hospital DNR form dated [DATE]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. During an interview on [DATE] at 1:08 pm the Licensed Practical Nurse (LPN) #1 stated she would check the wrist band then the spine of the chart. If there were discrepancies or if she could not tell from a quick look in the chart she would start CPR. The first place she would look would be the wrist band. When asked where in the chart she would look the LPN stated the orders inside the chart. During an interview on [DATE] at 10:30 am the LPN #2 stated the wristbands are checked for color of dot and placement on the resident. The accuracy to see if the dot corresponds with the medical record is not what the signature is. This is completed during medication pass there would not be time to check each residents chart. During an interview on [DATE] at 1:20 pm the Registered Nurse Manager #1 stated that she would look at the wristband and then the spine of the chart for the residents code status. If she could not tell from those areas she would start CPR. During an interview with the Administrator and RNUM #3 on [DATE] at approximately 9:00am they both stated that Resident #93 did have a green dot on his wrist band which was incorrect and that it had been changed to a red dot to reflect DNR status. Resident # 87: The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. During an observation on [DATE] at approximately 10:30 am the resident was observed to have a red dot on the wristband. During an interview on [DATE] at 1:08 pm the Licensed Practical Nurse (LPN) #1 stated she would check the wrist band then the spine of the chart. If there were discrepancies or if she could not tell from a quick look in the chart she would start CPR. The first place would be the wrist band. The LPN stated she would check the orders inside the chart. The current signed physicians orders, dated [DATE], did not include an order for [REDACTED]. During an interview with the Medical Director on [DATE] at approximately 9:15 am he stated the residents should have a doctors order for their advanced directives. 10NYCRR415.12

Based on medical record review and staff interview the facility did not ensure that residents were free of any significant medication errors for 1 (#42) of 5 residents reviewed during the extended recertification survey. Specifically, the facility did not ensure the resident received medication for a potential reaction to an antibiotic as ordered by the physician. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. This is evidenced by: Resident #42 The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] assessed the resident was severely cognitively impaired. The Nurses Notes dated 8/12/12 at 3:00pm documented the resident continued on antibiotic for a urinary tract infection. The Nurses Note dated 8/13/12 (no time noted) documented the resident was seen by the physician for a rash on both cheeks. The note documented the physician ordered the [MEDICATION NAME] (antibiotic) to be discontinued, and the resident was to receive [MEDICATION NAME] (used for itching) 25mg by mouth (PO) three times a day (TID) for three days, and [MEDICATION NAME] (steroid) 30mg PO every day (QD) for 2 days, then 20mg PO QD for 3 days. The physician's orders [REDACTED]. 3 days. The Nurses Note dated 8/14/12 at 10:30am documented the [MEDICATION NAME] 25mg was not available, the pharmacy was sending the medication, and the resident's rash remained, but was less red and the resident denied any itching. The Nurses Note dated 8/14/12 at 9:00pm documented the resident's medications ([MEDICATION NAME] and [MEDICATION NAME]) were not delivered by the pharmacy. There was no documented evidence the physician was notified of the above. The Nurses Note dated 8/15/12 at 2:30pm documented the resident's cheeks remained slightly reddened with a rash, and the resident received the [MEDICATION NAME] and the [MEDICATION NAME]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. This same MAR indicated [REDACTED]. There was no documented evidence a medication error was completed for the above medication errors. During interview on 11/8/12 at 2:15pm, the Registered Nurse Unit Manager (RNUM) acknowledged the above medications were not documented as being administered as ordered by the physician and she was unsure if the physician was notified of the medication errors. The RNUM also stated a medication error form should have been completed for the above errors. 10NYCRR 415.12(m)(2)

Based on record review and staff interview, the facility failed to ensure that residents are free of any significant medication errors. Specifically, 11 (Resident #s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11)of 11 resident's reviewed were not administered routine and emergency medications as ordered by the physician due to unavailability of medications. This caused actual harm for Resident #3 that is Immediate Jeopardy to resident health or safety and Substandard Quality of Care for Residents . This had the potential to affect all 112 residents at the facility. This is evidenced by the following: The Policy and Procedure (P&P) for Medication and Treatment Errors dated 11/91 and reviewed/revised 4/2012, documented that residents were to receive accurate, timely and consistent treatment and care. In the Error Criteria section of the P&P was documented that an error included omission of medication or treatment as ordered or unsigned for. Actual errors were to be reported to the physician and nursing supervisor and a Medication And Treatment Error form was to be initiated by the nurse discovering the error. The nursing supervisor was to evaluate the resident and immediately notify the Director of Nursing (DON), Administrator, Physician and Pharmacist if there was a possibility of severe effects to the resident. Each medication or treatment error was to be reviewed by the DON and the Medical Director, and was to be presented at the Quality Assurance Committee. Resident #3: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident with severe cognitive impairment. Laboratory Results faxed from the hospital on [DATE] at 3:01 pm, documented that the resident ' s swab of the right buttock wound was positive for infection (Cocci and Rods). Documented on the results is the Registered Nurse Managers (RNM) initials dated 11/9/12 and a telephone order taken from physician #2 on 11/10/12 to start [MEDICATION NAME] ( an antibiotic)100mg twice per day for 10 days, signed by Licensed Practical Nurse (LPN) # 2. A physicians (MD) order dated 11/10/12 at 8:00 pm documented an order for [REDACTED]. Nurse's notes dated 11/10/12 (untimed) documented the telephone order from MD #2, [MEDICATION NAME] 100mg for 10 days for a wound to the right buttocks and that the final lab report had been received on 11/9/12. Nurse's notes dated 11/11/12 at 2:00 pm documented that the [MEDICATION NAME] was not started in the morning because the medication was not delivered by the pharmacy and there were no antibiotics in the emergency kit. The note documented that the next scheduled dose for the resident was due at 12:00 am and it that should arrive by then. The note documented that the supervisor was aware. Nurse's note dated 11/11/12 at 9:00 pm documented that the [MEDICATION NAME] was to start at 12:00 am, waiting for the pharmacy to deliver the medication and that the resident did not receive [MEDICATION NAME]( anti-[MEDICAL CONDITION] medication) as it was unavailable. The note documented that the pharmacy was faxed the order and the supervisor was aware. Nurse's note dated 11/12/12 at 4:10 am documented awaiting antibiotics and no deliveries from the pharmacy. Nurse's note dated 11/12/12 at 3:00 pm documented that the Medical Director (MD) was contacted and ordered the antibiotics to start when it arrived from the pharmacy. MD Order dated 11/12/12 (untimed) documented [MEDICATION NAME] 100mg twice per day for 10 days when it arrives from pharmacy. Nurse's note dated 11/12/12 at 4:00 pm documented that both medications, the [MEDICATION NAME] and [MEDICATION NAME] were still unavailable and the pharmacy was contacted and stated that the medications would be delivered in an hour or two at the most. November Medication Administration Record (MAR) documented that the [MEDICATION NAME] was not administered to the resident. Nurse's note dated 11/12/12 at 9:15 pm documented that the resident was found unresponsive to verbal and painful stimuli, skin was very warm and had a temperature of 101.4. An order was received for transport to the hospital. Nurse ' s note dated 11/13/12 at 6:00 am documented that the resident was admitted to the hospital diagnosed with [REDACTED]. During an interview on 11/14/12 at 11:00 am, LPN #1 stated that she contacted the MD on 11/12/12 after realizing that the [MEDICATION NAME], ordered on [DATE], was not available. LPN #1 stated that the MD told her " this is a pharmacy issue, call the pharmacy and when it is available, give it. " LPN #1 stated that the MD is usually notified when the first dose of a medication is not available, but " we have had a lot of issues, the MD thinks it's a pharmacy issue and I think the MD has had it. " During an interview on 11/14/12 at 1:30 pm, the Medical Director stated the facility contacted him on 11/12/12 and told him that MD #2 ordered [MEDICATION NAME] for the resident on 11/10/12, however, it still had not been delivered from the pharmacy. The Medical Director stated that he told LPN #1 " what can I do about it, the pharmacy has to be made to deliver the medications. " The Medical Director stated that there have been problems with the pharmacy since July 2012 and the lack of medications available is becoming more and more common " . The Medical Director stated that medications are not always available in the emergency kit. The Medical Director stated that this resident had a chronic wound and, infection was always a concern, " that ' s why the antibotics were ordered and not getting the antibiotics would have a direct correlation with a [DIAGNOSES REDACTED].' t do anything about it, they need to be made to deliver the medications, I wish you (the surveyor) would focus on the untimely meds from the pharmacy, I can ' t do anything about it. " During an interview on 11/16/12 at 1:30 pm, the RNM stated that on 11/12/12 she was made aware that the [MEDICATION NAME], ordered on [DATE], had not been delivered over the weekend and that the physician was notified on 11/12/12. The RNM stated that the physician should have been contacted right away after the [MEDICATION NAME] was not available to the resident on 11/10/12. The RNM stated " we have a lot of issues with the pharmacy, we don ' t always get the medications when we expect them. " The RNM stated that there is no real system in place to order medications or reconcile what was ordered with what has been received to insure timely administration to the residents. The RNM stated that the staff assume if the reorder sticker is gone that it has been ordered but days could pass and only when they don ' t have the medication to give to the residents, do they realize that it was not delivered as expected. Resident #1: The facility failed to ensure that this resident received [MEDICATION NAME] (a medication used to control acid reflux in the stomach) as ordered by the physician. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE], documented the resident had modified independence in cognitive decision making. A Physician Re-admission Evaluation dated 09/25/12 included hospital admission 09/13/12 for upper GI bleeding due to erosive esophagitis and returned to the facility on [DATE]. The physician order [REDACTED]. The original order date for this medication was 09/25/2012. The Medication Administration Record (MAR) dated 10/2012 documented that the resident was to receive 40 milligrams (mg) of [MEDICATION NAME] by mouth twice daily. For the dates of 11/01/2012 through 11/14/2012 the nurse's initials are circled in 18 out of 27 boxes on the front of the MAR. On the back of the MAR it is documented that the [MEDICATION NAME] was not available on 11/3/2012, 11/4/12, 11/5/12/, 11/7/12, 11/8/12, 11/10/12, and 11/12/12. It was further documented on 11/10/12 that the physician and pharmacy were to be notified that day. Review of Medication Error Reports for 8/2012, 9/2012 and 10/2012 and 11 /2013 revealed there were no error reports completed for the resident not receiving a total of 18 doses from 11/01/2012 through 11/14/2012. A Nurses Note written by a Registered Nurse (RN) and dated 11/08/2012 documented that the RN spoke with the pharmacy about the [MEDICATION NAME] order. The pharmacist explained to her that [MEDICATION NAME] was not covered by insurance and the order had been changed in 10/2012 to [MEDICATION NAME]. The RN left a note in the physician's communication book (a book used to make the physician aware of concerns and/or issues on the physician's next visit to the facility) for clarification from the physician. A nurses note dated 11/11/12 on the 3:00 pm to 11:00 pm (evening) shift, documented that the [MEDICATION NAME] had arrived from pharmacy that evening. The Registered Nurse Manager (RNM) had been reminded that morning to contact the pharmacy about the unavailable [MEDICATION NAME]. During an interview on 11/14/12 at 12:10pm Licensed Practical Nurse (LPN) # 11 stated that to reorder medications they pull the refill tab off the medication card and stick it on the reorder sheet and then it is faxed to the pharmacy. The reorder sheet is then placed in a basket by the fax machine to be kept by the DON. The LPN stated the reorder sheet needed to be faxed by 11:00 am and the delivery would be on the 11:00 pm to 7:00 am (night) shift. She stated she would follow up on the order if it did not arrive in a couple of days and that there was no sytem to track the ordered medications. The LPN stated newly ordered meds were also faxed and if they were needed right away they would call the pharmacy. If the medications did not arrive, the pharmacy would use their back up pharmacy but you would have to call and ask for this. The LPN stated that when the medications did not arrive the nurses circled their initials on the MAR and documented on the back that the medication was not available. She stated that this should have been documented in a nurses note and the nursing supervisor and physician should have been notified. She also stated that a Medication Error Report would not be completed because it was a pharmacy error. During an interview on 11/14/12 at 12:25pm the RNM # 13 stated that if medication orders were faxed to the pharmacy by noon (12:00 pm) that sometimes they would be delivered by 6:00 pm, sometimes 11:00 pm and sometimes on the night shift. Immediate orders would be called into the pharmacy and it would have to be made clear that they were needed and the pharmacy would use a local pharmacy to deliver. She stated that sometimes she would have to argue with the pharmacy to get a medication to be delivered to the facility. The RNM stated that the nurses should report to her when there were medications that were not available. The RN Manager did not know why she was not notified of the unavailable [MEDICATION NAME] for 8 days. She stated when she called the pharmacy about this medication, she was told the medication needed physician approval because the insurance did not cover [MEDICATION NAME]. She further stated she could not get the pharmacy to understand that the resident needed the [MEDICATION NAME] as ordered by the physician. The RN Manafer stated a medication error should have been completed for unavailable medications. During an interview on 11/14/12 at 1:15pm the LPN # 12 stated the medication orders were faxed to the pharmacy and the forms were left in a basket for the DON. He stated that the nurses do their own follow-up of the medications ordered and would call the pharmacy if they were not delivered. The LPN #12 stated "it's ridiculous", that it could take from 24 hours to 48 hours and longer for medications to be delivered from the pharmacy. He stated that when there was a seven day supply of medication remaining, he reordered those medications to ensure that the medication did not run out, but that they sometimes still did not arrive in the facility on time. During an interview on 11/14/12 at 2:00pm, RNM # 1 stated that the medication orders were faxed to the pharmacy in the afternoon and medications were delivered at 6:00 pm or on the night shift. Reorders should be done three days ahead and new orders should be delivered the same night. She stated that when a medication was unavailable and a call was made to the pharmacy that the call was documented on the "pharmacy log" to track all of these issues and there were many. When a medication did not arrive from the pharmacy, the RNM and the physician were to be notified. She stated a Medication Error Report would not be completed for pharmacy missed medications unless there was a medical event related to the omission of a medication. Resident #4: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Nursing assessment dated [DATE] documented that the resident was alert and oriented to person, place and time. A nurses note dated 11/2/12 at 1:00 pm, documented that the resident was admitted to the facility from the hospital. The physician orders [REDACTED]. [MEDICATION NAME] (a blood pressure medication) 25mg by mouth twice daily (BID). [MEDICATION NAME] (a medication to help with bowel movements) 100mg by mouth BID. Senna (another bowel medication) 17.2mg by mouth daily at bedtime (qHS). [MEDICATION NAME] (a cholesterol medication) 10mg by mouth qHS. [MEDICATION NAME] (a diuretic) 50mg by mouth BID. [MEDICATION NAME] (another diuretic) 3mg by mouth BID. The Medication Administration Record (MAR) dated 11/2012 documented that the nurses initials for each of these medications for the evening shift was circled which indicated that there was a note on the back of the MAR. On the back of the MAR was documented that on 11/2/12 all evening shift oral medications were unavailable and were awaiting delivery from the pharmacy. Another note on the back of the MAR documented on 11/3/12 at 5:00 pm, that all oral medications were not available and were awaiting pharmacy delivery. Additionally, on the 11/2012 MAR it was documented that the resident did not receive Lanthanum [MEDICATION NAME] from 11/2/12 until he received his first dose of the medication on 11/7/12 for a total of 15 missed doses. On the back of the MAR it was documented on the following dates that the Lanthanum [MEDICATION NAME] was not available: 11/4/12, 11/5/12, 11/6/12, and for the day shift of 11/7/12. Review of the Medication And Treatment Error forms revealed that there were no reports documented for the medication omissions from 11/2/12 through 11/7/12. Review of the physician notes revealed that there was no documentation related the medication omissions from 11/2/12 through 11/7/12. A Re-Order Medication form dated 11/4/12, which had been faxed to the pharmacy, documented that the resident's Lanthanum [MEDICATION NAME] had never been received. Review of the nurses notes for 11/2/12 revealed that there was no documentation that the nursing supervisor or the physician were notified that the resident did not receive the evening medications as ordered by the physician. A nurses note dated 11/5/12 at 2:00 pm, documented that the 7:30 am and 11:30 am Lanthanum [MEDICATION NAME] was not given for three days. The pharmacy was called and the physician was aware. A nurses note dated 11/8/12 at 10:40 pm, documented that on 11/4/12 at 5:00 pm, the resident's Lanthanum [MEDICATION NAME] was not given. The pharmacy was called and the physician was aware. During an interview on 11/14/12 at 11:22 am, Licensed Practical Nurse (LPN) #7 stated that when this resident arrived on the unit on 11/2/12 she faxed the physician orders [REDACTED]. When she left for the day at 3:30 pm, the medications had not yet arrived from the pharmacy. When she returned to work on 11/5/12, the medications had arrived with the exception of the Lanthanum [MEDICATION NAME]. She stated that she called the pharmacy and again faxed to the pharmacy an order for [REDACTED]. She stated that she notified the physician on 11/5/12 that the resident had not received the medication. During an interview on 11/14/12 at 4:27 pm, LPN#8 stated that when she received report on this resident on 11/2/12 at 3:00 pm, the resident's evening medications had not yet arrived from the pharmacy. At the end of her shift at 11:00 pm, the medications still had not arrived from the pharmacy. She stated that the resident did not receive his evening medications and that she did not notify the nursing supervisor or the physician about the unavailability of the medications. She also stated that she did not complete a Medication And Treatment Error form for the omission. The LPN stated that it happened so often that medications were not available from the pharmacy that they (the nurses) just kept calling and hassling the pharmacy in an attempt to get the medications. She no longer notified the physician or supervision about the problems because it happened too often. She said that not a day goes by when some resident's medication is not available and that she spent considerable time on the phone with the pharmacy every day. During an interview on 11/14/12 at 1:25 pm, the DON stated that if a resident did not receive a medication that had been ordered by the physician, the nurses were supposed to document the reason the medication was held on the back of the MAR. She stated in the case of a medication not being available, it was to be documented on the back of the MAR that it was unavailable from the pharmacy. She stated that she would expect nurses to use their judgment in notifying the physician of medications that had been held or were unavailable from the pharmacy. The facility did not have a P&P that addressed the notification of the physician if a medication was omitted due to unavailability from the pharmacy. The DON also stated that the nurses were doing the best they could to get missing medications for the residents and that it was, "a crap shoot," if the residents would get their medications, especially if it was a new admission or if the medication was not available on the weekends. She stated that there had been a significant problem in the facility with medications being unavailable from the pharmacy since they switched to a new pharmacy in 7/2012. She also stated that they did not complete Medication And Treatment Error forms when medications were not available from the pharmacy, and that the facility did not track how often medications were not available from the pharmacy. She was not aware of how often this was happening because it happened so often that the nurses no longer reported it every time it happened. 10NYCRR 415.12(m)(2) .

Based on medical record review and staff interviews the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident during the extended recertification survey. Specifically, the Administration failed to develop and implement careplans for residents with known behaviors and failed to provide adequate supervision and protect residents from potential resident to resident abuse, and psychological harm. Additionally, the Administration failed to accurately identify the residents' wishes for advance directives; regarding cardiopulmonary resuscitation (CPR) and do not resuscitate (DNR). This resulted in no actual harm but has the potential for serious harm that is Immediate Jeopardy for the health and safety of all residents. Refer to Quality of Care F 224 scope and severity - K Refer to Quality of Care F 225 scope and severity- K Refer to Resident Assessment F 279 scope and severity-K Refer to Quality of Care F 323 scope and severity - K During an interview with the Director of Nurses (DON) on [DATE] at 10:30 am she stated that the facility did not have individual care plans for potential victims or aggressors of wandering residents . Additionally stating there should be no concerns if the wandering residents were being monitored accurately. During an interview with the DON on [DATE] at 11:00 am stated that they are concentrating on the residents with behaviors not the residents who have the potential to be affected. The DON stated hopefully the staff are keeping an eye on the residents who wander. The DON stated there should be no concerns with other residents if the residents who wander are being accurately monitored. The DON also stated there were no care plans for either residents who have the potential to be either the aggressor or to be victimized. The DON stated she has to keep all the resident safe, and she doesn't know what else she can do. Refer to Quality of Care F 309 scope and severity -K Findings include conflicting indicators, physician orders [REDACTED]. A second resident had a physician's orders [REDACTED]. The identified inaccuracies and inconsistent application of the facility policy and procedures have the potential to affect the health and safety of all residents whose Advanced Directives were not appropriately identified. During interview on [DATE] at 8:25am the Director of Nursing (DON) stated the resident's bands are checked and documented on the Medication Administration Record (MAR) to make sure the bands are in place. The DON stated the staff are not comparing the bands to the chart at this time. The DON stated it is the social worker's responsibility to do periodic audits to check the resident's advance directive order and compare it to the resident's wrist band and the MAR. The DON also stated the only concern with advance directives she was aware of was with Resident #29 who changes her mind frequently. The DON stated the physician signed a DNR status on [DATE], but it was still in the physician's book, as the resident had not yet signed this. During interview on [DATE] at 8:45am the Social Worker (MSW) stated she had been employed by the facility since July. The MSW also stated the previous Social Worker may have completed audits on advance directives, but she does not. The MSW stated on admission, annually and at quarterly reviews for the resident , she will check the advance directives section of the chart, and the dots on the spine of the chart. The MSW stated she does not check the physician's orders [REDACTED]. During interview on [DATE] at 9:30am the Administrator stated the facility has 2 audits in place to check advance directives. The Administrator stated after the previous survey and when the facility started using a new pharmacy, it was documented on the MAR that the residents wristbands were to be checked. The Administrator stated the staff should check to make sure the resident's wrist band is in place and the dot is correct. The Administrator stated she was unsure if the staff compared the dot on the wristband to the dot on the medical chart. When asked if the staff compare the dot on the wristband to the dot on the resident's medical chart, the Administrator stated she was unsure. The Administrator also stated the second audit is completed by the Social Worker at the time of the care conference reviews. 10NYCRR 415.26

Based on record review and staff and resident interviews, the Administration failed to ensure that the facility operated in a manner that enabled it to effectively use its resources to maintain the highest practicable well-being and safety of each resident. Additional findings rising to the level of Immediate Jeopardy were identified on 11/14/12 during monitoring for the 11/7/12 and 11/9/12 Immediate Jeopardies. Concerns rising to the level of immediate risk to resident health and safety included the facility failed to ensure residents were provided routine and emergency medication in a timely manner as ordered by the physician and failed to ensure these medications were obtained timely from their contract pharmacy. Interviews revealed staff were unaware of policies and procedures provided by the contract pharmacy, that were located in the Nursing Office and on each nursing unit. Investigation further revealed the facility failed to address the availability of medications from the pharmacy and lacked a system to monitor medications ordered and received. This has been an ongoing issue at the facility since changing pharmacy vendors in July 2012. This resulted in IMMEDIATE JEOPARDY to resident health and safety and Substandard Quality of Care and had the potential to affect all 112 residents in the facility. This was evidenced by: Refer to F 333 scope and severity- L- Medication Errors Refer to F425 scope and severity - L - Pharmaceutical Services During an interview on 11/14/12 at 1:25 pm, the Director of Nurses (DON) stated that there had been a significant problem in the facility with medications being unavailable from the pharmacy since they switched to a new pharmacy in 7/2012. There was no Policy and Procedure (P&P) in place to instruct staff what to do if medications were unavailable, that the nurses would refax orders or fax a pharmacy form, and they often called the pharmacy about the unavailable medications. The DON also stated that the nurses were doing the best they could to get missing medications for the residents and that it was, "a crap shoot," if the residents would get their medications, especially if it was a new admission or if the medication was not available on the weekends. The DON also stated that she had frequent communication since 7/2012 with the facility owner and the owners of the pharmacy with complaints that there were problems with consistently obtaining medications from the pharmacy. During her conversations with the pharmacy owners, they wanted specific problems identified and she told them that the issues were too numerous and that she just wanted the problem fixed. She stated that the problem was not that the facility owner and the pharmacy owners were not aware of the problems, "we just haven't figured out how to fix it." During an interview on 11/14/12 at 3:49 pm, the Administrator stated that the facility had significant problems with medications not being available from the pharmacy since switching pharmacies in 7/2012. She stated that she had repeated complaints from nurses and had repeated conversations with the facility owner and the two owners of the pharmacy but that the problem still had not been resolved. The Administrator stated that she had complained on several occasions to the facility owner that residents were not getting all of their medications and that they could not get the system fixed and she told the facility owner that they should switch pharmacies. The Administrator stated that the whole system is no good but felt that it was not from the facility's lack of communication. She also stated that recently the DON had begun tracking the unavailability of medications from the pharmacy but felt that the nurses were not always notifying the DON or her because there were so many occurrences that it could not be kept track of. 10NYCRR 415.26

Based on medical record review and staff interviews the Quality Assurance (QA) program failed to have a program that readily identified issues that had the potential to cause serious harm to resident during the extended recertification survey. Specifically, The QA program failed to have a procedure in place to identify and investigate allegations of resident to resident abuse, failed to develop and implement careplans for residents with known behaviors and failed to ensure adequate supervision was provided to protect residents from potential resident to resident abuse, and psychological harm. Additionally, the QA program failed to accurately identify the residents' wishes for advance directives; regarding cardiopulmonary resuscitation (CPR) and do not resuscitate (DNR). This resulted in no actual harm but has the potential for more than serious harm that is Immediate Jeopardy for the health and safety of all residents. Refer to Quality of Care F 224 scope and severity - K Refer to Quality of Care F 225 scope and severity- K Refer to Resident Assessment F 279 scope and severity-K Refer to Quality of Care F 323 scope and severity - K During an interview with the Director of Nursing on [DATE] at 11:00 am stated that they are concentrating on the residents with behaviors not the residents who have the potential to be affected. During an interview with the Administrator on [DATE] at 10:30 am she stated that they did not have careplans in place for potential victims or aggressors for wandering residents . Refer to Quality of Care F 309 scope and severity -K Findings include conflicting indicators, physician orders [REDACTED]. One alert resident with a DNR order was issued a green wrist band indicating CPR was to be initiated. A second resident had a physician's orders [REDACTED]. The identified inaccuracies and inconsistent application of the facility policy and procedures have the potential to affect the health and safety of all residents whose Advanced Directives were not appropriately identified. During interview on [DATE] at 8:25 am the Director of Nursing (DON) stated the resident's bands are checked and documented on the Medication Administration Record (MAR) to make sure the bands are in place. The DON stated the staff are not comparing the bands to the chart at this time. The DON stated it is the social worker's responsibility to do periodic audits to check the resident's advance directive order and compare it to the resident's wrist band and the MAR. The DON also stated the only concern with advance directives she was aware of was with Resident #29 who changes her mind frequently. The DON stated the physician signed a DNR status on [DATE], but it was still in the physician's book, as the resident had not yet signed this. During interview on [DATE] at 8:45 am the Social Worker (MSW) stated she had been employed by the facility since July. The MSW also stated the previous Social Worker may have completed audits on advance directives, but she does not. The MSW stated on admission, annually and at quarterly reviews for the resident , she will check the advance directives section of the chart, and the dots on the spine of the chart. The MSW stated she does not check the physician's orders [REDACTED]. During interview on [DATE] at 9:30 am the Administrator stated the facility has 2 audits in place to check advance directives. The Administrator stated after the previous survey and when the facility started using a new pharmacy, it was documented on the MAR that the residents wristbands were to be checked. The Administrator stated the staff should check to make sure the resident's wrist band is in place and the dot is correct. The Administrator stated she was unsure if the staff compared the dot on the wristband to the dot on the resident's medical chart. The Administrator also stated the second audit is completed by the Social Worker at the time of the care conference reviews. 10NYCRR 415.27(a-c)

Based on interview the facility did not ensure the quality assessment and assurance committee developed and implemented appropriate plans of action to correct identified quality deficiencies. Additional findings rising to the level of Immediate Jeopardy were identified on 11/14/12 during monitoring for the 11/7/12 and 11/9/12 Immediate Jeopardies. Concerns rising to the level of immediate risk to resident health and safety included the facility failed to ensure residents were provided routine and emergency medication in a timely manner as ordered by the physician and failed to ensure these medications were obtained timely from their contract pharmacy. Interviews revealed staff were unaware of policies and procedures provided by the contract pharmacy, that were located in the Nursing Office and on each nursing unit. Investigation further revealed the facility failed to address the availability of medications from the pharmacy and lacked a system to monitor medications ordered and received. This has been an ongoing issue at the facility since changing pharmacy vendors in July 2012. This resulted in IMMEDIATE JEOPARDY to resident health and safety and had the potential to affect all 112 residents in the facility. This was evidenced by: Refer to F 333 scope and severity- L- Medication Errors Refer to F425 scope and severity - L - Pharmaceutical Services During an interview on 11/14/12 at 1:25 pm, the Director of Nurses ( DON) stated that there had been a significant problem in the facility with medications being unavailable from the pharmacy since they switched to a new pharmacy in 7/2012. The DON also stated that she had frequent communication since 7/2012 with the facility owner and the owners of the pharmacy with complaints that there were problems with consistently obtaining medications from the pharmacy. During her conversations with the pharmacy owners, they wanted specific problems identified and she told them that the issues were too numerous and that she just wanted the problem fixed. She stated that the problem was not that the facility owner and the pharmacy owners were not aware of the problems, "we just haven't figured out how to fix it." The DON also stated that the incidents and the issue of medications not being delivered from the pharmacy in a timely manner were not being tracked and trended by the Quality Assurance Committee. During an interview on 11/14/12 at 3:49 pm, the Administrator stated that the facility had significant problems with medications not being available from the pharmacy since switching pharmacies in 7/2012. She stated that she had repeated complaints from nurses and had repeated conversations with the facility owner and the two owners of the pharmacy but that the problem still had not been resolved. The Administrator stated that she had complained on several occasions to the facility owner that residents were not getting all of their medications and that they could not get the system fixed and she told the facility owner that they should switch pharmacies. The Administrator stated that the whole system is no good but felt that it was not from the facility's lack of communication. She also stated that recently the DON had begun tracking the unavailability of medications from the pharmacy but felt that the nurses were not always notifying the DON or her because there were so many occurrences that it could not be kept track of. 10NYCRR 415.27(a-c)

Based on observation, staff interview and medical record review the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property during the extended recertification survey. Specifically, the facility did not ensure the Resident-to-Resident Abuse Policy and Procedure was implemented to protect 11 (Resident #s 4, 12, 21, 27, 29, 32, 34, 51, 55, 62 and 63) of 14 residents reviewed from potential abuse from other residents. This resulted in no actual harm but has the potential for serious harm that is Immediate Jeopardy and Substandard Quality of Care to residents health and safety. This is evidenced by the following: The undated Policy and Procedure (P&P) entitled "Resident to Resident Abuse Policy and Procedure" documented that the facility was to protect residents from harm at all times. This included protection from physical and verbal abuse from other residents. If a resident-to-resident incident occurred, staff were to immediately intervene. The residents were to be separated and taken away from each other until the situation calmed down. The nursing supervisor was to be immediately notified and all necessary documentation for reporting the incident was to be completed. All incidents were to be documented in each resident's medical record with monitoring for at least 24 hours or longer as needed. Resident #29: This resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] assessed the resident's cognitive skills for daily decision making were intact. The Nurses Notes dated 8/25/12 at 11:40pm documented the resident was not happy at the facility due to "poor care", "no one listens" and she wants out of the facility either via the hospital or she will call the cops. This same note documented the resident's daughter was aware of the resident's recent increase in behaviors. The Nurses Notes dated 10/19/12 at 5:30pm documented the resident was agitated due to a new resident on the unit who was yelling continuously. The note documented this was upsetting Resident #29 and she complained the constant yelling was giving her a headache. The Nurses Notes dated 10/21/12 at 11:00pm documented the resident was unable to tolerate another resident's loud yelling (throughout the shift) . The note documented Resident #29 stated she "can't take her yelling and is going to kill her" This note also documented the supervisor was aware. The untimed Social Progress Notes dated 10/17/12, documented increased time was spent with the resident to increase redirection. The note documented the resident was crying, depressed and her mood swings had increased. This note also documented the Social Worker (MSW) had contact with the resident's daughter to discuss the resident's problem with another resident's statements who had dementia. The note documented the MSW would continue to follow the resident. The untimed Social Progress Notes dated 10/22/12, documented the MSW interacted frequently with the resident. The note documented support was offered to the resident and the resident was redirected as needed when focused on certain issues. This same note documented the resident's mood swings continue and the MSW will follow for needs. There was no documentation in the above notes regarding the resident's statements in the above nursing notes. The document entitled "Follow-up Psychiatric Consultation" which was dated 10/29/12 documented the resident was "very angry about another resident who yells constantly. The note documented Resident #29 wants this resident moved out or away. The resident's Comprehensive Care Plans (CCP) documented no evidence the resident's emotional and psychological needs related to other residents were being addressed. During interview on 11/6/12 at approximately 8:15am the resident stated there was a new resident who goes into everyone's rooms and sleeps in their beds. The resident stated she was asleep in her chair when the other resident came into her room and started pounding on her legs. This resident then tried to get into Resident #29's bed. Resident #29 stated she tells the resident to get out of her room but she won't leave. The resident stated she yells for the staff to come and assist her, but the staff are too busy. Resident #29 stated the staff will try closing the resident's door (#29). The resident stated she is afraid this resident is going to hurt someone, but "I'm not going to put up with it, I feel like belting her!" The resident stated "I'm afraid if she comes into my room, I will deck her, and staff will "dope" me up. I don't want that to happen". The resident also stated right now, she feels as if she's in danger from this resident and she knows the staff will say she's not. The resident was visibly upset and crying as she spoke, and had to pause several times during this conversation to dry her eyes. During interview on 11/8/12 at 2:30pm, the Licensed Practical Nurse (LPN) on the A unit stated Resident #34 goes in and out of other resident's rooms and sometimes sits on their beds. When asked how frequently this occurs, the LPN replied "every day, multiple times a day. " When asked what interventions staff have tried, the LPN stated they attempt to redirect this resident. During interview on 11/9/12 at approximately 9:30am the Registered Nurse Unit Manager (RNUM) stated Resident #34 has been at the facility for about a week, and is still adjusting. The RNUM stated this resident forgets where her room is and will go into other resident ' s rooms throughout the day. When asked what residents do when this resident enters their room, the RNUM stated the other residents will tell her to stay away. When asked when interventions have been implemented , the RNUM stated the other residents will tell her to stay away, and staff will attempt to redirect Resident #34. The RNUM stated she is trying to introduce residents to each other and encourage them to start over. The RNUM stated we are still getting to know Resident #34, and I try to encourage the other residents to be understanding. I don't want anyone to get hurt, that won't solve anything. During interview on 11/9/12 at approximately 9:30am the RNUM stated she knows Resident #29 spoke with the SW about resident #34 banging on her legs. The RNUM stated she thought there was an investigation that went to the administrator. When asked what measures have been put into place to protect Resident #29 from Resident #34, the RNUM stated she knows Resident #29 does not like noise, so the RNUM stated she suggested this resident go to the day room where it is quiet. The RNUM stated I can't make everything go away. During interview on 11/9/12 at 8:50am the MSW stated Resident #34 has a history of entering other resident's rooms, it's normal for her. The MSW stated its not good she does this, as she has dementia and it's an invasion of the other resident's privacy. The MSW stated Resident #29 also came to see her, as she had concerns with Resident #34 coming into her room. The MSW stated sometimes it is hard for Resident #29 to adjust to new residents, and she sometimes exaggerates things. The MSW stated Resident #29 came to her a few weeks ago saying she was asleep in her chair when she woke up and Resident #34 was in her room. Resident #29 stated Resident #34 grabbed her legs and her left arm. Resident #29 stated she tried to get Resident #34 to leave, but she wouldn't, she tried to climb in her bed. When asked what interventions she had implemented to protect both residents from potential abuse, the MSW replied she tries to redirect Resident #34 when she sees her in other resident ' s rooms and the nurses should do the same. The MSW also stated she keeps in frequent contact with Resident #29, so she would know if there was a problem. The MSW did state Resident #29 stated she feels like she could retaliate against Resident #34, but the MSW stated she doesn't really think Resident #29 would do that. The MSW acknowledged both residents have the potential to be both a victim and an aggressor, and stated she had not implemented a victim or aggressor care plan (CP) for either resident. The MSW stated it is her responsibility to develop those types of CPs. During interview on 11/9/12 at 10:30am the Administrator stated if there is a resident to resident incident and there is physical contact, an investigation should be completed. If this a repeat behavior or one resident has concerns with the other, an incident and investigation should also be completed and it is the responsibility of the nurse manager or supervisor to start the investigation. When asked about Resident #34, the Administrator stated the facility was having a lot of difficulties with this resident. The Administrator stated she was aware of an incident when Resident #29 stated Resident #34 walked into her room and did something to her legs. The Administrator stated Resident #29 stated this event was frightening to her. The Administrator stated she was aware of an incident involving Resident #34 and Resident #21, but was unaware of any concerns with residents who wander into other resident's rooms. When asked what interventions had been implemented to ensure the resident safety, the Administrator stated after the above incident she knows Resident #29 was offered a Velcro stop sign for her door, and the staff was looking for additional stop signs. The Administrator also stated sometimes residents are redirected or placed on 15 or 30 minute checks, and this information should be on the resident CP. The Administrator stated she is also aware Resident #63 will sometimes wander into other residents rooms and lay in their beds, however this resident usually doesn't bother anyone. The Administrator stated Resident #63 has also come into her office and rearranged things, but she is usually easily redirected. The Administrator also stated she's sure some residents have been upset by Resident #34 and #63's behavior. During interview on 11/9/12 at 11:00am the Director of Nursing (DON) stated the staff was still in the process of getting to know Resident #34, and they need to keep everyone safe while watching this resident. When asked about resident to resident concerns, the DON stated she was aware of an incident between Resident #34 and Resident #29, and she had offered to move Resident #29 to a different wing, however the resident declined. The DON stated she recently offered the resident a stop sign for her room, but the resident won ' t allow that. The DON stated she tries to do whatever works for Resident #29. The DON stated the only other incident she was aware of regarding a resident who wandered into another resident's room was between Resident #34 and Resident #21 and the DON stated there was no harm there because Resident #21 got her shoes back. When asked how the facility protects residents from residents who wander, the DON stated hopefully the staff are keeping an eye on the residents who wander. The DON stated there should be no concerns with other resident if the residents who wander are being accurately monitored. The DON also stated there were no care plans for either residents who have the potential to be either the aggressor or to be victimized. The DON stated she has to keep all the resident safe, and she doesn't know what else she can do. Resident #55: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) dated 10/22/12 documented the resident had long and short term memory problems with severe cognitive impairment and was not capable of understanding or being understood. Nursing Notes (NN) dated 10/12/12 at 10:00 pm documented the resident had increased wandering, increased disorientation and was continuously talking. The Resident was wandering into resident's rooms and taking their belongings. NN dated 10/13/12 at 7:00 documented the resident is alert, very confused, verbally aggressive towards staff and roommate and difficult to redirect. NN dated 10/15/12 documented the resident was unable to be redirect, had confusion with words and sentences, attempted to steal/take other residents belongings. Staff were unable to get belongings back due to the residents combativeness and were unable to reason with the resident. When reapproached the resident would scream and become combative. NN dated 10/18/12 at 9:00pm documented the resident was found numerous times on unit A & C taking others residents belongings and became combative when asked to give them back. NN dated from 10/20/12 through 10/31/12 documented the resident had aggressive, combative and verbally abusive behaviors to staff and other residents, with continuous wandering into other residents rooms. During an interview on 11/7/12 at approximately 10:30 am the Nurse Manager (NM) stated that the resident ambulates independently around facility and it is difficult to keep her on one unit. The resident has been redirected by the supervisor numerous times and medication has been increased to decrease the behaviors, but at times the medications have little or no effect. The resident is redirected to her room when fatigue is noticed. During an interview on 11/9/12 at 10:30 am the DON and Administrator stated if repeat behaviors or issues with other residents are ongoing the NM should fill out an Accident and Incident (A&I) investigation form, the NM and the supervisor should investigate the issues, make changes to the careplan and make a determination for medical or psychological intervention. Resident # 51: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) documented the resident was able to understand and was understood with mild impairment to short term memory. During the group meeting on 11/6/12 at 2:15pm Resident #51 she stated that she and other residents do not like the lack of privacy that is provided at the facility. The resident stated that there are residents who wander into our rooms and take our things and these residents could get hurt. During an interview on 11/7/12 at approximately 1:45pm, the resident stated Resident #63 comes into her room and takes her things quite often. Resident #51 stated Resident #63 will take off the bed pads and bring them to another residents room, will take some of my clothes and then come back and sit on my bed. Resident #51 stated she doesn't"t want anyone sitting on her bed. Resident #51 stated Resident #63 "makes me mad, I snatched her by the chest and pushed her out". Resident #51 also stated "when I yell for help, if staff are around, they just come and get her and close my door. I do not like having my door closed all the time but that is the only way to keep her out." The nurses note dated 10/19/12 at 1:30pm documented the resident was extremely angry regarding another resident who wandered into her room. This same note documented the writer, registered nurse #2 (RN#2), redirected the wandering resident without incident and explained to Resident #51 that Resident #63 is confused. Resident #51 stated to RN#2 she (resident #63) will remember when I hit her." The note documented RN #2 explained that would be inappropriate for her to do and to ask staff for assistance. Resident #51 remained insistent that she would hit the resident if she came in her room. During an interview on 11/7/12 at approximately 2:30pm RN#2 she stated that she did not write up an investigation, she wrote a note in chart. During an interview on 11/8/12 at 11:00 am the DON and Administrator stated that the resident is independent and walks throughout the building. The certified nurses aides (CNA's) need to be more aware of the residents who wander. During an interview on 11/9/12 at 4:30pm the DON and Administrator stated if repeat behaviors or issues with other residents are ongoing the nurse manager should fill out an Accident and Incident ( A&I) investigation form, the nurse manager and the supervisor should investigate and make changes to the careplan and determine the need for medical or psychiatric intervention. Resident # 34: The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. There was no MDS available. During an observation on 11/7/12 at 10:30 am the resident was wandering in the hallway in and out of resident rooms. During an observation on 11/8/12 at 11:20 pm the resident was observed wandering into two different resident rooms. At the time of the observation a certified nurses aide (CNA) was walking down the hallway and did not redirect the resident or address the resident at all. The CNA continued walking down the hallway. The nursing notes revealed the following: On 11/1/12 resident wanders and was easily redirected. On 11/2/12 at 6:00 am the resident was wandering out in the hall without undergarments on, was easily redirected, also noted wandering into other resident rooms four times. On 11/2/12 at 6:15 pm the nurses notes documented the resident was agitated and in continuous motion walking from one room to another, taking possessions from residents and redistributing them to other rooms. Supervision of staff ineffective and redirection was unsuccessful. On 11/3/12 at 7:00pm the resident is difficult to redirect, became combative and agitated, was noted wandering into other resident rooms, taking their personal belongings. The Resident was also noted to fall asleep in other residents beds. On 11/4/12 resident roaming about unit, at 7:00pm NN documented the resident was found wandering on her unit and other units and into resident rooms taking their personal belongings. Resident is difficult to redirect, easily agitated, argumentative and combative with staff. Other residents are complaining that the resident is is going into their rooms and yelling at them. The nursing notes further documented for 11/4/12 at 8:40 pm that the resident is agitated and disruptive to other residents, "verbally threatening" to staff and residents, wanders continuously in and out of resident rooms, "redirecting is impossible" On 11/5/12 at 3:01 the resident made an attempt to open a door at the end of the hallway of the unit, the alarm was sounding. Resident was standing at the door. NN further documented that on the first part of the shift the resident was wandering in and out of other residents rooms, disrupting the floor. Did settle down later in the shift. On 11/6/12 at 12:00 pm the resident was observed in another residents room, the resident who resides in the room was yelling at for the resident to leave the room, the resident was yelling at staff to keep Resident #34 out of her room. On 11/7/12 at 10:00 am NN documented Resident#34 was in the hallway when Resident #21 placed her hand on residents right upper extremely was told by Resident #21 to please stay out of my room and was speaking in profane language. On 11/8/12 at 1:30 pm NN documented the resident was out on the patio alarms were sounding, daughter agreed to 15 minute checks. At 2:15 pm the nurses note documented resident had to be redirected away from Resident #32 as she was walking into the residents room. Resident #32 stated he wanted her out of there, the resident stated she wanted to get into bed, was observed with Resident #32 call light pulled from the wall. On 11/8/12 at 2:45 pm NN documented the resident was alone in another residents room with the bed crank in her hand. The Comprehensive Care Plan (CCP) dated 11/6/12 documented a SW adjustment care plan. The goal documented was to reduce behaviors and redirect out of resident rooms. The evaluation on 11/6/12 (same date the care plan was initiated) documented to redirect resident, discuss privacy of other residents going into other resident rooms and SW to follow for needs. During an interview on 11/7/12 at 10:40 am LPN #6 stated that the resident wanders into other resident rooms, they try to redirect her but it doesn't always work. During an interview on 11/9/12 at 12:02 pm the CNA who was caring for the resident stated they are not doing anything different with this resident than the other residents, she is not on frequent checks. They watch her but the staff has to get their work done so they do what they can. She cannot be watched all of the time. The CNA further stated the resident can become hostile so they let her wander. During an interview on 11/9/12 at 12:10 pm LPN # 6 stated that there is nothing different or special they are doing for this resident. When asked specifically about 15 minute checks the LPN was not aware of any. During interview on 11/9/12 at 8:50 am the MSW stated Resident #34 has a history of entering other resident's rooms, it's normal for her. The MSW stated its not good she does this, as she has dementia and it's an invasion of the other resident's privacy. The MSW stated Resident #29 also came to see her, as she had concerns with Resident #34 coming into her room. The MSW stated sometimes it is hard for Resident #29 to adjust to new residents, and she sometimes exaggerates things. The MSW stated Resident #29 came to her a few weeks ago saying she was asleep in her chair when she woke up and Resident #34 was in her room. Resident #29 stated Resident #34 grabbed her legs and her left arm. Resident #29 stated she tried to get Resident #34 to leave, but she wouldn't, she tried to climb in her bed. During interview on 11/9/12 at approximately 9:30am the Registered Nurse Unit manager (RNUM) #1 stated she was aware Resident #29 spoke with the SW about Resident #34 banging on her legs. The RNUM stated she thought there was an investigation that went to the administrator. When asked what measures have been put into place to protect Resident #29 from Resident #34, the RNUM stated she knows Resident #29 does not like noise, so the RNUM stated she suggested this resident go to the day room where it is quiet. The RNUM stated I can't make everything go away. During an interview on 11/9/12 at 12:14 pm the RNUM #1 stated she did not have the 15 minute check documentation. The RNUM stated she didn't do 15 minute checks. During an interview on 11/9/12 at 12:25 pm the DON was asked for the 15 minute checks documentation the DON stated the RNUM initiated the checks and should have them. During interview on 11/9/12 at 11:00am the DON stated the staff was still in the process of getting to know Resident #34, and they need to keep everyone safe while watching this resident. When asked about resident to resident concerns, the DON stated she was aware of an incident between Resident #34 and Resident #29, and she had offered to move Resident #29 to a different wing, however the resident declined. The DON stated she recently offered the resident a stop sign for her room, but the resident won't allow that. The DON stated she tries to do whatever works for Resident #29. 10 NYCRR 415.4

Based on medical record review and staff interview the facility failed to have evidence that all alleged violations of abuse were thoroughly investigated for 3 (#s 29, 51 and 63) of 14 residents and those interviewed during the group interview during the extended recertification survey. Specifically, the facility failed to investigate multiple incidents when 1 (Resident #63) resident wandered into other residents' rooms, and failed to investigate 2 (Resident #s 29 and 51) resident's concerns regarding other residents. This resulted in no actual harm but has the potential for serious harm that is Immediate Jeopardy and Substandard Quality of Care to the health and safety of the residents'. This is evidenced by: The undated Policy and Procedure (P&P) entitled "Resident to Resident Abuse Policy and Procedure" documented that the facility was to protect residents from harm at all times. This included protection from physical and verbal abuse from other residents. If a resident-to-resident incident occurred, staff were to immediately intervene. The residents were to be separated and taken away from each other until the situation calmed down. The nursing supervisor was to be immediately notified and all necessary documentation for reporting the incident was to be completed. All incidents were to be documented in each resident's medical record with monitoring for at least 24 hours or longer as needed. Resident #29 The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS)dated 10/5/12 assessed the resident's cognitive skills for daily decision making were intact. The Nurses Notes dated 8/25/12 at 11:40pm documented the resident was not happy at the facility due to "poor care", "no one listens" and she wants out of the facility either via the hospital or she will call the cops. This same note documented the resident's daughter was aware of the resident's recent increase in behaviors. The Nurses Notes dated 10/19/12 at 5:30pm documented the resident was agitated due to a new resident (#34) on the unit who was yelling continuously. The note documented this was upsetting Resident #29 and she complained the constant yelling was giving her a headache. The Nurses Notes dated 10/21/12 at 11:00pm documented the resident was unable to tolerate another resident's loud yelling (throughout the shift) . The note documented resident #29 stated she "can't take her yelling and is going to kill her." This note also documented the supervisor was aware. The facility was unable to provide documented evidence the above incidents had been investigated. The Social Progress Notes dated 10/17/12 which was not timed, documented increased time was spent with the resident to increase redirection. The note documented the resident was crying, depressed and her mood swings had increased. This note also documented the Social Worker (MSW) had contact with the resident's daughter to discuss the resident's problem with another resident's statements who had dementia. The note documented the MSW would continue to follow for needs. The Social Progress Notes dated 10/22/12 which was not timed, documented the MSW interacts frequently with the resident. The note documented support was offered to the resident and the resident was redirected as needed when focused on certain issues. This same note documented the resident's mood swings continue and the MSW will follow. There was no documentation in the above notes regarding the resident's statements in the above nursing notes. The document entitled "Follow-up Psychiatric Consultation" which was dated 10/29/12 documented the resident was "very angry about another resident who yells constantly. The note documented Resident #29 wants this resident moved out or away, refused any mood stabilizer, although briefly expressed some interest in [MEDICATION NAME]. The 24 hour reports documented the following: 11/1/12 11:00pm-7:00am shift: Resident #34 was wandering out into the hall with no undergarments on 11/2/12 3:00pm-11:00pm Resident #34 was wandering in and out of other residents rooms, taking items from other residents rooms, not easily redirected. Staff closed the unit doors to prevent the resident from leaving the unit 11/3/12 3:00pm-11:00pm Resident #34 became easily combative and agitated when attempting to redirect her from wandering into other resident ' s rooms and taking their personal belongings 11/4/12 7:00am-3:00pm Resident #34 roaming around the unit 11/4/12 3:00pm-11:00pm Resident #34 with increased behaviors and difficult to redirect. Resident taking other resident's belongings, argumentative with staff and residents During interview on 11/6/12 at approximately 8:15am the resident stated there was a new resident who goes into everyone's rooms and sleeps in their beds. The resident stated she was asleep in her chair when the other resident came into her room and started pounding on her legs. This resident then tried to get into Resident #29's bed. Resident #29 stated she tells the resident to get out of her room but she won't leave. The resident stated she yells for the staff to come and assist her, but the staff are too busy. Resident #29 stated the staff will try closing the resident's door (#29). The resident stated she is afraid this resident is going to hurt someone, but "I'm not going to put up with it, I feel like belting her!" The resident stated "I'm afraid if she comes into my room, I will deck her, and staff will "dope" me up. I don't want that to happen". The resident also stated right now, she feels as if she's in danger from this resident and she knows the staff will say she's not. The resident was visibly upset and crying as she spoke, and had to pause several times during this conversation to dry her eyes. During interview on 11/8/12 at 2:30pm, the Licensed Practical Nurse (LPN#2) on the A unit stated Resident #34 goes in and out of other resident's rooms and sometimes sits on their beds. The LPN stated this happens "every day, multiple times a day ". The LPN stated they attempt to redirect this resident. During interview on 11/9/12 at approximately 9:30am the Registered Nurse Unit Manager (RNUM) stated Resident #34 has been at the facility for about a week, and is still adjusting. The RNUM stated this resident forgets where her room is and will go into other resident's rooms throughout the day. The RNUM stated the other residents will tell her to stay away, and staff will attempt to redirect Resident #34. The RNUM stated she is trying to introduce residents to each other and encourage them to start over. The RNUM stated we are still getting to know Resident #34, and I try to encourage the other residents to be understanding. I don't want anyone to get hurt, that won't solve anything. During interview on 11/9/12 at approximately 9:30am the RNUM stated she knows Resident #29 spoke with the MSW about Resident #34 banging on her legs. The RNUM stated she thought there was an investigation that went to the Administrator. The RNUM stated she knows Resident #29 does not like noise, so the RNUM stated she suggested this resident go to the day room where it is quiet. When shown the nurses notes from 10/19/12 and 10/21/12, the RNUM stated she was unaware of any investigations into these incidents. The RNUM stated I can't make everything go away. During interview on 11/9/12 at 8:50am the MSW stated Resident #34 has a history of entering other resident's rooms, it's normal for her. The MSW stated its not good she does this, as she has dementia and it's an invasion of the other resident's privacy. The MSW stated Resident #29 also came to see her, as she had concerns with Resident #34 coming into her room. The MSW stated sometimes it is hard for Resident #29 to adjust to new residents, and she sometimes exaggerates things. The MSW stated Resident #29 came to her a few weeks ago saying she was asleep in her chair when she woke up and Resident #34 was in her room. Resident #29 stated Resident #34 grabbed her legs and her left arm. Resident #29 stated she tried to get resident #34 to leave, but she wouldn't, she tried to climb in her bed. During interview on 11/9/12 at 10:30am the Administrator stated if there is a resident to resident incident and there is physical contact, an investigation should be completed. If this a repeat behavior or one resident has concerns with the other, an incident and investigation should also be completed and it is the responsibility of the nurse manager or supervisor to start the investigation. The Administrator stated the facility was having a lot of difficulties with Resident #34. The Administrator stated she was aware of an incident when Resident #29 stated Resident #34 walked into her room and did something to her legs. The Administrator stated Resident #29 stated this event was frightening to her. The Administrator stated she was aware of an incident involving Resident #34 and Resident #21, but was unaware of any concerns with residents who wander into other resident's rooms. The Administrator stated she is also aware Resident #63 will sometimes wander into other resident's rooms and lay in their beds, however this resident usually doesn't bother anyone. The Administrator stated Resident #63 has also come into her office and rearranged things, but she is usually easily redirected. The Administrator also stated she's sure some residents have been upset by Resident #34 and #63 ' s behavior. During interview on 11/9/12 at 11:00am the Director of Nursing (DON) stated the staff was still in the process of getting to know Resident #34, and they need to keep everyone safe while watching this resident. The DON stated she was aware of an incident between Resident #34 and Resident#29, and she had offered to move Resident #29 to a different wing, however the resident declined. The DON stated she had no documentation of these conversations. The DON stated she recently offered the resident a stop sign for her room, but the resident won't allow that. The DON stated she tries to do whatever works for Resident #29. The DON stated the only other incident she was aware of regarding a resident who wandered into another resident's room was between Resident #34 and Resident #21 and the DON stated there was no harm there because Resident #21 got her shoes back. The DON stated hopefully the staff are keeping an eye on the residents who wander to protect them. The DON stated there should be no concerns with other resident if the residents who wander are being accurately monitored. The DON also stated there were no care plans for either residents who have the potential to be either the aggressor or to be victimized. The DON stated she has to keep all the resident safe, and she doesn't know what else she can do. Resident # 51 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) documented the resident was able to understand and was understood with mild impairment to short term memory. During the group meeting on 11/6/12 at 2:15pm Resident #51 she stated that she and other residents do not like the lack of privacy that is provided at the facility. Resident #51 stated she has told numerous staff of her concerns with the wandering residents. The resident stated that there are residents who wander into our rooms and take our things and these residents could get hurt. Resident #51 stated she was told by staff they would look into her allegations. During an interview on 11/7/12 at approximately 1:45pm, Resident #51 stated Resident #63 comes into her room and takes her things quite often. Resident #51 stated Resident #63 will take off the bed pads and bring them to another residents room, will take some of my clothes and then come back and sit on my bed. Resident #51 stated she doesn't want anyone sitting on her bed. Resident #51 stated Resident #63 "makes me mad, I snatched her by the chest and pushed her out". Resident #51 also stated "when I yell for help, if staff are around, they just come and get her and close my door. I do not like having my door closed all the time but that is the only way to keep her out." The nurses note dated 10/19/12 at 1:30pm documented the resident was extremely angry regarding another resident who wandered into her room. This same note documented the writer, Registered Nurse #2 (RN#2), redirected the wandering resident without incident and explained to Resident #51 that Resident #63 is confused. Resident #51 stated to RN#2 she (Resident #63) will remember when I hit her." The note documented RN #2 explained that would be inappropriate for her to do and to ask staff for assistance. Resident #51 remained insistent that she would hit the resident if she came in her room. During an interview on 11/7/12 at approximately 2:30pm RN#2 she stated that she did not write up an investigation, she wrote a note in chart. During an interview on 11/8/12 at 11:00 am the Director of Nursing (DON) and Administrator stated that the resident is independent and walks throughout the building. The certified nurses aides (CNA's) need to be more aware of the residents who wander. There were no investigations of the residents allegations regarding Resident #63. During an interview on 11/9/12 at 4:30pm the DON and Administrator stated if repeat behaviors or issues with other residents are ongoing the nurse manager should fill out an Accident and Incident ( A&I) investigation form, the nurse manager and the supervisor should investigate and make changes to the careplan and determine the need for medical or psychiatric intervention. Resident # 63 The resident was readmitted to the facility on 6/27/12 with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented the resident to be severely cognitively impaired and unable to understand or be understood with a history of wandering. A Safety Device/Restraint Assessment dated 5/7/10 identified the resident to be a high risk for unsafe wandering. The goal and desired outcome was documented to decrease risk for unsafe wandering. The Nurses Note dated 10/8/12, documented the resident was in and out of other residents room, hard to redirect and was upsetting other residents. The Nurses Note dated 10/18/12 8:50 pm documented the resident had increased agitation and anxiety, her gait was unsteady and she was found in the kitchen picking through food and utensils. The note documented the resident refused to leave, and the writer needed another certified nurses aid (CNA) to assist with the resident due to increased agitation. The Nurses Note dated 10/23/12 at 9:00 pm documented the resident had increased behaviors this shift. The note documented the resident was hitting staff and residents during activities, was removed from activities with assist of 2 staff and was placed in barco chair (lounge chair) with a table. The Nurses Note dated 10/25/12 at 11:00 pm,documented the resident had signs and symptoms of unusual behaviors and was found in the center court by the Administrator. On 11/8/12 at approximately 3:00pm the resident was observed walking in the hallway on unit A. The resident went to the medication cart, took gloves out of the box on the cart and started using the pill crusher. The resident then walked into room [ROOM NUMBER], closed the door and was in the room for approximately 2 minutes. (Resident #63 resides on Unit B) The resident then opened the door and the gloves were observed to be placed on the end of the first bed in room [ROOM NUMBER]. Resident # 63 was observed standing in the doorway of room#5. The resident who lives in room [ROOM NUMBER] was coming up the hall in his wheelchair and yelled for Resident #63 to get out of his room. Resident # 63 did not move. The other resident then stated he had to use his bathroom. A CNA was called to the room and had to remove Resident #63 from the doorway. During an interview on 11/8/12 at 3:15pm the CNA stated that this is normal behavior for Resident # 63, we just remove her and send in her in another direction. During an interview on 11/9/12 at approximately 10:30am, the Registered Nurse Unit Manager (RNUM) stated the resident ambulates independently around the facility and it is difficult to keep her on one unit. The resident has been redirected by the supervisor numerous times and medication has been increased to decrease the behaviors, but at times the medication have little or no effect. The RNUM stated the resident is redirected to her room when fatigue is noticed. The RNUM stated an Accident and Incident (A&I) investigation form was not completed for Resident #51 pushing Resident # 63. There were no investigations regarding the wandering behaviors of Resident #63. During an interview on 11/9/12 at 4:30pm the DON and the Administrator stated if repeat behaviors or issues with residents are ongoing, the RNUM should fill out an Accident and Incident ( A&I) investigation form, the RNUM and the supervisor should investigate and make changes to the careplan and determine the need for medical or psychiatric intervention. 10NYCRR415.4(b)(1)(ii)

Based on observation, medical record review and staff interview the facility failed to ensure each resident received adequate supervision to prevent accidents for 3 (#s 34, 55 and 63) of 3 residents reviewed during the extended survey. Specifically, the facility failed to adequately supervise residents who had a documented history of wandering into other resident's rooms to protect residents from abuse. This resulted in no actual harm but has the potential for serious harm that is Immediate Jeopardy to resident's health and safety and Substandard Quality of Care for the residents. This is evidenced by: Resident #34: The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. There was no Minimum Data Set (MDS)available. During an observation on 11/7/12 at 10:30 am the resident was wandering in the hallway in and out of resident rooms. During an observation on 11/8/12 at 11:20 pm the resident was observed wandering into two different resident rooms. At the time of the observation a certified nurses aide (CNA) was walking down the hallway and did not redirect the resident or address the resident at all. The CNA continued walking down the hallway. On 11/8/12 at approximately 2:50 pm Resident #34 was observed walking in the hallway on the A unit speaking in a garbled manner, appearing angered. The resident was holding a metal bed crank in her right hand and swinging her right arm. The resident then turned toward room #11, at which point the surveyor called for a nurse. A nurse and a CNA responded and took the resident into her room. During observation on 11/8/12 at approximately 2:00 pm Resident #34 was observed to follow the Registered Nurse Unit Manager (RNUM) into Resident #32's room. Resident #32 was heard yelling, " I want her out! I want you out! " During observation on 11/9/12 at approximately 10:15am Resident #34 was observed to go into room #11 on the A unit. Resident #12 was heard yelling for her not to go in there. The nursing notes revealed the following: On 11/1/12 resident wanders and was easily redirected. On 11/2/12 at 6:00 am the resident was wandering out in the hall without undergarments on, was easily redirected, also noted wandering into other resident rooms four times. On 11/2/12 at 6:15 pm the nurses notes documented the resident was agitated and in continuous motion walking from one room to another, taking possessions from residents and redistributing them to other rooms. Supervision by staff ineffective and redirection was unsuccessful. On 11/3/12 at 7:00pm the resident is difficult to redirect, became combative and agitated, was noted wandering into other resident rooms, taking their personal belongings. The Resident was also noted to fall asleep in other residents beds. On 11/4/12 resident roaming about unit, at 7:00pm NN documented the resident was found wandering on her unit and other units and into resident rooms taking their personal belongings. Resident is difficult to redirect, easily agitated, argumentative and combative with staff. Other residents are complaining that the resident is going into their rooms and yelling at them. The nursing notes further documented for 11/4/12 at 8:40 pm that the resident is agitated and disruptive to other residents, "verbally threatening" to staff and residents, wanders continuously in and out of resident rooms, "redirecting is impossible" On 11/5/12 at 3:01 the resident made an attempt to open a door at the end of the hallway of the unit, the alarm was sounding. Resident was standing at the door. NN further documented that on the first part of the shift the resident was wandering in and out of other residents rooms, disrupting the floor. Did settle down later in the shift. On 11/6/12 at 12:00 pm the resident was observed in another residents room, the resident who resides in the room was yelling at for the resident to leave the room, the resident was yelling at staff to keep Resident #34 out of her room. On 11/7/12 at 10:00 am NN documented Resident#34 was in the hallway when Resident #21 placed her hand on residents right upper extremity was told by Resident #21 to please stay out of my room and was using profane language. On 11/8/12 at 1:30 pm NN documented the resident was out on the patio alarms were sounding, daughter agreed to 15 minute checks. At 2:15 pm the nurses note documented resident had to be redirected away from Resident #32 as she was walking into the residents room. Resident #32 stated he wanted her out of there, the resident stated she wanted to get into bed, was observed with Resident #32 call light pulled from the wall. On 11/8/12 at 2:45 pm NN documented the resident was alone in another residents room with the bed crank in her hand. There was no documented evidence the physician was notified of thre above noted behaviors. Review of the 24 hour report sheets documented the following: 11/1/12 on the 11-7 shift Resident #34 was wandering out into the hall with no undergarments on. 11/2/12 on the 3-11pm shift Resident #34 wandering in and out of other residents rooms, taking items from other residents rooms, not easily redirected. Staff closed the unit doors to prevent the resident from leaving the unit. 11/3/12 on the 3-11pm shift Resident #34 resident became easily combative and agitated when attempting to redirect her from wandering into other resident ' s rooms and taking their personal belongings. 11/4/12 7-3pm shift Resident #34 roaming around the unit. On the 3-11pm shift the Resident #34 with increased behaviors and difficult to redirect. Resident taking other resident 's belongings, argumentative with staff and residents. During an interview on 11/7/12 at 10:40 am the LPN #6 stated that the resident wanders into other resident rooms, they try to redirect her but it doesn't always work. During interview on 11/8/12 at 2:20 pm Resident #32 stated stated " I just want her out of my room, she makes me mad " . When asked how frequently Resident #34 comes into his room, Resident #32 replied, " enough " . When asked what he does when this resident comes into his room, Resident #32 replied " I yell for staff. " Resident #32 also stated " she upsets me and I have a bad temper. " During an interview on 11/9/12 at 12:02 pm the CNA who was caring for the resident stated they are not doing anything different with this resident than the other residents, she is not on any frequent checks, they watch her but the staff has to get their work done so they do what they can. She cannot be watched all of the time. The CNA further stated the resident can become hostile so they let her wander. During interview on 11/9/12 at 11:00am the Director of Nurses (DON) stated, The DON stated hopefully the staff are keeping an eye on the residents who wander. The DON stated there should be no concerns with other resident if the resident who wander are being accurately monitored. The DON also stated there were no care plans for either residents who have the potential to be either the aggressor or to be victimized. The DON stated she has to keep all the resident safe, and she doesn't know what else she can do. The DON stated the only other incident she was aware of regarding a resident who wandered into another resident room was between Resident #34 and Resident #21 and the DON stated there was no harm there because Resident #21 got her shoes back. Resident 63: The resident was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident to be severely cognitively impaired and unable to understand or be understood with a history of wandering. On 11/8/12 at approximately 3:00pm Resident #63 was observed walking in the hallway on unit A. The resident went to the medication cart, took gloves out of the box on the cart and started using the pill crusher. The resident then walked into room 5, closed the door and was in the room for approximately 2 minutes. (Resident #63 resides on the B unit-this was not her room or unit) The resident then opened the door, and the gloves were observed to be placed on the end of the first bed in room 5. Resident #63 was observed to be standing in the doorway of room 5. The resident from room 5 was observed coming up the hall in his wheelchair, and when he noticed Resident #63 in his doorway, he yelled for her to get out of his room. Resident #63 did not move. The other resident then stated he needed to use the bathroom, and a CNA was called to assist in removing her from the doorway. During an interview with the CNA on 11/8/12 at 3:15pm, she stated that this is normal behavior for Resident # 63, we just remove her and send in another direction we are not doing anything different with this resident than the other residents, she is not on any frequent checks, they watch her but the staff has to get their work done so they do what they can. She cannot be watched all of the time. The CNA further stated the resident can become hostile so they let her wander. During an interview with the Nurse Manager (NM) on 11/9/12 at approximately 10:30am, she stated that the resident ambulates independently around facility and it is difficult to keep her in one unit. The resident has been redirected by staff numerous times but continues to walk and pace, medications are being monitored to find the correct dosage., but at times the medication have little or no effect. The resident is redirected to her room when fatigue is noticed. Resident #55 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated 10/22/12 documented the resident to have long and short term memory problems with severe cognitive impairment and not capable of understanding or being understood. Nursing Notes (NN) dated 10/12/12 at 10:00pm documented the resident to have increased wandering and increased disorientation, talks non stop. Resident wandering into resident's rooms and taking other residents belongings. NN dated 10/13/12 at 7:00 documented the resident is alert and very confused, verbally aggressive towards staff and roommate ambulating about unit and towards center core, difficult to redirect. NN 10/15/12 Unable to redirect, confusion with words and sentences, attempts to steal/take other residents belongings unable to get belongings back due to combativeness and unable to reason with resident when resident was reapproached would scream and become combative. NN 10/18/12 at 9:00pm documented the resident was found numerous times on unit A & C taking others residents belongings and getting combative when asked to give them back. NN dated from 10/20/12 through 10/31/12 documented the resident had aggressive, combative and verbally abusive behaviors to staff and other residents, with continuous wandering into other residents rooms. During an interview with the Nurse Manager (NM) on 11/7/12 at approximately 10:30am, she stated that the resident ambulates independently around facility and it is difficult to keep her on one unit. The resident has been redirected by the supervisor numerous times but continues to wander and become abusive. We are not doing anything different with this resident than the other residents, she is not on any frequent checks, they watch her but the staff has to get their work done so they do what they can. She cannot be watched all of the time. She can be very combative. During an interview with the Administrator and DON on 11/9/12 at 11:00am the DON stated hopefully the staff are keeping an eye on the residents who wander. The DON stated there should be no concerns with other residents if the resident who wanders are being accurately monitored. The DON stated she has to keep all the residents safe, and she doesn't know what else she can do. 10NYCRR 415.12(h)(1)(2)

Based on observation, staff interview and medical record review the facility failed to develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for residents reviewed on the recertification survey. Specifically, there were no comprehensive care plans (CCP) in place for 8 (# 21, 29, 32, 34, 51, 55, 62 and 63) of 113 residents that have the potential to be victims and/or to be aggressors and 2 (#18 and #67) of 3 residents who were on [MEDICAL CONDITION] medications. This resulted in no actual harm but has the potential for more than serious harm that is Immediate Jeopardy and Substandard Quality of Care to residents health and safety. This is evidenced by: Resident #29: There is no victim and/or aggressor comprehensive care plan (CCP). The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] assessed the resident's cognitive skills for daily decision making as intact. The Nurses Notes dated 8/25/12 at 11:40 pm documented the resident was not happy at the facility due to "poor care", "no one listens" and she wants out of the facility either via the hospital or she will call the cops. This same note documented the resident's daughter was aware of the resident's recent increase in behaviors. The Nurses Notes dated 10/19/12 at 5:30pm documented the resident was agitated due to a new resident on the unit who was yelling continuously. The note documented this was upsetting resident #29 and she complained the constant yelling was giving her a headache. The Nurses Notes dated 10/21/12 at 11:00 pm documented the resident was unable to tolerate another resident's loud yelling (throughout the shift) . The note documented resident #29 stated she "can't take her yelling and is going to kill her" This note also documented the supervisor was aware. The Social Progress Notes dated 10/17/12 which was not timed, documented increased time was spent with the resident to increase redirection. The note documented the resident was crying, depressed and her mood swings had increased. This note also documented the Social Worker (MSW) had contact with the resident's daughter to discuss the resident's problem with another resident's statements who had dementia. The note documented the MSW would continue to follow for needs. The Social Progress Notes dated 10/22/12 which was not timed, documented the MSW interacts frequently with the resident. The note documented support was offered to the resident and the resident was redirected as needed when focused on certain issues. This same note documented the resident's mood swings continue and the MSW will follow for needs. There was no documentation in the above notes regarding the resident's statements in the above nursing notes. The document entitled "Follow-up Psychiatric Consultation" which was dated 10/29/12 documented the resident was "very angry about another resident who yells constantly. The note documented resident #29 wants this resident moved out or away,refuses any mood stabilizer, although briefly expressed some interest in [MEDICATION NAME]. The 24 hour reports documented the following: 11/1/12 11:00 pm-7:00 am shift: resident #34 was wandering out into the hall with no undergarments on. 11/2/12 3:00 pm-11:00 pm resident #34 was wandering in and out of other residents rooms, taking items from other residents rooms, not easily redirected. Staff closed the unit doors to prevent the resident from leaving the unit. 11/3/12 3:00 pm-11:00 pm resident #34 became easily combative and agitated when attempting to redirect her from wandering into other resident's rooms and taking their personal belongings 11/4/12 7:00 am-3:00 pm resident #34 roaming around the unit 11/4/12 3:00 pm-11:00 pm resident #34 with increased behaviors and difficult to redirect, was taking other resident's belongings, and was argumentative with staff and residents Review of the resident's Comprehensive Care Plans (CCP) documented no evidence the resident's emotional and psychological needs related to other residents were being addressed. During interview on 11/6/12 at approximately 8:15 am the resident stated there was a new resident who goes into everyone's rooms and sleeps in their beds. The resident stated she was asleep in her chair when the other resident came into her room and started pounding on her legs.. This resident then tried to get into resident #29's bed. Resident #29 stated she tells the resident to get out of her room but she won't leave. The resident stated she yells for the staff to come and assist her, but the staff are too busy. Resident #29 stated the staff will try closing the resident's door (#29). The resident stated she is afraid this resident is going to hurt someone, but "I'm not going to put up with it, I feel like belting her!" The resident stated "I'm afraid if she comes into my room, I will deck her, and staff will "dope" me up. I don't want that to happen". The resident also stated right now, she feels as if she's in danger from this resident and she knows the staff will say she's not. The resident was visibly upset and crying as she spoke, and had to pause several times during this conversation to dry her eyes. During interview on 11/8/12 at 2:30 pm, the Licensed Practical Nurse (LPN) on the A unit stated resident #34 goes in and out of other resident ' s rooms and sometimes sits on their beds. When asked how frequently this occurs, the LPN replied "every day, multiple times a day ". When asked what interventions staff have tried, the LPN stated they attempt to redirect this resident. During interview on 11/9/12 at approximately 9:30 am the registered nurse unit manager (RNUM) #1 stated resident #34 has been at the facility for about a week, and is still adjusting. The RNUM stated this resident forgets where her room is and will go into other resident ' s rooms throughout the day. When asked what residents do when this resident enters their room, the RNUM stated the other residents will tell her to stay away. When asked when interventions have been implemented , the RNUM stated the other residents will tell her to stay away, and staff will attempt to redirect resident #34. The RNUM stated she is trying to introduce residents to each other and encourage them to start over. The RNUM stated we are still getting to know resident #34, and I try to encourage the other residents to be understanding. I don't want anyone to get hurt, that won't solve anything. During interview on 11/9/12 at approximately 9:30 am the RNUM #1 stated she knows resident #29 spoke with the SW about resident #34 banging on her legs. The RNUM stated she thought there was an investigation that went to the administrator. When asked what measures have been put into place to protect Resident #29 from Resident #34, the RNUM stated she knows resident #29 does not like noise, so the RNUM stated she suggested this resident go to the day room where it is quiet. The RNUM stated I can't make everything go away. During interview on 11/9/12 at 8:50 am the MSW stated Resident #34 has a history of entering other resident's rooms, it's normal for her. The SW stated its not good she does this, as she has dementia and it ' s an invasion of the other resident ' s privacy. The SW stated resident #29 also came to see her, as she had concerns with resident #34 coming into her room. The SW stated sometimes it is hard for resident #29 to adjust to new residents, and she sometimes exaggerates things. The SW stated resident #29 came to her a few weeks ago saying she was asleep in her chair when she woke up and resident #34 was in her room. Resident #29 stated resident #34 grabbed her legs and her left arm. Resident #29 stated she tried to get resident #34 to leave, but she wouldn't -she tried to climb into her bed. The SW stated she tries to redirect resident #34 when she sees her in other resident ' s rooms and the nurses should do the same. The MSW also stated she keeps in frequent contact with resident #29, so she would know if there was a problem. The MSW did state resident #29 stated she feels like she could retaliate against resident #34, but the MSW stated she doesn't' really think resident #29 would do that. The MSW acknowledged resident #29's CCP did not address her emotional and psychological needs related to other residents. The MSW stated she is responsible for developing these care plans. During interview on 11/9/12 at 10:30 am the Administrator stated if there is a resident to resident incident and there is physical contact, an investigation should be completed. If this a repeat behavior or one resident has concerns with the other, an incident and investigation should also be completed and it is the responsibility of the nurse manager or supervisor to start the investigation. The Administrator stated the facility was having a lot of difficulties with this resident. The Administrator stated she was aware of an incident when resident #29 stated resident #34 walked into her room and did something to her legs. The Administrator stated resident #29 stated this event was frightening to her. The Administrator stated she was aware of an incident involving resident #34 and resident #21, but was unaware of any concerns with residents who wander into other resident's rooms. The Administrator stated after the above incident she knows resident #29 was offered a Velcro stop sign for her door, and the staff was looking for additional stop signs. The Administrator also stated sometimes residents are redirected or placed on 15 or 30 minute checks, and this information should be on the resident CCP. The Administrator stated she is also aware Resident #63 will sometimes wander into other res rooms and lay in their beds, however this resident usually doesn't bother anyone. The Administrator stated Resident #63 has also come into her office and rearranged things, but she is usually easily redirected. The Administrator also stated she's sure some residents have been upset by Resident #34 and #63 ' s behavior. During interview on 11/9/12 at 11:00 am the Director of Nursing (DON) stated the staff was still in the process of getting to know resident #34, and they need to keep everyone safe while watching this resident. The DON stated she was aware of an incident between Resident #34 and Resident#29, and she had offered to move resident #29 to a different wing, however the resident declined. The DON stated she recently offered the resident a stop sign for her room, but the resident won't allow that. The DON stated she tries to do whatever works for Resident #29. During interview on 11/9/12 at 11:00 the DON stated the only other incident she was aware of regarding a resident who wandered into another resident's room was between resident #34 and resident #21 and the DON stated there was no harm there because resident #21 got her shoes back.The DON stated hopefully the staff are keeping an eye on the residents who wander. The DON stated there should be no concerns with other resident if the residents who wander are being accurately monitored. The DON also stated there were no care plans for either residents who have the potential to be either the aggressor or to be victimized. The DON stated she has to keep all the resident safe, and she doesn't know what else she can do. Resident # 63: There is no victim and/or agressor comprehensive care plan (CCP). The resident was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] assessed the resident as cognition as severely impaired and unable to understand or be understood with a history of wandering. A Safety Device/Restraint assessment dated [DATE] identified the resident to be a high risk for unsafe wandering. The Nurses Notes dated 10/8/12 at 10:30pm documented the resident in and out of other residents room, hard to redirect upsetting other residents. Resident was wandering into other residents room. The Nurses Notes dated 10/18/12 at 8:50 pm documented resident with increased agitation and anxiety, gait unsteady found in kitchen picking through food and utensils. Resident refused to leave writer needed another CNA to assist with resident due to increased agitation. The Nurses Notes dated 10/23/12 at 9:00 pm documented the resident with increased behaviors this shift, hitting staff and residents in activities, resident removed from activities with 2 assist and placed in barco chair with table. Medicated with prn (as needed) and scheduled [MEDICATION NAME]. The Nurses Notes dated 10/25/12 at 11:00 pm documented the resident with signs and symptoms of unusual behaviors found in center court by Administrator. Review of the resident's Comprehensive Care Plans (CCP) documented no evidence the resident's emotional and psychological needs related to other residents were currently being addressed. During an interview on 11/9/12 at 10:30 am the Director of Nursing and Administrator stated if repeat behaviors or issues with other residents are ongoing the RNUM should fill out an Accident and Incident (A/I) investigation form, the RNUM and the supervisor should investigate and make changes to the care plan and make determination for medical or psychiatric intervention. During an interview with the Social Worker she stated that the resident was independent and very confused, she does not mean to wander into other rooms. When asked if this resident could be a victim of abuse due to her wandering the SW stated yes. During interview on 11/9/12 at 10:30am the Administrator stated if there is a resident to resident incident and there is physical contact, an investigation should be completed. If this a repeat behavior or one resident has concerns with the other, an incident and investigation should also be completed and it is the responsibility of the nurse manager or supervisor to start the investigation. When asked about resident #34, the Administrator stated the facility was having a lot of difficulties with this resident. The Administrator stated she was aware of an incident when resident #29 stated resident #34 walked into her room and did something to her legs. The Administrator stated resident #29 stated this event was frightening to her. The Administrator stated she was aware of an incident involving resident #34 and resident #21, but was unaware of any concerns with residents who wander into other resident's rooms.When asked what interventions had been implemented to ensure the resident safety, the Administrator stated after the above incident she knows resident #29 was offered a Velcro stop sign for her door, and the staff was looking for additional stop signs. The Administrator also stated sometimes residents are redirected or placed on 15 or 30 minute checks, and this information should be on the resident CCP. The Administrator stated she is also aware resident #63 will sometimes wander into other res rooms and lay in their beds, however this resident usually doesn't bother anyone. The Administrator stated resident #63 has also come into her office and rearranged things, but she is usually easily redirected. The Administrator also stated she's sure some residents have been upset by resident #34 and #63 ' s behavior. Resident # 18: The resident did not have a CCP for [MEDICAL CONDITION] medication. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident as having moderately impaired cognition. The physician orders [REDACTED]. Review of the CCP for the resident documented a CCP titled [MEDICAL CONDITION] Drugs dated 12/9/10. The CCP has nothing written on the problem list as to what medication the resident is on or when the medication was started. The care plan goal is to adjust to long term care. The evaluations dated 12/9/10 and 3/1/11 documented the resident would receive medication review by psychiatry. During an interview on 11/8/12 at 9:00 am the Licensed Practical Nurse (LPN) stated that the resident has a medication monitoring sheet but she is unaware of any special care plan in place for them to use to monitor the resident. She stated a while ago the resident had a protruding tongue but that was a long time ago, nothing now. During an interview on 11/8/12 at 9:10 am the Registered Nurse Manager stated the resident should have a CCP completed with which medications and what to monitor for the resident. She stated that the resident did not have a current CCP to monitor the medications or side effects. 10NYCRR415.11(c)(1)