Every finding on record at The Osborn

Based on interview and record review conducted during the recertification survey from 2/12/2025 to 2/19/2025, the facility did not ensure the facility-wide assessment was updated to determine what resources were necessary to care for residents competently during day-to-day operations. This was evident during review of Staffing. Specifically, the Facility Assessment did not include the education required by all personnel, a third-party staffing agency contract required to meet staffing needs, and used acuity data from 4/2023 through 6/2023 to determine their resident population staffing needs. The findings are: The Facility assessment dated [DATE] documented the facility had 42 resident beds on the Short Term Rehab Unit with 157 admissions and 42 resident beds on the Long Term Unit with 13 admissions between 4/2023 to 6/2023. The Facility Assessment documented the Resident Utilization Group percentages reflected on Minimum Data Set 3.0 assessments completed between 4/2023 and 6/2023. The Facility Assessment did not document the level of staff assistance required to assist residents with activities of daily living. The Staffing Plan did not document the required level of education for all personnel listed and did not include third-party staffing agency contracts used to meet staffing par levels. On 2/18/2025 at 3:18 PM, the Administrator was interviewed and stated they were responsible for creating the Facility Assessment and determining the staffing and equipment necessary to adequately serve residents. The Administrator stated the Facility Assessment staffing plan included nurse staffing par levels reflective of the facility's goals and not the actual numbers of staff required to provide day-to-day care to residents. The Administrator stated the facility identified the 1st Floor as the Short Term Rehab Unit and the 2nd Floor as the Long Term Unit a few years ago. The 2nd Floor was no longer defined as the Long Term Unit because the facility began using beds on this unit to accommodate an increasing number of short-term admissions. The Administrator stated the facility worked with a third-party staffing agency to meet their par levels and address staffing shortages in their schedule. The facility also used a computer application/program to create the nurse staffing schedule, communicate with staff regarding their schedule, and compile staffing data. 10 NYCRR 415.26

Based on record review and interviews conducted during the recertification survey from 2/12/25 to 2/19/25, the facility did not ensure that the resident and/or resident representative were notified in writing of the reason for the transfer/discharge to the hospital for one of one residents reviewed for hospitalization (Resident #7). Specifically, Resident #7 was transferred to the hospital and the facility could not provide evidence that a written notice of transfer/discharge was provided to the resident or the resident's representative, and that notification was sent to the Ombudsman Office. Findings include: The facility policy and procedure titled Transfer and Discharge last revised 7/27/2022, documented before the facility will transfer or discharge a resident, the facility will provide a written notice to the resident and or representative in a manner and language in which the recipient can understand. The policy also required that a copy of the notice be sent to a representative of the State Long- Term Care Ombudsman's Office. The facility admission agreement documented the resident and their designated representative will be given prior written notice of the transfer or discharge in accordance with applicable regulations. Resident # 7 had diagnoses including schizophrenia, dementia, and chronic respiratory failure. The Quarterly Minimum Data Set, a resident assessment tool, dated 1/22/25 documented the resident had severe cognitive impairment. The progress note dated 8/22/24 at 5:23 PM documented Resident #7 experienced shortness of breath and wheezing. The physician was notified, and the resident was transferred to the hospital. The progress note dated 8/23/24 at 9:02 AM documented Resident #7 was admitted to the hospital with asthma exacerbation and respiratory distress. The progress note dated 8/29/24 at 11:30 AM documented Resident #7 returned to the facility in stable condition. Review of the resident's record on 2/18/25 revealed no documented evidence the family was notified or that Resident #7's representative received written information regarding transfer. A review of discharges and transfers submitted to the Ombudsman's Office for the month of August 2024, revealed no documented evidence the Ombudsman was notified. During an interview on 2/18/25 at 1:00 PM, the Director of Social Services stated that social workers were responsible for providing the transfer/discharge notice and it was not completed for Resident #7. During an interview on 2/19/25 at 1:03 PM, the Director of Nursing stated the nursing staff and social workers collaborated to ensure that resident representatives were notified of the transfer to the hospital. The Director of Nursing was unable to explain why Resident #7's representative did not receive notification. During an interview on 2/19/25 at 1:10 PM, the facility Administrator stated the resident's family should have received written information regarding the transfer and discharge process. The Administrator further stated that the social worker and nursing staff were responsible for ensuring the notification was provided. During an interview on 2/19/25 at 4:00 PM, the Ombudsman office stated there was no documentation that the facility submitted information regarding Resident #7's discharge on [DATE]. 10 NYCRR 415.3(i)(1)(iii)(a-c)

Based on record review and interview conducted during the Recertification Survey conducted from 2/12/25 to 2/19/2,the facility did not ensure that a resident's representative was informed of the facility's bed hold policy before and upon transfer to a hospital for one of one residents reviewed for hospitalization (Resident #7). Specifically, Resident #7 was transferred to the hospital on 8/22/24, and the facility did not provide the resident or their representative written information regarding the bed hold. Findings include: The policy and procedure titled Bed Hold last revised 3/24/23, documented the resident and the representative would receive bed hold and return information at admission and before a hospital transfer. The policy further stated that a resident transferred to a hospital would receive written information regarding bed hold and payment amount. Resident # 7 had diagnoses including schizophrenia, dementia, and chronic respiratory failure. The Quarterly Minimum Data Set, a resident assessment tool dated 1/22/25 documented the resident had severe cognitive impairment. The progress note dated 8/22/24 at 5:23 PM, documented Resident #7 experienced shortness of breath and wheezing. The physician was notified, and the resident was transferred to the hospital. The progress note dated 8/23/24 at 9:02 AM, documented Resident #7 was admitted to the hospital with asthma exacerbation and respiratory distress. The progress note dated 8/29/24 at 11:30 AM, documented Resident #7 returned to the facility in stable condition. Review of the resident's medical record revealed no documented evidence Resident #7 or the representative received written information regarding the bed hold policy. During an interview on 2/18/25 at 1:00 PM, the Director of Social Services stated that social workers were responsible for providing bed hold policy notice and it was not completed. 10NYCRR 415.3 (i) 3(i)(a)

Based on record review and interviews during the Recertification survey from 02/12/2025 to 02/19/2025, the facility did not ensure that a complete preadmission screening was conducted. This was evident for 2 (Resident #169 and Resident # 35) residents reviewed for Preadmission Screening and Resident Review (PASARR) of 16 residents. Specifically, the SCREEN DOH - 695 form was incomplete. There was no documentation of answers to items 21, 24, 25, and 26. The findings are: The facility Policy with Title Preadmission Screening and Resident Review (PASARR) with effective date 01/15/2025 and last review date 01/1/2025 documented It is the policy to screen all potential admissions on an individual basis. As part of the preadmission process, the facility participates in the Preadmission Screening and Resident Review (PASARR) process (Level 1) for all new and readmissions per requirement to determine if the individual meets the criteria for mental disorder, intellectual disability, or related condition. Based upon the Level 1 screen, the facility will not admit an individual with a mental disorder or intellectual disability until the Level II screening process has been completed and the recommendations allow for a nursing facility admission and the facility's ability to provide the specialized services determined in the Level II screen. 1) Resident #169 was admitted from acute care hospital with diagnoses and conditions including to spinal stenosis of lumbar region, Diabetes Mellitus, and Benign Prostatic Hypertrophy. The SCREEN Form DOH-695 completed for Resident #169 dated 7/25/2024, item # 21 was not answered. 2) Resident #35 was admitted from acute care hospital with diagnoses and conditions including fracture of the lower end of right radius, congestive heart failure, and atrial fibrillation. The SCREEN Form DOH-695 completed for Resident #35 dated 01/10/2025, the section Level I Review for Possible Mental Retardation/Developmental Disability (MR/DD) items 24, 25 and 26 were not completed. During an interview on 02/19/25 at 9:06 AM, the Director of Admissions stated they reviewed the screens for all residents prior to admission to the facility admission and ensured they were complete. During the interview, the Screen forms for Resident #169 and Resident #35 were reviewed with the Director of Admissions and they stated the items should have been answered. On 02/19/2025 at 10:43 AM, the Administrator stated the Admissions Department was responsible for reviewing the PASARR SCREEN forms prior to resident admission and they were unaware they were not complete. 10 NYCRR 415.11(e)

Based on observation, interview, and record review conducted during the recertification survey from 2/12/2025 to 2/19/2025, the facility did not ensure person-centered comprehensive care plans were developed with objectives and timeframe's to meet the resident's needs. This was evident for 1 (Resident #30) of 5 residents reviewed for unnecessary medications. Specifically, Resident #30 did not have a care plan developed to address antibiotic medication use. The findings are: Resident #30 had diagnoses of COVID-19, acute and chronic respiratory failure with hypercapnia, and urinary tract infection. The Admission Minimum Data Set 3.0 assessment dated [DATE] documented Resident #30 had mild cognitive impairment, received anticoagulant medication, and received antibiotic medication. The Physician's Orders documented Resident #30 was ordered to receive Amoxicillin-pot clavulanate antibiotic 875-125mg twice daily prophylactically as of 1/27/2025 and Cefdinir antibiotic 300mg daily prophylactically as of 1/27/25. There was no documented evidence a Comprehensive Care Plan related to antibiotic use was developed and implemented for Resident #30. On 2/19/2025 at 10:49 AM, Registered Nurse #2 was interviewed and stated the admitting nurse was responsible for initiating care plans for newly admitted residents. Registered Nurse #2 stated they were the charge nurse for the unit and was responsible for reviewing all resident care plans within a few days of their admission to ensure the care plan reflected the resident's medical condition and medication regime. Resident #30 was prescribed antibiotics on a prophylactic basis upon their admission to the facility. Registered Nurse #2 stated they were unsure why the antibiotics were prescribed for Resident #30 and there should be a correlating care plan in place with interventions to monitor the resident for relative side effects. Registered Nurse #2 stated they had not reviewed Resident #30's chart since their admission to the facility and the antibiotic care plan had not been initiated and currently was not in place. 10 NYCRR 415.11(c)(1)

Based on observation, interview and record review during the Recertification survey from 2/12/25 to 2/19/25, the facility did not ensure a resident who needed respiratory care was provided such care consistent with professional standards of practice for 1 of 2 residents (Resident #281) reviewed for respiratory care. Specifically, Resident #281 was receiving supplemental oxygen without a physician's order, indication for use, flow rate and route of administration. Findings include: Resident #218 had diagnoses including cerebral infarction, congestive heart failure, and asthma. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #218 was severely cognitively impaired and did not document the use of oxygen. The facility policy titled Oxygen Therapy and Evaluation effective 03/01/2024 and last reviewed 03/01/2024 documented A Physician/Nurse Practitioner/Physician Assistant order is required for oxygen therapy. The order must include the type of administration system to use, flow rate, and monitoring parameters. A Nurse Practitioner order dated 2/7/25 documented Titrate to maintain sat >92. There was no documented liter flow rate or route of administration. The February 2025 Treatment Administration Record documented to titrate to maintain sat greater than 92% every shift with a start date of 2/7/25 at 3:30 PM. The oxygen saturation was documented every shift however there was no documented Liter flow. The comprehensive care plan, revised 2/12/2025, documented no evidence the resident used oxygen. On 02/12/25 at 12:49 PM, Resident #218 was observed in bed with oxygen via nasal cannula. A bedside oxygen concentrator was delivering oxygen at 4 Liters per minute. On 02/13/25 at 09:25 AM, Resident #218 was observed in their room in in wheelchair, awake, alert, with oxygen via nasal cannula at 4 Liters per minute. During observation and interview on 2/14/25 at 10:45 AM, Licensed Practical Nurse #1 observed the bedside concentrator and stated the oxygen was set at 4 Liters per minute. They stated they documented the oxygen in the Treatment Administration Record. During an interview on 02/14/25 at 10:55 AM, Registered Nurse Manager #2 stated a physician's order was required for oxygen therapy and oxygen therapy was documented in the Medication Administration Record. Registered Nurse Manager #2, observed the resident's medical record and stated the Nurse Practitioner order dated 02/7/2025 was to Titrate to maintain saturation greater than 92%. Registered Nurse Manager #2 stated they did not see an order that mentioned oxygen. The February 2025 Treatment Administration Record documented Oxygen at 2 Liters via nasal cannula to maintain oxygen saturation greater than 92% with a start date of 2/14/25 at 3:30 PM. 10 NYCRR 415.12 (k) (6)

Based on observation, interview, and record review conducted during the recertification survey from 2/12/2025 to 2/19/2025, the facility did not ensure the posted nurse staffing included the census and total actual hours worked by nursing staff. This was evident during review of Staffing. Specifically, the posted nurse daily staffing did not contain the facility's current census and actual hours worked by Certified Nursing Assistants on each shift. The findings are: The facility Daily Nurse Staffing dated 2/15/2025 documented 7 Certified Nursing Assistants worked on the 7:00 AM to 3:30 PM shift for a total of 52.5 hours. The Assignment Sheets for the 1st and 2nd Floors dated 2/15/2025 documented 8 Certified Nursing Assistants worked on the Day Shift. There is no documented evidence the 2/15/2025 Daily Nurse Staffing reflected the accurate number of actual working Certified Nursing Assistants on the 7:00 AM to 3:30 PM shift. The facility Daily Nurse Staffing dated 2/16/2025 documented 5 Certified Nursing Assistants worked on the 7:00 AM to 3:30 PM shift for a total of 37.5 hours and 7 Certified Nursing Assistants worked on the 11:30 PM to 7:30 AM shift for a total of 56 hours. The facility census was not documented. The Assignment Sheets for the 1st and 2nd Floors dated 2/16/2025 documented 1 of 5 Certified Nursing Assistants working on the Day Shift was late and 6 Certified Nursing Assistants worked on the Night Shift. There is no documented evidence the 2/16/2025 Daily Nurse Staffing reflected the accurate number of actual working Certified Nursing Assistants on the 11:30 PM to 7:30 AM shift and total hours worked by Certified Nursing Assistants on the Day Shift. The facility Daily Nurse Staffing dated 2/18/2025 documented 9 Certified Nursing Assistants worked on the 7:30 AM to 3:30 PM shift for a total of 67.5 hours. The Assignment Sheets for the 1st and 2nd Floors dated 2/18/2025 documented 10 Certified Nursing Assistants worked on the Day Shift. There is no documented evidence the 2/18/2025 Daily Nurse Staffing reflected the accurate number of actual working Certified Nursing Assistants on the 7:30 AM to 3:30 PM shift. On 2/18/2025 at 3:11 PM, the Daily Nurse Staffing was observed posted by the entrance to the facility on the 1st Floor resident unit. There was no documented evidence of the facility census. On 2/18/2025 at 3:18 PM, the Administrator was interviewed and stated the Staffing Coordinator was responsible for posting the Daily Nurse Staffing every day at the beginning of each day. The Administrator stated the Daily Nurse Staffing was not posted at the beginning of each shift, did not account for unforeseen changes to the schedule, and did not reflect the actual hours worked by nursing staff. The Daily Nurse Staffing did not include the facility's daily census, and the Administrator stated they were required to include census information in the daily posting. 10 NYCRR 415.13

Based upon record review, observations,and interviews conducted during a recertification survey from 02/12/2025 to 02/19/2025, the facility did not ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety. Specifically, unmarked undated containers of food were observed in the refrigerator and freezer, and food was not maintained at the proper temperature in the second-floor dining facility's small refrigerator. The findings include: The facility policy Preparation of Potentially Hazardous Foods dated 03/01/2024, states that All potentially hazardous food is to be stored at or 45 degrees Fahrenheit or below and All potentially hazardous foods are to be visibly dated with the date of receipt unless previously dated with or by the manufacturer. Additionally, the facility policy cooling and storage states All storage areas will be inspected daily and weekly by supervisory staff to insure the correct labeling, dating, and storage standards are being met. An initial tour of the kitchen took place on 02/12/2025 at 9:38 AM with the Director of Food Services and the Executive Chef. During the tour of the produce refrigerator, multiple food items were observed unlabeled and undated. One tray containing two salmon fish, one plastic bag of herbs, and boxes of produce (zucchini, brussels, sprouts, and cantaloupe) were undated and unlabeled. During the tour of the freezer, five food items were observed unlabeled and undated while not in their original containers. One bag of pasta large shells, two bags of small pasta, and two bags of hash browns were observed unlabeled and undated. During an interview at the time of observation, the Executive Chef stated thet knew what the unlabeled food was and when it arrived since they did all the ordering. During an observation of the second-floor dining room on 02/13/2025 at 12:08 PM, the small refrigerator, which was stocked with food and snacks for the residents was recorded at an inside temperature of 46 degrees Fahrenheit. During the observation, the Dining Operations Manager stated that refrigerator temperatures were checked every day, and acknowledged the refrigerator was operating at a elevated temperture. 10 NYCRR 415.14 (h)

Based on observation, record review and interviews conducted during an abbreviated survey (NY00311309), the facility did not ensure that the Resident and designated resident representative (RR) was immediately informed of a change in condition for 1 of 4 residents (Resident#1) reviewed for notification. Specifically, Resident#1 developed an unstageable pressure ulcer (PU) in the sacral area which was discovered on 11/16/2022. Facility initiated wound treatment and new interventions without informing the RR. RR was notified on 11/23/2022. The Findings are: The facility policy on Notification of Changes last updated 6/11/2020 documented that changes in a resident's condition or treatment are immediately shared with the resident and/or the resident representative. The nurse will document the notification and any new orders in the medical records, will educate the resident and/or representative about the proposed plan to treat, the risks and benefits of the proposed treatment change, and provide an opportunity to make an informed choice. Resident #1 had diagnoses that included but were not limited to Hip Replacement, Atrial Fibrillation (an irregular heart rhythm), and Arthritis. The Admission Minimum Data Set (MDS, an assessment tool) dated 11/12/2022 documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #1 required extensive two-person assistance for bed mobility, transfer, toileting, and personal hygiene Resident # 1 was always incontinent of bladder and bowel function. The MDS documented Resident # 1 had a stage 2 PU present on admission, was at risk for pressure ulcer (PU), and had skin and ulcer/injury treatments. The Admission Nursing Progress Note dated 11/8/2022 documented Resident # 1 was admitted with blanchable redness to sacrum, skin warm and dry with good turgor. Review of Resident #1's Total Body-Skin and Wound assessment dated [DATE] revealed no documentation of a stage 2 PU on the sacrum. Resident #1's Potential for Impairment of Skin Integrity Nursing Care plan related to fragile skin and decreased mobility dated 11/9/2022 documented the goal was skin will remain intact through the review period (1/28/2023). Interventions included encourage good nutrition and hydration, use draw sheet or lifting device to move resident, encourage turning and positioning while in bed. There was no additional documentation of preventative measures for pressure relief. Review of Wound Notes from 11/09/2022 through 11/11/2022 documented intact blister to sacrum, small skin tear to buttock when removing Allevyn dressing from buttock. Area treated with butt paste. There was no documented evidence that the RR was notified that the PU had deteriorated from a reddened sacrum to an unstageable PU and that treatment changes were made. During an interview conducted with Registered Nurse (RN # 4) on 6/01/2023 at 2:32 PM, RN # 4 stated the first time they assessed the sacral wound it appeared black, not open, and had no drainage. RN # 4 applied Allevyn foam dressing to the sacral area. RN #4 stated the family visited at different times. RN # 4 stated they did not speak to the family about the wound because they thought the family was already told about the PU. During an interview conducted with the Administrator on 6/1/23 at 2:54 PM, the Administrator stated the nurses and unit managers were supposed to notify resident's families whenever they identified new wounds or when there was a change in the resident's condition. The Administrator stated they met with the RR and Resident # 1 soon after admission but never discussed the PU status with the family. During an interview conducted with the Director of SW (DSW) on 6/01/2023 at 7:29 PM, the DSW stated they had the first care plan meeting within 10 days. Resident #1's family was present, and they discussed functional status, goals for discharge, and plans to return home with additional care. The DSW stated they were not aware of Resident # 1's PU when they held the first meeting, so they did not notify the RR of the worsening PU. During an interview conducted with the Director of Nursing (DON #1) on 6/5/23 at 4:05PM, DON #1 stated they saw Resident #1 on 11/09/2022 and assessed their skin. The DON stated they identified a sacral unopened blister of approximately 3cm x 3cm. DON #1 stated they would not speak to the RR about a skin condition that was present at the time of admission since it started in the hospital and the assumption was that the RR was already aware. DON #1 stated they were away for 2 weeks on vacation and upon return they assessed the resident's PU on the sacrum, which was now open and unstageable, measured 6cm x 3cm. DON #1 stated the RR was very upset about the PU and stated that staff did not inform them about the PU, and they were surprised when they saw the PU status. DON #1 stated nurses on the unit or the nurse manager should have informed the resident and their RR when the status of the PU changed/worsened. S483.10(g)(i)(B)

Based on observation, record review and interview conducted during an abbreviated survey (NY00311309) the facility did not ensure all residents received treatment and services to prevent and/or heal pressure ulcers for 1of 4 residents (Resident #1) reviewed for pressure ulcers (PU). Specifically, Resident #1 was identified to have a Stage II pressure ulcer a day after admission that was not re-assessed timely, and Resident #1 was not provided with pressure relief interventions as planned to promote healing. Resident #1's PU worsened and progressed to a stage 4 PU. There was no evidence the facility initially applied and/or modified interventions to attempt to stabilize, reduce or remove underlying risk factors when the residents developed the PU. Findings include: The Facility Policy dated 6/03/2021, documented Registered Nurse (RN) to assess all new admissions and readmission residents within 24 hours and weekly for 4 weeks, as well as residents with significant change, using the Braden Scale. Residents with immobility/bedrest are considered high risk regardless of Braden Scale. Pressure reduction intervention may include pressure reduction overlay or mattress and pressure reduction chair cushion for Stage I PU's involving the ischial, sacral and buttock area. The policy documented the requirement of ongoing documentation by nurse manager or designee in the medical record to describe the specific interventions, effectiveness of interventions and resident's response to therapy. Resident # 1 was admitted to the facility with diagnoses that included but were not limited to surgical repair of fractured right femur, constipation, and anemia. The Admission Minimum Data Set (MDS, an assessment tool) dated 11/12/2022 documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #1 received extensive assistance of two staff for bed mobility, transfer, toileting, and personal hygiene. Resident # 1 was always incontinent of bladder and bowel functions. Resident #1 was in pain rated at level 10/10. Resident #1 had a stage 2 PU present on admission, was on a risk for PUs, and had ulcer/injury treatments that included pressure reducing device for chair and bed, turning/repositioning program, and PU/injury care. Review of Resident #1's Hospital Discharge Record Physician History and Physical dated 11/08/2023 documented Resident #1's skin was warm and dry. There was no documentation of a PU in the hospital discharge record. Review of Resident #1's Admission Nursing Progress Note dated 11/08/2022 documented the resident had blanchable redness to heels and sacrum, skin warm and dry with good turgor. Review of Resident # 1's Total Body-Skin and Wound assessment dated [DATE] evidenced no documentation of a stage 2 PU on the sacrum. Review of Resident # 1's PU to sacrum care plan dated 11/09/2022 documented the staff will administer treatment as ordered, monitor for effectiveness, follow facility policy for prevention/treatment of skin breakdown. Review of Resident # 1's Wound Notes from 11/09/2022 through 11/11/2022 documented intact blister to sacrum, small skin tear to buttock when removing Allevyn dressing from buttock treated with Butt paste. Review of Medication Administration Record (MAR) dated 11/08/2022 through 11/16/2022 revealed no documented evidence of any medication orders for the sacral PU. Review of Resident # 1's MAR dated 11/17/2022 documented initiation of Zinc Oxide Paste 40% to sacral wound. Review of Resident # 1's Treatment Administration Record (TAR) from 11/08/2022 through 11/15/2022 documented saline cleanse and skin barrier cream to left buttock skin tear treatment. Review of Resident # 1's TAR dated 11/16/2022 documented application of Prime Aire Mattress for pressure relief. Review of Resident # 1's TAR dated 11/17/2022 documented initiation of Turn and position Q 2H schedule to reduce pressure from sacrum. Review of Resident # 1's Nursing Note dated 11/17/2022 documented resident was assessed, and sacrum pressure ulcer noted. Turn and position initiated every 2 hours. The Social Worker Progress Note dated 11/23/2022 documented an interdisciplinary team (IDT) meeting with the Resident's family. Family voiced their concerns regarding the resident's care, lack of communication, pain management, intravenous fluids, PU, enema, and the lack of follow through with concerns. Review of Resident # 1's Wound Notes dated 11/25/2022 documented unstageable ulcer to sacrum 6 X 3cm, 90% slough (yellow/grey/black dead tissue), every 2hours (Q2H) turn and position, out of bed schedule, poor appetite, impaired mobility. Review of Resident # 1's Wound Notes 11/12/2023 through 11/24/2023 documented no evidence of wound assessment including measurement, interventions, effectiveness of interventions and resident's response to therapy. During an interview conducted with Certified Nursing Assistant (CNA# 1) on 5/31/2023 at 3:30PM, CNA # 1 stated they received directions for the care of residents from the kiosk tasks and from the nurses. CNA # 1 stated they often accompany the admission nurses to evaluate residents' skin. They also check resident's skin every morning and report any changes to the nurse. CNA stated they were not assigned to care for Residnet#1. During an interview conducted with RN # 1 on 5/31/2023 at 4:12 PM, RN #1 stated the admission nurse assesses the residents on admission and have the CNA assist to turn and reposition the residents to check their skin. The admitting nurse does a head-to-toe body check to determine the skin status on arrival and documents it in the admission notes. RN #1 stated the nurse will notifiy the MD of any skin redness or PU. If there was redness, the MD orders moisture barrier cream or a dressing such as Allevyn foam dressing. The MD orders would be careplanned so the staff had directions for care of the reddened area. RN #1 stated they also check the skin of residents when alerted of any changes in skin by the CNAs. RN#1 revealed they did not perform the admission for Resident#1. During an interview conducted with the Registered Dietician (RD) on 5/31/2023 at 12:40 PM, the RD stated they initially met with Resident # 1 on 11/11/2022. The resident had a poor appetite, so they were placed on Ensure (a food supplement) on 11/15/2022. The RD stated that Resident # 1's intake was between 50-75 % and they had an intact blister on sacrum taken from the nurses note on 11/09/2022. During an interview conducted with CNA# 4 on 06/01/2023 at 1:49 PM, CNA# 4 stated they provided care to Resident #1 starting a few days after they were admitted to the facility. CNA# 4 recalled there was a black discolored area on the resident's sacrum. Sometimes the resident would refuse to eat or to get up from bed and the CNA reported this to the nurse. CNA # 4 received directions for care of the resident from the nurse and in the care plan located in the kiosk. Initially, pressure relief measure used were booties for Resident # 1's feet then later there was an air mattress. During an interview conducted with RN # 4 on 06/01/2023 at 2:32 PM, RN #4 stated the first time they assessed the sacral wound, it was black looking, not open, and had no drainage. RN # 4 stated that they applied Allevyn foam dressing to the sacral area. The resident mostly wanted to stay in bed. During an interview conducted with the Administrator on 06/01/2023 at 2:54 PM, the Administrator stated that the facility did not previously track wounds to determine the effectiveness of pressure ulcer prevention measures. The Administrator stated if the need arises for obtaining supplies during care, the staff will inform them to and they will take measures to provide the staff what they need. The Administrator stated the former Director Of Nursing (DON#1) was involved with wound rounds which included the effectiveness of wound care measures/goals set up by the Quality Assurance Performance Improvement (QAPI) committee. During an interview conducted with DON#1(the former DON) on 06/02/2023 at 6:48PM, DON #1 stated they functioned as the wound nurse in the facility when they were employed. DON #1 confirmed that they they were informaed by a nurse of Resident # 1 sacral blister on 11/09/2022. DON#1 assessed Resident #1 and identified a sacral unopened blister of approximately 3 cm x 3cm. DON #1 stated they do not cover a blister, they apply Zinc Oxide paste. DON #1 stated the order for zinc oxide was placed on Treatment Assessment Record. DON#1 was away on vacation for 2 weeks. Upon their return they assessed the resident's sacral PU and noted that the blister was now opened and measured 6cmx3cm and was unstageable. The resident representative (RR) was very upset about the PU and reported that staff did not inform them about the PU. The nurses on the unit or the nurse manager should inform the RR when the status of the PU changed or worsened. DON #1 stated turning and positioning (T&P) was in place, but they also applied an air mattress and staff continued to T&P. Resident # 1's mobility was very impaired, and they complained of pain with movement. During an interview conducted with the DON # 2 (the current DON) on 06/05/2023 at 4:30 PM, DON #2 stated they were not the director of nursing on record when Residnet #1 was admitted . However the facility's way of monitoring and tracking wounds was lacking when they were hired so DON #2 proposed to hire a wound specialist and a dedicated wound nurse to make weekly wound rounds to better manage wounds in the facility. DON#2 stated that Resident # 1 had poor nutrition that also contributed to the decline in their wound status. During a follow-up interview conducted with RN # 4 on 06/20/2023 at 6:06 PM, RN #4 stated on 11/09/2023 they observed Resident # 1's sacral area and it had discoloration and a blister. RN#4 did not measure the blister but they informed DON # 1 who assessed the wound and notified the Attending Physician (AP). Resident # 1's AP gave the order for skin prep and butt paste to be applied daily starting on 11/09/2023. RN #4 stated wounds are to be measured and assessed at each dressing change and documented. RN #4 stated the nurses should notify the AP and the RR when they observed a new/change in a PU from previous assessment as per facility policy. Nurses needed an AP's order to apply an Allevyn dressings to wounds and to provide residents with an air mattress and seat cushion for pressure relief. RN #4 stated they do not know why Resident # 1 was not ordered for pressure relieving devices since they were assessed as high risk for PUs, and had a stage 2 sacral PU after admission to the facility. The need for pressure relieving devices is usually communicated to the AP by the nurses who perform assessments on the residents. Usually the nurses on the unit or the nurse manager are responsible for PU care.Their assessments are documented in the progress notes/wound notes founf in the Electronis Health Record(EHR), so if notes were not found for Resident #1's PU during 11/12/2022 to 11/16/2022, they were not documented by the nurse. During a follow-up interview conducted with RN #2 on 06/22/2023 at 9:16 AM, RN #2 stated per protocol, Resident # 1 should have had pressure relieving devices in addition to measures used for residents at risk of PU such as air mattress, wheelchair cushion, and scheduled turning and positioning. RN #2 stated the charge nurse did the wound dressing changes and if notes were missing, they were probably not done. During an interview conducted with the AP on 06/26/2023 at 11:50 AM, the AP stated they first examined Resident #1 on 11/09/2022 and did not recall if they saw the resident's skin at that visit. The AP stated if the resident's PU was a stage 2 when they first assessed it they would have followed the facility policy for treating PUs. AP stated Resident #1 developed the PU so quickly after admission, and there were no warning signs. AP stated they did not recall been notified by the nurses that Resident #1's PU had worsened from a stage 2 blister until it had progressed and become unstageable. Nurses usually notifiy the AP of the resident skin intergrity and request orders in order to manage the PU. The resident had Gastrointestinal problems that kept them from eating and the resident's pain management was a factor in their inability to move. S483.25(b)(1)

Based on observations, interviews, and record review during the recertification and abbreviated surveys (NY00309912), it was determined for two of two resident occupied floors, the facility did not maintain a safe and comfortable environment by not ensuring the exclusion of mice in the facility. Specifically, during an on-site investigation conducted on 2/13/23 through 2/14/23, between the hours of 9:00 AM to 4:00 PM, observation was made of a mouse and mouse droppings in a resident room. The findings are: An observation on 2/13/23 at 10:00 am revealed double doors adjacent to the kitchen were propped open, there was a gap of greater than 1 at the bottom of the doors which would allow mice to enter the facility. In an interview on 2/13/23 at 1:00 pm, the resident in room [ROOM NUMBER] stated they had seen mice in the room on several occasions. At 1:15 pm on the same day, the resident in room [ROOM NUMBER] stated that they often saw mice in their room at nighttime. At 1:25 pm on the same day, the resident in room [ROOM NUMBER], stated that mice had come out from under the Packaged Terminal Air Conditioner (PTAC) unit in their room. A 2/13/23 at 2:30 pm review of the exterminator logs revealed the following complaints/sightings of mice: 10 sightings from 8/11/22 to 8/31/22, 20 sightings from 9/1/22 to 9/30/22, 10 sightings from 10/1/22 to 10/31/22, 10 sightings from 11/1/22 to 11/30/22, 15 sightings from 12/1/22 to 12/31/22 and 14 sightings from 1/1/22 to 1/31/22. On 2/14/23 at approximately 2:10 PM, during a tour of the second floor, the resident in room [ROOM NUMBER], called out for assistance, indicating there was a mouse in their room. The Director of Facilities and Sanitarian entered the room, upon removing the cover to the (PTAC), it was noted that there were mouse droppings on the floor beneath the PTAC unit. In an interview at the time of the finding, the Director of Facilities stated that mice have been seen in the facility and perhaps they were disturbed by nearby construction of a new building. The construction started about a year ago and the mice were seen in the facility a few months after that. The facility has an exterminator addressing the issue and coming twice or more per week. Traps are being set and checked daily. The new exterminator recommended repairs to the doors, and it is in progress. The November 2022, January 2023 and February 2023, facility work orders documenented that repairs of doors and grates of the PTAC units were in progress and had not been completed. During the exit conference on 2/14/23 at approximately 3:30 PM, the Administrator stated that the issue was being addressed by the exterminator. The Administrator further stated that the facility has changed to another exterminator company starting in November 2022, hoping to get better results. Review of QAPI minutes revealed that pest control efforts of poison stations, glue boards and bait traps have been incorporated. However, since November 2022, the exterminator had been recommending door sweeps and door repairs to seal off entry points. The garage doors have door sweeps in disrepair. The double doors adjacent to the kitchen lacked a door sweep. The vendor invoice dated February 15, 2023, again recommended door sweeps and door repairs. CFR S483.10(i); S483.10(i)(6) NYCRR 483.90(i)(4)

Based on observation, interview, and record review conducted during the Recertification survey (2/13/23 to 2/17/23), it was determined that the facility did not implement care plan interventions and the facility did not develop a comprehensive person-centered care plan that included measurable objectives and timeframes to meet a resident's medical, and nursing needs that were identified in the comprehensive assessment. Specifically, 1 of 2 residents (#5) reviewed for pressure ulcers had an order for bilateral heel booties that were not being implemented as per the care plan, 1 of 2 residents (#37) reviewed for antipsychotic medications was prescribed an antipsychotic medication but did not have a care plan for antipsychotic medications, and 1 of 1 resident (#43) reviewed for nutrition had significant weight loss but did not have a care plan for nutrition, Additionally Resident (#3) was on an anti-depressant medication, Resident (#39) was receiving dialysis, Resident (#44) was on antipsychotic and anticoagulant medications, and Resident (#68) had a diagnosis of diabeties. There were no care plans to address the above medical conditions. The findings are: 1. Resident #5 was admitted to the facility on [DATE] with diagnoses and conditions that included weakness, unspecified severe protein-calorie malnutrition, history of falling, and difficulty walking. The resident was readmitted on [DATE]. The readmission Minimum Data Set (MDS) (MDS - a resident assessment tool) dated 10/26/2022 documented (1) stage 1 and (1) stage 3 pressure ulcers. A review of the Multiple Pressure Ulcer Care Plan created 10/20/22 documented multiple pressure areas and pain as a result. Interventions included the resident will keep heel booties on while in bed. A review of the Physician's order dated 12/8/22 documented Foam boots to be worn when in wheelchair to protect heels, every shift for protection of heels. A review of nursing note dated 12/8/22 documented following wound care rounds, foam boots provided heels when in wheelchair. Heel elevator requested for time in bed. A review of the quarterly Minimum Data Set (MDS) dated [DATE] documented the resident was at risk for pressure ulcers and had no pressure ulcers. A review of the Braden Scale dated 2/10/23 documented the resident scored a 14 which indicated moderate risk for pressure sores. During an observation on 02/13/23 at 11:45 AM and on 2/14/23 at 9:26 AM, the resident was in bed, and no heel boots were observed on the resident's lower extremities. Heel boots were located on the shelf in the resident's room. During an observation on 2/16/23 at 10:30 AM and 2/17/23 at 9:28 AM, the resident was observed in their wheelchair with no heel boots on the lower extremities. Heel boots were located on the shelf in the resident's room. During an interview with Certified Nurse Assistant, (CNA #1) on 2/17/23 at 9:41 AM, CNA #1 stated the resident was not wearing the heel boots today because they were sent the to be laundered. Additionally, on 2/17/23 at 12:10 PM, CNA #1 stated that they never alerted the nurse that the resident's heel boots were sent to the laundry. 2. Resident #37 was admitted to the facility on [DATE] with diagnoses including major depressive disorder, vascular dementia, and anxiety disorder. Review of the Quarterly MDS dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 2 which indicated severe cognitive impairment and received 7 days of antipsychotic medication. Review of the Physician's orders documented 12/2/22 Risperidone 0.5 mg tab- give 1 tablet orally every 12 hours for psychosis with agitation and aggression. Review of the comprehensive care plan revealed there was no care plan for antipsychotic medication and no care plan for anxiety. 3. Resident # 43 was admitted to the facility on [DATE] with diagnoses which included COVID-19, Alzheimer's disease, and depression. Review of the annual MDS dated [DATE] documented the resident had a BIMS score of 3 which indicated severe cognitive impairment. The resident required limited assistance with eating and documented weight loss and was not on a prescribed weight loss program. Review of the 11/29/22 Nutrition Assessment documented significant weight loss over 6 months. Causes included diuretic use, behaviors, medication adjustments. Review of the Registered Dietician (RD) note dated 10/25/22 documented the resident was hospitalized ,d+[DATE]-[DATE]. The readmission weight was 198.4, significant weight loss 6.5% status post hospitalization . Review of the RD note dated 1/30/2023 documented significant weight loss 14.3 % in 6 months. During an interview on 2/15/23 at 3:03 PM, the Director of Nursing (DON) stated the admitting nurse was responsible for completing the initial care plans. The following day after admission, the DON, infection control nurse, and unit manager were supposed to review the initial care plans. The DON stated all residents should have standard care plans such as COVID, nutrition, behavior, abuse, etc. The DON stated the unit manager was responsible for ensuring the nursing care plans were completed, the dietician was responsible for completing the nutrition care plan, and each department head was responsible for ensuing their section of the care plan was completed. During an interview on 2/16/23 at 10:16 AM, the Administrator stated they were aware that admission care plans were not being completed. The Administrator stated they were not aware of quarterly care plans not being completed. The Administrator stated that since the unit manager for the long-term care left, care plan concerns were discovered. The Administrator stated that social services, activities, nursing, dietary (each member of the Interdisciplinary Team (IDT)) was responsible for completing their section. The unit manager was responsible for ensuring the Nursing Care Plans were completed in its entirety, and the Registered Dietician was responsible for the Nutrition Care Plans. The Admin further stated if a unit had no unit manager, the DON or other staff member was assigned, and was responsible for the Care Plans. During an interview on 2/16/23 at 9:00 AM, the Registered Dietician (RD) stated the Nutrition Care Plan was not in the record of Resident #43. The RD stated they were aware of the resident's significant weight loss, and they did not know why the Nutrition Care Plan was not in the resident's record. The RD stated that creating Nutrition Care Plans was their responsibility and stated they should have created the Nutrition Care Plan after doing the nutrition assessment on 11/29/22. The RD stated that they transitioned from the old electronic medical record (EMR) to the current EMR and the transition plan was that the staff was to enter care plans when the next quarterly care plan was due. During a follow up interview on 2/17/23 at 8:41 AM, the administrator stated the facility did not have a care plan policy. 415-12 45478 45541 47626

Based on observation, record review, and interviews conducted during the recertification survey 2/13/2023- 2/17/2023, the facility did not ensure that a resident who required respiratory care, was provided such care consistent with professional standards of practice and the comprehensive person-centered care plan. This was identified for one of one resident (#432) reviewed for Respiratory Care. Specifically, Resident #432 was observed receiving three liters of oxygen via nasal cannula, although the physician order documented the resident was to receive 2 liters of oxygen. The finding is: Resident #432 was admitted on [DATE] with diagnoses including metastatic breast cancer, Syncope, and collapse. Review of the 2/9/2023 5-Day Minimum Data Set (MDS) (MDS - a resident assessment tool) documented the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact and the resident received oxygen therapy. Review of the 2/3/2023-2/14/2023 Physician's orders documented aminister oxygen 2 liters. Review of the Comprehensive Care Plan (CCP) revealed the resident had no care plan for oxygen therapy. Review of the 2/2023 Treatment Administration Record (TAR) documented oxygen 2 Liters every shift was administered on 2/14/2023 during the day shift. During observations on 02/14/23 at 10:57 AM and 3:10 PM and on 2/15/23 at 8:50 AM, Resident #432 was observed receiving 3 liters of oxygen via nasal canula. On 2/17/23 at 11:39 AM, an interview was conducted with the Licensed Practical Nurse (LPN #4) who stated they set the oxygen flow meter based on the physician's order. LPN #4 stated that the resident had taken the oxygen cannula off at times, but LPN #4 stated they had never seen the resident touch the compressor or change the flow meter. LPN #4 stated that if the physician's order was for oxygen at 2 liters, they would have been sure the concentrator was set at 2 liters, and they did not know how the oxygen concentrator was set at 3 liters. On 2/15/23 at 10:00 AM, an interview was conducted with the Director of Nursing (DON). The DON stated this resident had an order for 2 liters of oxygen and should not have received 3 liters of oxygen. On 2/16/23 at 1:00 PM, an interview was conducted with the Nurse Practitioner (NP). The NP stated an oxygen order should contain the method of delivery as well as how many liters and parameters when needed. The NP stated they expected when there is a medical provider order the liter flow would be set by the nursing staff and if no parameters are written, the staff would discuss with them any need to increase or decrease the oxygen On 02/17/23 at 10:37 AM, an interview was conducted with the Registered Nurse (RN #4). RN #4 stated the nurse caring for the resident was responsible for ensuring the correct oxygen liter flow, and that they should review the physician's order to determine the oxygen flow rate. 415.12(k)(6)

Based on interview and record review conducted during the recertification survey 2/13/2023 - 2/17/2023, the facility did not ensure that pain management was provided to 1 of 1 resident (Resident #74) reviewed for pain mamagement who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences Specifically, nursing staff did not administer pain medications as per physician order to Resident #74 who complained of pain. The finding is: The 10/19/2017 facility Policy and Procedure titled 'Pain Management Program documented that residents have the right to have their pain thoroughly assessed and promptly treated, residents will be assessed for pain using the appropriate pain scale on admission and new onset of pain either verbal or observed and after an intervention of pain relief. Resident #74 was admitted to the facility with diagnoses which included malignant neoplasm of the pancreas, hypertention, and gastro esophageal reflux disease. The 1/31/2023 Admission Minimum Data Set (MDS) (MDS -a resident assessment tool), documented the resident was cognitively intact and had a Brief Interview of Mental Status (BIMS) score of 15 and received 3 days of opioids. Review of the 12/4/2023 Care Plan titled Resident is on pain medication therapy related to (r/t) cancer of the pancreas, interventions included to review pain medication efficacy. A review of the 12/4/2023 Care Plan titled Potential for pain related to a pancreatic mass, interventions included respond immediately to any complaint of pain, monitor and document probable cause of each pain episode, and monitor/record/report the resaidents pain to the nurse. The 1/29/2023 Pain Assessment documented Frequent pain. The 2/20/2023 Physician's orders documented oxycodone HCL oral 5mg every 12 hours at 9am and 9pm. Review of the 2/13/2023 Medication Administration Record (MAR) documented oxycodone 5 mg was administered at 9am and the pain scale was documented as 5 on a scale of 0-10 prior to administration. During observation on 02/13/23 at 10:10 AM, Resident # 74 was observed crying in pain and the call bell was pressed to alert the nurses. An overhead speaker response indicated the nurse was coming. At 10:15am LPN #1 was observed going into the resident's room with the resident's oxycodone 5mg and giving it to the resident. The nurse did not ask the resident what her pain scale was. 0n 2/13/23 at 10:10 AM, an interview was conducted with Resident #74. Resident #74 stated they had a pain scale of 7 or 8 out of 10. REsident #74 stated they rang the call bell prior to the surveyor coming in the room and the staff said they would come. Resident #74 stated they were usually medicated between 8-10 am. Resident #74 stated they had abdominal pain. On 2/13/23 at 10:15 AM, an interview was conducted with the Licensed Practical Nurse (LPN #1) who brought the resident's pain medication at 10:15. LPN #1 stated the medication was due at 9am, but they started administering medications at the other side of the unit because those residents were scheduled to go to therapy earlier and had to recieve their medications. When asked if anyone notified them earlier that the resident requested their medication, LPN #1 stated no. On 2/15/23 at 09:41 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the resident's medication would be considered late if scheduled for 9am and given at 10:15AM. The DON stated pain medication for a cancer resident should be prioritized. The DON stated it is the policy that the nurse should be asking for the resident's pain scale before and after pain medication is given On 02/17/23 at 09:55 AM, an interview was conducted with the Certified Nursing Assistant (C.N.A #2). C.N.A # 2 stated on Monday 2/13/2023 in the morning, the resident rang the bell, and when they went into the resident's room, the resident stated they had pain. C.N.A #2 stated the nurse was down the hall in the back, and they told the nurse the resident complained of pain. CNA #2 stated the nurse came about 30 minutes after they reported that the resident had pain. 483.25

Based on record review and interview during the recertification survey conducted from [DATE]-[DATE], the facility did not ensure a baseline care plan (BCP) was developed within 48 hours of admission for 1 of 1 resident reviewed for death (#429) and 1 of 1 reviewed for respiratory care (#432). Specifically, a BCP was not completed for Residents # 429 and # 432 within 48 hours of admission to the facility. The findings are: A review of the Policy and Procedure Base Line Care Plan dated [DATE] should include Physician Orders, Therapy Orders, Social Services, PASAR recommendations if applicable, and life enrichment within 48 Hours of Admission. A written summary of the care plan will be provided to the resident or representative. Resident # 429 was admitted to the facility on [DATE] with diagnoses including multiple myeloma. Resident #429 expired in the facility on [DATE]. Review of the medical record revealed there was no documented evidence that a BCP was developed for resident #429 or that a BCP was reviewed with the resident or the resident's representative. Resident #432 was admitted to the facility on [DATE] with diagnosis including metastatic breast CA, syncope and collapse. Review of the [DATE] Admission 5 Day Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15 The [DATE] Physician Orders documented Oxygen at 2L (liter) every shift. Review of the medical record revealed there was no documented evidence that a BCP was developed to address the use of Oxygen for Resident # 432 or that the plan of care was reviewed with the resident or the resident's representative. On [DATE] at 11:41 AM, an interview was conducted with the Administrator regarding baseline care plans. The Administrator stated the social worker was responsible for providing the written summary of the plan of care to the resident/resident representative in a manor they can understand. On [DATE] at 12:01 PM, an interview was conducted with the Director of Social Work who stated they had not not been providing the resident or representative with a summary of the plan of care. 415.11(c)

Based on record review and interview conducted during the Recertification Survey 2/13/23-2/17/23, it was determined for 3 of 3 residents (#5, #27 and #179) reviewed for hospitalization s, the facility did not ensure the resident or the resident's representative were notified in writing of the reason for the transfer/discharge to the hospital in a language that they understood and the facility did not notify the Ombudsman. Specifically, Resident #5, #27 and Resident #179 were transferred to the hospital and the facility could not provide evidence that a written notice of transfer/discharge was provided to the residents or the resident's representatives or that notification was sent to the Ombudsman. This was evidenced by the following: A review of the facility policy, 'Transfer and Discharge', last revised 7/27/2022 documented that the facility may issue a discharge notice to the resident if a resident's needs can no longer be met by the facility, which will include the reason for transfer/discharge, the effective date of the transfer/discharge, the location to which the resident will be transferred/discharged , a statement of the resident's appeal rights and contact information for appeal requests, the name of facility staff which who will assist to complete the appeal form, and the Ombudsman's contact information. 1. Resident #5 was admitted to the facility on [DATE] with diagnoses that included unspecified severe protein-calorie malnutrition, history of falling, and difficulty walking, and was readmitted to the facility on [DATE]. The readmission Minimum Data Set (MDS) (MDS -a resident assessment tool), dated 10/26/2 documented the resident had a (Brief Interview of Mental Status) BIMS score of 13 (cognitively intact). Review of the resident's electronic medical record (EMR) revealed that Resident #5 was hospitalized on [DATE] due to difficulty breathing and radiating pain starting on her left shoulder. The facility was unable to provide documented evidence that Resident #5 or their representative had been notified in writing of the resident's transfer/discharge from the facility and the reason for the transfer/discharge or that notification was sent to the Ombudsman. On 2/17/23 at 10:46 AM, an interview was conducted with the Director of Social Work (DSW) who stated the facility does not provide transfer notices or notify the Ombudsman for long term residents. 2. Resident #27 was admitted to the facility on [DATE] with diagnoses that included acute cholecystitis, enterocolitis, and pulmonary embolism. The admission MDS dated [DATE], documented that the resident had a BIMS score of 5 (severe cognitive impairment). Review of the resident's EMR revealed that Resident #27 was hospitalized on [DATE] for evaluation of cholecystectomy tube and elevated temperature. The facility was unable to provide documented evidence that Resident #27 or their representative had been notified in writing of the resident's transfer/discharge from the facility and the reason for the transfer/discharge or that notification was sent to the Ombudsman. On 2/15/23 at 3:55 PM, an interview was conducted with the Administrator who stated the facility did not provide the resident or resident representative with a transfer notice and did not notify the Ombudsman of the transfer to the hospital. The Administrator stated it is the responsibility of either one of the 2 Social Workers to provide the transfer notice and to notify the Ombudsman. On 2/15/23 at 4:00 PM, an interview was conducted with the DSW, who stated the resident/resident representative were not given a transfer notice. The DSW stated it was unclear to him/her who should give the transfer notice to the resident/resident representative and to notify the Ombudsman of the residents who are discharged . The DSW stated they were unclear if the Ombudsman should be notified of the residents who had been transferred to the hospital. The DSW stated the facility did not notify the Ombudsman. On 2/16/23 at 10:00 am, an interview was conducted with Registered Nurse (RN #2), they stated they did not provide the resident or resident representative with a transfer notice. RN #2 stated they were unaware of the forms. 3. Resident #179 was admitted to the facility on [DATE] with diagnoses that included obesity, hypertension, acute embolism and thrombosis of the left femoral vein. The 5-day MDS assessment dated [DATE], documented that the resident had a BIMS score of 14 (cognitively intact). Review of the resident's EMR revealed that Resident #179 was hospitalized on [DATE] for a Hypoxia and COVID-19. The facility was unable to provide documented evidence that Resident #179 or their representative was notified in writing of the resident's transfer/discharge from the facility and the reason for transfer/discharge or that notification was sent to the Ombudsman. On 2/15/23 at 1:00PM, an interview was conducted with the Administrator who stated the facility did not provide the resident or resident representative with a transfer notice or notification to the Ombudsman of the transfer to the hospital. The Administrator stated it is the responsibility of either one of the 2 Social Workers to provide the Transfer Notice to the resident/resident representative, and to notify the Ombudsman. On 2/15/23 at 1:25 PM, an interview was conducted with the Director of Social Work (DSW), who stated the resident was not given a transfer notice. The DSW stated it was unclear to them who should give the transfer notice to the resident/resident representative and to notify the Ombudsman of the residents who were discharged home. The DSW stated they were unclear if the Ombudsman should be notified of the residents who had been transferred to the hospital. The DSW stated the facility did not notify the Ombudsman. On 2/15/23 at 2:21 PM, an interview was conducted with Registered Nurse (RN#1) who stated they did not remember the resident and they did not remember if they gave the resident a transfer notice 415.3((h)(1) 45541

45541 Based on record review and interview conducted during the Recertification Survey 2/13/23-2/17/23, it was determined that for 3 of 3 residents (#5, #27 and #179) reviewed for hospitalization s, the facility did not ensure that the residents or the resident's representatives were notified in writing of the facility Bed Hold Policy. Specifically, Resident #5, #27 and Resident #179 were transferred to the hospital and the facility could not provide evidence that a written notice of the facility Bed Hold Policy was provided to the residents or the resident's representatives. This was evidenced by the following: A review of the facility policy, ''Bed Hold last reviewed 9/18/2019 documented that the facility will provide written information about bed hold and payment amount before transfer to the hospital. 1. Resident #5 was originally admitted to the facility on [DATE] with diagnoses that included unspecified severe protein-calorie malnutrition, history of falling, and difficulty walking, and was readmitted to the facility on [DATE]. The readmission Minimum Data Set (MDS) (MDS -a resident assessment tool), dated 10/26/2 documented the resident had a Brief Interview of Mental Status (BIMS) score of 13 (cognitively intact). Review of the resident's electronic medical record (EMR) revealed that Resident #5 was hospitalized on [DATE] due to difficulty breathing and radiating pain starting in her left shoulder. The facility was unable to provide documented evidence that Resident #5 or their representative had been provided a written Notice of Bed Hold Policy. On 2/17/23 at 10:46 AM, an interview was conducted with the Director of Social Work (DSW) who stated the facility does not provide Notice of Bed Hold Policy for long term care residents. 2. Resident #27 was admitted to the facility on [DATE] with diagnoses that included acute cholecystitis, enterocolitis, and pulmonary embolism. The admission MDS dated [DATE], documented that the resident had a BIMS score of 5 (severe cognitive impairment). Review of the resident's EMR revealed that Resident #27 was hospitalized on [DATE] for evaluation of cholecystectomy tube and elevated temperature. The facility was unable to provide documented evidence that Resident #27 or their representative had been provided a written Notice of Bed Hold Policy. On 2/15/23 at 3:55 PM, an interview was conducted with the Administrator who stated the facility did not provide the resident or resident representative with a Notice of Bed Hold Policy. The Administrator stated it is the responsibility of either one of the 2 Social Workers to provide the Notice of Bed Hold Policy to the resident/resident representative. The Administrator stated that since the resident is a resident of the Assisted Living, the facility is not required to provide a Notice of Bed Hold Policy. On 2/15/23 at 4:00 PM, an interview was conducted with the DSW, who stated the resident was not given a Notice of Bed Hold Policy. The DSW stated the Social Workers are responsible to provide the Notice of Bed Hold Policy. The DSW stated the facility did not send the Notice of Bed Hold Policy to the resident/resident representative. On 2/16/23 at 10:00 am, an interview was conducted with Registered Nurse (RN #2), they stated they did not provide the resident or resident representative with a Notice of Bed Hold Policy. The RN stated they were unaware of the Notice of Bed Hold Policy form. 3. Resident #179 was admitted to the facility on [DATE] with diagnoses that included obesity, Hypertension, acute embolism and thrombosis of left femoral vein. The 5-day MDS assessment dated [DATE], documented that the resident had a BIMS score of 14 (cognitively intact). Review of the resident's EMR revealed that Resident #179 was hospitalized on [DATE] for a Hypoxia and COVID-19. The facility was unable to provide documented evidence that Resident #179 or their representative had been provided a written Notice of Bed Hold Policy. On 2/15/23 at 1:00PM, an interview was conducted with the Administrator who stated the facility did not provide the resident or resident representative with Notice of Bed Hold Policy. The Administrator stated it was the responsibility of either one of the 2 Social Workers to provide the Notice of Bed Hold Policy to the resident/resident representative. On 2/15/23 at 1:25 PM, an interview was conducted with the DSW, who stated the resident was not given a Notice of Bed Hold Policy. The DSW stated the Social Workers are responsible to provide the Notice of Bed Hold Policy. The DSW stated the facility did not provide the resident/resident representative with a Notice of Bed Hold Policy. 415.3(h)(4)(i)(a)

Based on observation and interview conducted during a recertification survey, the facility did not ensure that food was prepared and served in accordance with professional standards of food safety practice. The FDA guidelines, a model code used by most jurisdictions to develop State and Local regulations, Chapter 1 Subpart 14 State Sanitary Code documented that dietary staff must wear hair restraints (e.g., hairnet, hat, and/or beard restraint) to prevent hair from contacting food according to citing Subpart 14-1.72 (c) all persons with a food service establishment who work in areas where food is prepared are to use hats, caps, or hair nets as restraints which minimize hair contact with hands, food and food contact surfaces. The findings: 1. During the initial tour of the kitchen area on 11/7/19 at 9:30AM, an overhead ceiling duct located along a pathway between the food prep area and the washing, sanitizing, and disposal areas of the kitchen was observed with pieces of peeling white paint. During interview with the Food Service Director (FSD) at the time, he acknowledged the potential for falling paint to contaminate exposed foods or cleaned items. The FSD stated that the wall and the ceiling duct were in need of restoration. 2. During a tour of the family and pantry refrigerators on 11/14/19 at 10:06 AM, a Dietary Aide (DA) and a Certified Nursing Assistant (CNA) on Pavilion 2 were observed setting up and preparing the breakfast meal without hair restraints. The FSD was interviewed at 10:12AM and stated that nursing staff and CNAs are often tasked with assisting during mealtimes. He also confirmed the findings, adding that both staff observed without proper hair restraints should be trained on proper food safety practice. 3. During an observation at lunchtime on 11/13/19 in the cafeteria, one DA did not have a hair restraint on while serving the meal. A second DA stationed at the cash register behind the counter also was not utilizing a hair restraint. The Food Service Director (FSD) was interviewed on 11/14/19 at 9AM and stated that all staff are required to use hair restraints and are inserviced on proper food safety practice. 415.14(h)

Based on observation, interview, and record review conducted during a recertification survey, the facility did not ensure that facility staff followed proper hand hygiene, and gloving technique to prevent cross contamination, and the spread of infection. Specifically, removal of soiled gloves and hand hygiene were not observed during a wound care procedure for 1of 3 residents (Resident # 226) reviewed for pressure ulcer. The findings are: Resident #226 has [DIAGNOSES REDACTED]. physician's orders [REDACTED]. A wound care observation for Resident #226 was conducted on 11/13/19 at 11:23 AM on Pavilion Unit 1. Removal of soiled gloves and hand hygiene were not observed during the wound care procedure. Throughout the procedure, RN #1 used one pair of gloves to prepare the needed wound supplies, cleanse the wound, and applied the clean dressing resulting in potential cross-contamination, and potential contamination of the resident's wound. Registered Nurse (RN #1) donned a pair of gloves prior to removing the resident's sacral soiled dressing, then discarded it along with the gloves. Without washing or sanitizing her hands, RN #1 donned a new pair of gloves, opened 4x4 gauze sponges and a bottle of Sterile Water. Without removing her gloves or sanitizing her hands, RN #1 poured the sterile water and Derma [NAME] skin and hair soap cleanser onto the 4x4 gauze sponges. She then cleansed Resident #226's wound. RN #1 then, without replacing the soiled gloves, removed the prescribed tube of Santyl Ointment from a plastic bag, applied it to a Q tip applicator and applied it to the wound. With the same soiled gloves, RN #1 also applied a clean Allevyn cover dressing to the wound. Without removing the soiled gloves and sanitizing her hands, RN #1 returned the Santyl Ointment to the plastic bag and repositioned Resident #226 in bed. Following completion of the wound care procedure, RN #1 returned the potentially contaminated plastic bag and tube of Santyl Ointment to the treatment cart which was in the treatment storage room. RN #1 was interviewed on 11/13/19 immediately following the wound care procedure and confirmed that she did not practice appropriate hand hygiene or glove technique. 415.19 (a) (1-3)

Based on interviews and record review conducted during a recertification survey, the facility did not consistently ensure that for 1 of 7 residents reviewed for unnecessary medications that the professional standard of practice was met for the timely administration of medications. Specifically, Resident # 63 did not receive her blood pressure medication in a timely fashion. Resident #63 is a [AGE] year-old woman who was admitted to the facility on [DATE] for rehabilitation services with [DIAGNOSES REDACTED]. The resident's doctors' orders for the treatment of [REDACTED]. The medical record of Resident #63 was reviewed for the month of (MONTH) 2019 on 11/14/19. The resident was scheduled to receive her [MEDICATION NAME] CD medication at 9AM and 9PM daily. Review of the medical record revealed that the resident received her [MEDICATION NAME] CD medication outside of the professional standard of practice for the administration of medications. Acceptable professional standards of practice dictate that medications can be administered one hour before and one hour after their prescribed times. Some examples of [MEDICATION NAME] CD being administered beyond the accepted timeframe of one hour past prescribed times are as follows (not an all-inclusive list): 11/7/19 [MEDICATION NAME] administered at 10:40am, 1 hour and 40 past prescribed time 11/8/19 [MEDICATION NAME] administered at 11:57am, 2 hours and 57 minutes past prescribed time 11/9/19 [MEDICATION NAME] administered at 11:05pm, 2 hours and 5 minutes past prescribed time 11/12/19 [MEDICATION NAME] administered at 10:35am, 1 hour and 35 minutes past prescribed time 11/12/19 [MEDICATION NAME] administered at 11:44pm, 2 hours and 44 minutes past prescribed time 11/ 13/19 [MEDICATION NAME] administered at 10:59pm, 1 hour and 59 minutes past prescribed time On 11/15/19 at 2:42PM during an interview, LPN #3 who administered the medication on 11/12/19 was asked why it was administered 35 minutes past the prescribed time stated that the medication was delivered closer to the accepted time of 10:00AM. LPN #3 stated that he did not document the administration of the medication in the medical record until 10:35 AM. On 11/14/19 at 3:32PM during an interview, LPN #2 administered the medication on 11/13/19 at 10:59PM. LPN #2 stated that the medication was administered late because the resident also refuses to take her medication at 9:00PM and prefers to take the medication later. On 11/15/19 at 2:45PM during an interview, LPN #4 stated that he administered the [MEDICATION NAME] CD medication on 11/08/19 at 11:57AM almost 2 hours late because the resident had gone to physical therapy before he could administer the medication. On 11/14/19 at 4:00PM the staff educator RN was asked if it would be problematic if a resident received [MEDICATION NAME] CD outside of the professional standards of the administration of medications. The staff educator replied that the nurse would not be following the doctor's orders and therefore out of compliance. 415.12

Based on observations, record review, and staff interviews conducted during an abbreviated survey (Complaint # NY 501) it was determined that the facility medical director failed to coordinate and implement the facility ' s policies and procedures for residents' Advanced Directives (Cardiopulmonary Resuscitation, CPR, or Do Not Resuscitate, DNR). During an interview on [DATE] at 5:10 PM, the Medical Director stated that he was not aware that there was a problem until today when the ADON made him aware of a resident wearing a red wristband indicating a DNR status without physician orders. He states that he has fixed the problem today and wrote an order for [REDACTED]. 415.15(a)

Based on observations, record review and staff interviews conducted during an abbreviated survey (Complaint # NY 501) it was determined that the facility Administrator failed to ensure that the facility operated in a manner which its written policies and procedures were maintained regarding Advanced Directives (Cardiopulmonary Resuscitation, CPR, or Do Not Resuscitate, DNR). Specifically, the facility failed to have a system in place to ensure that physician orders [REDACTED]. Additionally, there was no policy for Medical Orders for Life -Sustaining Treatment (MOLST) form for DNR. This resulted in harm for Resident #1 the potential for serious harm to residents, which resulted in Immediate Jeopardy. Findings are: During an abbreviated survey a deficiency for Right to Refuse, Formulate Advanced Directives (F 155) was cited at an Immediate Jeopardy level. Specifically, resident physician orders [REDACTED]. Residents who requested Cardiopulmonary Resuscitation (CPR) were not wearing identifying wristbands. Residents who did not have Do Not Resuscitate (DNR) orders wore red wristbands that identify them as having a DNR status. Interviewed staff was not aware of color-coded wristbands for CPR and DNR status. During an interview on [DATE] at 10:25AM, the Administrator stated that he was not aware of any problems with the facility system or policies for Advanced Directives. 415.26

Based on observations, record review, staff and family interviews conducted during an abbreviated survey (Complaint # NY 501) the facility failed to comply with the requirements relating to maintaining written policies and procedures regarding Advanced Directives for 5 (# ' s 1, 2, 3, 5, and 6) of 6 residents reviewed. Specifically, Residents 's #1, 2, 3, 5, and 6 did not have physician orders [REDACTED].#1 and #3 who requested Cardiopulmonary Resuscitation (CPR) were not wearing identifying wristbands. Residents #2 and #6 who did not have Do Not Resuscitate (DNR) orders wore red wristbands that identified them as having a DNR status, and Resident # 5 who had Medical Orders for Life -Sustaining Treatment (MOLST) form for DNR. The facility-lacked documentation that residents' wishes were discussed, initiated, and implemented for Advanced Directives. Additionally, the facility did not have a system to routinely check wristbands, ensure that all staff were aware of color coded wristbands for CPR and DNR status and did not have a policy that included MOLST forms. This resulted in harm to Resident #1 when CPR was initiated, stopped, and restarted, and potential for serious harm that is Immediate Jeopardy for resident health and safety. This is evidenced by, but not limited to the following: The facility policy titled Cardiopulmonary Resuscitation (CPR) dated [DATE] and Revised [DATE], documented: It is the policy of this facility to perform CPR on all residents without a completed DNR order, CPR will be attempted only by persons certified in CPR while awaiting response from 911. CPR is attempted when the following conditions exist: 1) No pulse OR 2) No respiration ' s OR 3) Unconsciousness without respirations or pulses 911 will be called by first responder or designee immediately. Code Blue will be announced and second responder or designee will retrieve the AED/Code Blue Cart. The first responder will establish what the Advanced Directive status is. The facility will ensure that each resident ' s wish in regard to CPR and DNR is known to all staff involved. If resident wishes to have CPR the resident will have a green ID band signifying they do not have a DNR and do want CPR. The first CPR trained responder will assess the scene for safety, assess the victim and initiate CPR/apply AED per training. Once initiated, staff will continue CPR until EMS arrives and takes over resuscitation, or MD pronounces the patient ' s death. The facility policy titled Cardiopulmonary Resuscitation (DNR) revised [DATE], documented: In the absence of a DNR order, all residents are presumed to consent to CPR. A DNR order will only pertain to CPR, which involves initiation of CPR and transfer to hospital. It does not constitute consent to withdraw or withhold any other medical treatment. All residents presumed to have mental capacity to make decision to consent to a DNR order unless determined otherwise, as outlined in this policy and procedure. A. At the time of admission to the facility, and at least Quarterly the Social Worker will provide the applicant with written information regarding his/her right to have a DNR order and will complete the necessary paperwork with the resident/surrogate. B. The physician will write a DNR order after completing the DNR paperwork, which was initiated by the Social Worker. The physician will write a DNR order for a new admission that arrives with a valid DNR from the hospital or another facility unless the consent is revoked, until such time as a new DNR can be completed by Social Work. an order for [REDACTED]. C. The Charge nurse will pick up the DNR order and flag the resident ' s chart on the inside cover with a red DNR sticker and a red dot on the outside of the record next to the resident name and room number. This red ID band signifies the resident has a DNR order. D. The Physician will review and renew the DNR order at least every sixty days as evidenced by a notation in physician progress notes [REDACTED]. If the physician determines that a DNR order is no longer appropriate due to change in the patient ' s medical condition, he/she will notify the person consenting to the order. 1. Resident #1 was admitted to the facility [DATE] with [DIAGNOSES REDACTED]. The MDS (Minimum Data Set; a resident assessment tool) dated [DATE] documented residents Brief Interview for Mental Status (BIMS) score of 14 which indicated resident was cognitively intact. Physician orders [REDACTED]. Therefore, according to facility policy and procedure the resident was considered a full code. Review of Nursing Clinical Notes and Nursing Admission assessment dated [DATE] did not include written documentation regarding the resident ' s right to have Advanced Directives. Furthermore, there was no documentation on who placed the wristband or what color the wristband the resident received. Review of The Social Service Admission assessment dated [DATE] documented that the resident is alert, oriented, and participated in the assessment. In advanced directives portion the social worker documented, Will discuss wishes regarding advanced directives. On [DATE] the team meeting note did not specify the resident's wishes for Advanced Directives. Review of the resident's Comprehensive Care Plan initiated [DATE] did not include a care plan for advance directives. Review of the facility Accident/Incident report dated [DATE] documented at 3:40 AM a Certified Nursing Assistant (CNA) found the resident in room [ROOM NUMBER] by bathroom entrance lying on her left side across the cluster hall from her room [ROOM NUMBER]. The Registered Nurse Supervisor #1 (RNS#1) did a head to toe assessment with no visible injuries noted, it documented resident was unresponsive to tactile and verbal stimuli and could not feel a pulse. CPR initiated immediately, 911 called at 3:49 AM, police arrived at 3:54 AM, Emergency Medical Service (EMS) arrived at 4 AM, and CPR continued. Resident sent to hospital. Review of the facility documented time line of incident from video with explanations from staff recorded by the administrator dated [DATE] documented: 3:39AM CNA identified resident on the floor of room [ROOM NUMBER], left the resident to alert nurse at the nurses station. 3:43AM RNS and Licensed Practical Nurse (LPN#1) search for resident in her room [ROOM NUMBER]. 3:44AM RNS and LPN#1 leave resident room [ROOM NUMBER] and see resident lying on the floor inside entryway of room [ROOM NUMBER]. 3:45AM LPN#1 was sent for oxygen while the RNS started CPR. 3:45:20AM RNS stopped CPR to go and verify resuscitation status in medical chart. 3:49 AM the RNS calls code blue and 911 from the middle cluster. 3:51:39AM LPN#1 arrives with the oxygen concentrator and nasal cannula and resumes CPR. 3:52:26AM RNS arrives with the crash cart. 3:53:24AM RNS gives LPN#1 the Ambu bag and switches with her on chest compressions. 3:53:53AM Police arrived and assisted with CPR and applied Automated External Defibrillator (AED) which did not activate. 4:00AM EMS arrives applies their AED and it did not activate, CPR continues. 4:03AM EMS applies CPR machine to resident to continue chest compressions. 4:20AM EMS and RNS discover pulse and resident taken to hospital. During an interview on [DATE] at 8:45AM, the Acting Director of Nurses (ADON) stated that after the facility investigation it was felt that the RNS did not act in an emergent manor and facility terminated the RNS. She further stated that the RNS and LPN left the facility that morning without filing an incident/accident report, and neither the RNS nor LPN wrote a nurse's note regarding the occurrence. She stated that she is aware that there were holes and problems with the policy and system for Advanced Directives, and has initiated in-service for all staff for CPR/Code Blue, and identifying residents with wristband. She also stated that facility never had a tool for checking wristbands and initiated an audit tool on [DATE], but did not know if the list is being checked for physician orders [REDACTED]. ADON was unable to find the audits completed [DATE]. She did produce the audit for Pavilion 2 that dated [DATE]. She did not know if Pavilion 1 or Pavilion 2 units kept a list of residents with DNR status, and did not know the number of residents with DNR status without going to the medical records. During an interview on [DATE] at 10:25AM, the Administrator stated that he was not aware of any problems with the facility system or policies for Advanced Directives. During an interview on [DATE] at 2:15PM, the RNS stated that he does not remember seeing a wristband on the resident that morning. He stated he would not know what the color coded wristbands meant anyway. He further states that all the nurses go to the chart to check for DNR status. He stated that he has never been in-serviced or oriented about the color coded wristbands and thought that they were only to identify resident by name and room number for medications and treatments. He states that the facility has terminated him because he did not react in an emergent way and did not follow the facility policy. He states, I did stop CPR, after a few minutes to go to the medical record and check if resident had a DNR, there were no orders written so I returned to continue CPR after I got the crash cart and called 911. He stated he did not wait for LPN#1 to return because she took so long to find oxygen. He stated the unit ' s emergency oxygen tank was empty and the LPN#1 had to go to the second floor unit to find oxygen. He did not realize that there was oxygen on the crash cart. During an interview on [DATE] beween 12:00PM and 12:30PM the soccial worker states that all alert and oriented resident are asked about their advanced directives on admission. When she reviewed the admission assessment which documenbted, will discuss residents wishes regarding advanced directives she stated she was sure she followed up, but was unable to provide any documentation that follow up was done. During an interview on [DATE] at 11:30AM, the Administrator stated that he reviewed video with the RNS and LPN#1 and they all saw a green wristband on the resident. During an interview on [DATE] at 9:30 AM LPN#1 stated that she did not recall if the resident was wearing a wristband in the video or at the time of the incident. LPN#1 stated that she did not know that the wristband color identified residets Advanced Directives. She further stated that she reviewed the video with the Administrator so they could learn how to react to a code blue more appropriately. She states that she did not see a wristband in the video and at that time of incident, she did not know that the wristband identified resident ' s Advanced Directives. She stated nurses have always gone to the medical record to check DNR status. 2. Resident #2 was admitted to the facility [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented resident BIMS score of 11 which indicated resident had moderate impaired cognition. In an observation on [DATE] between 9:45AM, and 10:45 AM the resident was wearing a red wristband. Review of the physician orders [REDACTED]. Therefore, according to facility policy and Procedure the resident was to be considered a full code. Review of Nursing Clinical Notes and Nursing Admission Assessment from day of admission on [DATE] did not have written documentation regarding the resident ' s right to have Advanced Directives. Furthermore, there was no documented evidence regarding who placed wristband or what color wristband resident received. Review of The Social Service Admission assessment dated [DATE], 5 days after admission it documented that the resident was alert, anxious, disoriented and resident participated in assessment. In advanced directives portion the social worker documented, Will continue to speak with family. On [DATE], the social worker note documented, several conversations with resident's daughter regarding resident's discharge, there was no documentation to specify resident ' s wishes for Advanced Directives. Review of the resident Comprehensive Care Plan initiated [DATE] did not include a care plan for advance directives. During interview on [DATE] at 1:25PM, the ADON stated that she did not find Advanced Directives for the resident. If there is no Advanced Directive orders present in record, the resident considered a full code and did not know why the resident was wearing a red wristband. During an interview on [DATE] at 5:10 PM the Medical Director stated the ADON made him aware of resident wearing a red wristband that indicated resident had a DNR in place and has fixed the problem today and wrote an order for [REDACTED]. 3. Resident #3 was admitted to the facility [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented resident BIMS score of 15 which indicated resident was cognitively intact. In an observation with the ADON and CNA #2 between 10:00AM and 10:30AM on [DATE], the resident was not wearing an identification wristband issued by the facility to show her Advanced Directive preference. During interview with the resident, between 10AM and 10:30AM on [DATE], the resident stated that the wristband she was wearing was the band placed on her from the hospital not the facility. She stated that she never received a wristband from the facility, and then added, Why do I need one from here. Review of the physician orders [REDACTED]. Review of the Physicians History and Physical dated [DATE] documented resident as a full code. Review of Nursing Clinical Notes and Nursing Admission Assessment from day of admission on [DATE] did not have written documentation regarding the resident ' s right to have Advanced Directives. Furthermore, there was no documented evidence regarding who placed wristband or what color wristband resident received. Review of The Social Service Admission assessment dated [DATE], 5 days after admission it documented that the resident was alert and oriented and resident participated in assessment. In advanced directives portion the social worker documented, No Advanced Directives. Review of the resident Comprehensive Care Plan initiated [DATE] did not include a care plan for advance directives. During chart review the surveyor found a hospital discharge /transfer summary in the front sleeve of resident medical record. It contained a Heath Care Proxy (HCP), Anatomical Gift dated [DATE]. The HCP appointed her son as her health care agent to make all heath care decisions if unable to make her own. During an interview on [DATE] at between 12:00 PM and 12:30PM, the social worker stated that she goes over information with the alert and oriented residents about HCP and stated she knew this is part of Advanced Directives. She stated that this resident told her she did not have a HCP and she did not look for any in the hospital discharge paperwork. She stated there was no need to look for one because because the resident was alert and oriented and said that she did not have a HCP. She further stated it is her responsibility during the week to discuss Advanced Directives with residents on admission but the admission nurse is responsible to get physician orders. On the weekends or nights it is the responsibility of nurses to explain Advanced Directives and the unit clerks and CNAs are responsible for applying the wristbands. She states that she does not know how or when the facility checks wristbands for accuracy. 4. Resident #5 was admitted to the facility [DATE] with [DIAGNOSES REDACTED]. Review of the resident medical record found that resident was admitted to the facility with a MOLST dated [DATE] that documented resident wished to have DNR. It further documented specific treatment guidelines that included limited medical intervention, non-invasive ventilation, no feeding tube, and trial periods of IV fluids. Review of the physician orders [REDACTED]. Review of the Physicians History and Physical dated [DATE] documented resident has a MOLST /never is DNR. Review of Nursing Clinical Notes and Nursing Admission Assessment from day of admission on [DATE] did not have written documentation regarding the resident ' s right to have Advanced Directives. Furthermore, there was no documented evidence as to who applied or what color wristband resident received. Review of the resident Comprehensive Care Plan initiated [DATE] did not include a care plan for advance directives, MOLST, or the specific treatment guidelines resident designated. During an interview on [DATE] at between 12:00 PM and 12:30PM the social worker stated if a resident enters the facility with Advanced Directives and MOLST forms are already initiated the facility honors them, but she would still educate the resident or representative about facility Advanced Directives. She did not recall if the facility had a policy on MOLST forms. She states follow up for Advanced Directieves is usually done when there is a signioficant change, during the quarterly comprehensive care plan meeting, or family/resident requests, but there is no set times for follow ups. During interview on [DATE] at 2:30PM with resident ' s family, she stated that facility had her sign a DNR order yesterday. She states, My husband had a DNR in the hospital and thought that he already had one here, they put a red bracelet on him yesterday, I don ' t remember the color he had on. 5. Resident #6 is an [AGE] year old admitted to the facility [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident's BIMS score of 10, which indicated resident has moderately impaired cognition. The resident ' s medical record contained a Supreme Court order dated [DATE] for incapacitated person and a court appointed guardian was assigned to resident. Physician orders [REDACTED]. Therefore, according to facility policy and procedure the resident considered a full code. The Physician History and Physical dated [DATE] documented, resident has a guardian, had DNR at the hospital, but is unsure about this. In an observation on [DATE] between 9:45AM, and 10:45 AM the resident was wearing a Red wristband that indicating a DNR status. Review Nursing Admission assessment dated [DATE] documented resident was alert and confused, was not aware of her status and not capable of understanding/making his/her own plan of care. It did not include written documentation regarding the resident ' s right to have Advanced Directives. Furthermore, there was no documented evidence of what type of wristband placed on the resident. Review of Nursing Clinical Notes from day of admission on [DATE] did not have written documentation regarding the resident ' s right to have Advanced Directives. Furthermore, there was no documented evidence as to who applied or what color wristband resident received. Review of The Social Service Admission assessment dated [DATE] documented that the resident is alert, disoriented and resident participated in assessment. In the advanced directives portion the social worker documented, Will discuss with guardian, with a [DATE] effective date, entered [DATE] at 1:48 PM it documents, several messages for resident's guardian to return call to discuss advanced directives- No DNR in place. On [DATE] at 2:17 PM another note was entered documenting, After leaving another message for guardian regarding advanced directives the writer spoke to the nurse manger and felt that resident cognitive status has improved since admission, discussed DNR status and resident wanted to initiate DNR, DNR was put into place. On [DATE] at 6:10 PM it documented the guardian was informed that resident was able to express her wishes regarding DNR and DNR was initiated. Review of the resident Comprehensive Care Plan initiated [DATE] did not include a care plan for advance directives. During an interview on [DATE] at 11:30AM, the administrator stated he thinks that the guardianship appointed for financial matters not medical interventions. Interviews conducted from [DATE] through [DATE] were as follows: a. At 9:35 AM on [DATE] Unit Manager #1 stated that she did not maintain a list of residents who have DNR status, All residents are identified by a wristband . All residents who have red wristbands have physician orders [REDACTED]. She stated that there are no care plans initiated for resident Advanced Directives for resident who refuse to wear wristbands. b. At 9:50AM Physical Therapist Assistant stated that a green wristband means resident has a DNR. She further stated if resident did not have a wristband she would look at computer medical record to find the resident DNR status. c. At 10:00AM the Director of Physical Therapy stated that they do not maintain a list of residents who have DNR because the electronic medical record is available in the gym and she is able to check the medical record. She states the DNR status shows up on a ribbon that is across the top page of residents electronic medical record. d. At 10:15 a Certified Occupational Therapist #1 interviewed and stated she did not know what a red or green wristband meant. If she had to look up a resident DNR status, she would go to the medical record to find the physician order. e. At 11AM RN #2 was interviewed on [DATE] who stated that before all this commotion she would never have looked at the wristbands because she has found so many to be wrong. She stated that she would always check the medical record. She stated that it is social worker ' s responsibility to go over Advanced Directives and nursing would get the Physician orders [REDACTED]. She further stated that this has been a problem that was brought to the attention of administration months ago. 415.3(e)(1)(ii)